Short- and long-term clinical outcomes of self-expandable metal stents inserted for colorectal obstruction and efficacy of different insertion techniques | Gastroenterología y Hepatología (English Edition)

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Gargallo, Angel Ferrandez, Patricia Carrera, Miguel Angel Simon, Julio Ducons, Angel Lanas" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Carla J." "apellidos" => "Gargallo" "email" => array:1 [ 0 => "carlajerusalen@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Angel" "apellidos" => "Ferrandez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Patricia" "apellidos" => "Carrera" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Miguel Angel" "apellidos" => "Simon" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Julio" "apellidos" => "Ducons" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Angel" "apellidos" => "Lanas" "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria Aragón (ISS Aragón), Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "CIBER Enfermedades Hepáticas y digestivas (CIBERehd), Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Universidad de Zaragoza, Zaragoza, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados a corto y largo plazo de la colocación de prótesis metálicas autoexpandibles en la obstrucción colorrectal y eficacia de las diferentes técnicas de inserción" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 982 "Ancho" => 2333 "Tamanyo" => 185018 ] ] "descripcion" => array:1 [ "en" => "Flowchart of patients with obstructive CRC and SEMS placement." ] ] ] "textoCompleto" => "IntroductionColorectal obstruction is an abdominal emergency associated with high mortality and morbidity rates. Large bowel obstructions results from intrinsic or extrinsic factors, with colorectal cancer (CRC) by far the most common cause.<a class="elsevierStyleCrossRefs" href="#bib0140">1,2</a> It is unclear whether stent or surgery is the most appropriate modality for managing colorectal obstruction.<a class="elsevierStyleCrossRefs" href="#bib0150">3,4</a> Several uncontrolled studies have suggested that the placement of self-expandable metal stent (SEMS) in malignant large bowel obstruction could improve patients’ clinical conditions before elective surgery, leading to a decrease in mortality, morbidity, and the number of colostomies.<a class="elsevierStyleCrossRefs" href="#bib0140">1,5–7</a> It may also allow accurate tumor staging and serve as permanent palliation, allowing patients with not resectable disease and short life expectancy or unacceptable surgical risk to avoid surgery.<a class="elsevierStyleCrossRefs" href="#bib0175">8–10</a> The role of SEMS for benign colonic lesions or extracolonic causes is not clear, as the majority of studies are case reports or case series.<a class="elsevierStyleCrossRefs" href="#bib0190">11,12</a>The technical success (TS) and clinical success (CS) rates of SEMS vary widely between studies.<a class="elsevierStyleCrossRef" href="#bib0205">14</a> A recent meta-analysis reported a high mean success rate of 76.9% (46.7–100%).<a class="elsevierStyleCrossRef" href="#bib0185">10</a> However, there are also potential disadvantages as major complications or uncertainty regarding long-term outcomes.<a class="elsevierStyleCrossRefs" href="#bib0145">2,15–18</a>Finally, there are essentially two different SEMS insertion techniques: radiologic (XR) and endoscopic under fluoroscopic guidance (ER). In both cases, SEMS are placed under fluoroscopic guidance, but endoscopic assistance is only used in the ER technique.<a class="elsevierStyleCrossRef" href="#bib0200">13</a> However, very few studies have analyzed differences in the efficacy of these methods.To address these issues, we aimed to asses: (1) the short and long term clinical outcomes, including survival, of patients after SEMS placement and factors that could impact such outcomes and (2) the safety and efficacy of the stents to resolve the obstruction according to the insertion technique used [XR or ER].Patients and methodsPatientsThe Endoscopy Unit at University Clinical Hospital, Zaragoza, has used SEMS as a therapeutic option for patients with acute colonic occlusion (especially malignant obstruction) since January 2008. The Interventional Radiology Unit has also performed this procedure in this hospital since 1991. In our study, we included all patients with a SEMS implantation via XR between January 2002 and January 2010 that were registered in the Hospital database and all patients with a SEMS implantation via ER between January 2008 and January 2013. The characteristics of the SEMS of XR group were obtained from the medical histories and the characteristics of SEMS of ER group were collected from a proprietary database. Medical records of all patients were reviewed retrospectively. The study was terminated on September 2013 or upon the death of the patient, whichever occurred first. The vital status was confirmed by the medical records or via telephone contact when needed.ProceduresAll patients provided informed consent before the placement of SEMS. All patients underwent at least an abdominal computed tomography scan prior to insertion of the stent to diagnose the cause of the obstruction and to perform tumor staging in patients with malignant obstruction.In the ER group. Expert endoscopists performed SEMS placement with the same through-the-scope technique. A therapeutic endoscope was advanced until tumoral stricture was found. WallflexTM Colonic Stents (Boston Scientific), 6, 9 or 12cm in length and 2.5cm in diameter, were used in most patients. HanarostentsTM Esophagus stents (M.I. Tech.) were used in two patients. Image intensification was used during the endoscopic placement. Biopsies were taken from the lesion when possible.In the XR group. An expert interventional radiologist<a class="elsevierStyleCrossRefs" href="#bib0155">4,13</a> worked with two types of stents: the WallstentTM (Boston Scientific), 5–9cm in length and 1.6–2.5cm in diameter and SX-ELLA intestinal stent (Ella), 8.2–11.2cm in length and 2.2–3cm in diameter. The most appropriate size was chosen after visualization with fluoroscopy of the stenosis.DefinitionsTechnical success (TS) was defined as a successful SEMS insertion with correct deployment and precise positioning of the SEMS at the location of the stenosis. The expert endoscopist or radiologist determined the TS of stent placement after radiological confirmation. Clinical success (CS) was defined as successful colonic decompression with disappearance of obstructive symptoms within 72h of stent placement. Complications were defined as any adverse event related to SEMS placement, leading to new symptoms, re-intervention, patient hospital readmission or death. Migration, re-obstruction, perforation, failure to expansion, long-term clinical failure, bleeding and fecal incontenence were considered complications. Long-term clinical failure was considered when the patient had recurrence of colorectal obstructive symptoms, but it was not possible to determine which was the specific cause (reobstruction, migration, tumor growth, etc.).Statistical analysesAn initial exploratory analysis of all clinical variables was carried out. Continuous variables were expressed as the mean and standard deviation or median and interquartile range (IQR); whereas, qualitative variables were expressed as frequencies and percentages. The relationship between qualitative variables was evaluated with the Chi-square (χ2) test. Student's t-test or Mann–Whitney U test were employed for comparing means of two independent groups. Normality was tested using Kolmogorov–Smirnov test.Overall survival (OS) time was calculated from the date of the diagnosis to the date of last contact or death from any cause. In addition, the comorbidities of patients at hospital admission were evaluated using a previously validated adaptation of the Charlson Comorbidity Index.<a class="elsevierStyleCrossRef" href="#bib0230">19</a> Survival among different factors was calculated using the Kaplan–Meier method and compared using the Log rank test. Variables shown by univariate analysis to be significantly associated with survival were entered into a Cox proportional hazards regression model for multivariate analysis. For all tests, a two-sided p-value<0.05 was considered statistically significant. SPSS software v22.0 for Windows was used for performing statistical analyses.ResultsPatients demographicsA total of 196 SEMS were placed in 177 patients. Baseline data for these patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Males comprised 57.6% of the cohort, the median age was 73.5 (IQR: 63.8–79.3) years and the median age-adjusted Charlson comorbidity score was 4.0 (IQR: 3.0–5.0). Obstruction was distal to splenic flexure in 83% of patients. One patient presented obstruction in two different locations due to synchronous CRC. The most common cause of obstruction was primary CRC (89.3%). In patients with CRC, tumor stage was known in 142 patients and was stage IV in 51.4% (73/142). In patients with synchronous CRC, the most advanced CRC stage was chosen. The demographics of patients with CRC included in our study are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Technical and clinical outcomes and comparison of insertion techniquesNinety-two (46.9%) SEMS were placed by the XR technique and 104 (53.1%) by the ER method. The TS rates were 95.7% (88/92) for SEMS placed by XR and 95.2% (99/104) for those placed by ER (p=0.87). The CS rates were 77.3% (68/88) and 80.8% (80/99) for the XR and ER groups, respectively (p=0.27). The CS was unknown in 5 patients who were lost to follow-up and attended different hospitals. The rate of complications was higher with XR placement than ER (38.0% vs 20.2%; p=0.006). In the XR group, there were 35 complications: 13 migrations of SEMS, 8 re-obstructions, 8 perforations, 2 failures of expansion of SEMS, and 4 patients with severe rectal symptoms. In the ER group, there were 21 complications: 4 migrations, 6 re-obstructions, 5 perforations, 2 long-term clinical failures, 1 pneumoperitoneum without objectified perforation, 2 failures of expansion, and 1 patient with severe rectal symptoms. Seventeen patients underwent a second SEMS placement attempt after an initial clinical or technical failure (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Requirement of emergency surgery in the “bridge to surgery” group and requirement of surgery in the “palliative” groupOf the 158 patients with CRC, 85 SEMS were inserted as a “bridge to surgery” and 65 SEMS were placed in patients with non-resectable tumors (“palliative” group). In the “bridge to surgery” group, 37 (43.5%) SEMS were inserted by the XR technique and 48 (56.5%) by ER method. The indication for SEMS placement, “bridge to surgery” or “palliation” was determined by the most responsible physician based on the stage of the tumor, the age and the comorbidity of the patient. Eight patients were submitted from other centers and the indication for SEMS placement was not recorded (see <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1)“Bridge to surgery” Group. The TS and short-term CS rates were 96.5% (82/85) and 86.6% (71/82), respectively. Three patients were reevaluated and additional SEMS were implanted (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Emergency surgery was carried out in 15 (17.6%) patients and elective surgery in 68 patients (80%). Two patients did not undergo surgery. A resection with primary anastomosis could be done in 58 of the elective surgeries (85.3%) and in only 5 of emergency surgeries (33.3%), p<0.001. Thus, a stoma was not needed in 63 patients (76%). After excluding emergency surgeries, the mean time to surgery was 32.1 days (95%CI: 15.7–48.4) (<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010">2)Palliative SEMS Group. The TS and short-term CS rates were 95.4% (62/65) and 80.6% (50/62), respectively in this group. Eleven patients had endoscopic or radiological re-intervention and additional SEMS were implanted (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Twenty (30%) patients required surgery due to technical or clinical failure or SEMS complications (<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>).</li></ul><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Survival and predictors of survivalThe median follow-up of patients with obstructive CRC (after SEMS placement) was 14.6 months (range: 0.10–141.8). The median survival of patients with obstructive CRC, with a SEMS implanted, was 18.6 months (95%CI: 13.3–23.9); whereas, the median survival of patients with a SEMS implanted for palliative care was 3.1 months (95%CI: 0.3–6.0).Prognostic factors that independently impacted on survival in patients with obstructive CRC and a SEMS implanted, by univariate analysis were: Charlson index>4 [HR: 2.51 (95%CI: 1.71–3.70)], age>73 years [HR: 2.10 (95%CI: 1.44–3.09)], tumor stage IV [HR: 3.27 (95%CI: 2.16–4.95)], no CS [HR: 2.46 (95%CI: 1.52–4.00)], presence of complications [HR: 1.93 (95%CI: 1.22–3.06)] and a prolonged time to surgery after SEMS placement [HR: 1.006 (95%CI: 1.002–1.010)]. However, neither insertion technique [HR: 1.15 (95%CI: 0.79–1.67)] nor TS [HR: 1.32 (95%CI: 0.48–3.58)] was related to survival.Multivariate analysis of the significant variables determined by univariate analysis identified tumor stage IV [HR: 4.78 (95%CI: 2.84–8.04)], Charlson index>4 [HR: 1.97 (95%CI: 1.06–3.63)] and presence of SEMS complications [HR: 1.75 (95%CI: 1.06–2.90)] as factors related with survival in our cohort of patients.DiscussionEndoluminal decompression by stent insertion may be an alternative to emergency surgery in colorectal obstruction. In patients with obstructive CRC, SEMS can be used as a “bridge to surgery” if CRC is potentially resectable, or as palliative treatment in patients with disseminated disease or unacceptable surgical risk. In our series, the TS and CS rates of SEMS were 95.4% and 79%, respectively, similar to those reported in a recent meta-analysis of randomized controlled trials (mean success rate 76.9%)<a class="elsevierStyleCrossRef" href="#bib0185">10</a> and lower than those reported in a recent systematic review of 88 studies (96.2% and 92%, respectively).<a class="elsevierStyleCrossRef" href="#bib0205">14</a> Major complications of our series were migrations (8.6%), re-obstruction (7.1%), and perforation (6.6%). Our migration rate is lower than the median rate reported by Watt et al. in their systematic review including 54 studies (11%)<a class="elsevierStyleCrossRef" href="#bib0205">14</a> and also lower than reported by Khot et al. in technically successful cases (10%).<a class="elsevierStyleCrossRef" href="#bib0235">20</a> However, our rate of perforations is slightly higher than data reported from previous studies. Datye et al., in their article that included a total of 2287 patients, found an overall perforation rate of 4.9%<a class="elsevierStyleCrossRef" href="#bib0240">21</a> and Watt et al. showed a median rate of 4.5%.<a class="elsevierStyleCrossRef" href="#bib0205">14</a> This difference could be explained by our study including, not only perforations produced by the stent itself, but also perforations secondary to distension that occurred in patients with clinical failure after the procedure. Finally, our re-obstruction rate is lower than the mean rate reported in the review by Khot et al. (10%).<a class="elsevierStyleCrossRef" href="#bib0235">20</a>The SEMS can be placed using ER or XR. However, very few studies have analyzed if there are differences in the efficacies of these methods. In a recent retrospective study comparing both procedures, ER was more successful than XR method (90.3% vs 74.8%, p<0.001).<a class="elsevierStyleCrossRef" href="#bib0245">22</a> In another retrospective study, Kim et al. showed that while the TS rate was significantly higher with the ER than XR (100% vs 92.1%, p=0.038), the CS rates were similar with the two insertion techniques (91.8% vs 97.1%, p>0.05).<a class="elsevierStyleCrossRef" href="#bib0250">23</a> In our study, the TS and CS rates were similar in both groups (p>0.05). However, the complications rate was significantly higher when using XR placement compared with ER (38% vs 20.2%; p=0.006). We found a significantly higher number of migrations. It could be speculated that an indirect visualization during the SEMS release could result in a misplacement of the device, even in expert hands.<a class="elsevierStyleCrossRefs" href="#bib0155">4,13</a> These data and those previously published suggest that the ER method is the preferred technique. One of the limitations of our study is that we compared both procedures but in different time frames. It could condition certain biases mainly due to the evolution in the treatments directed to CRC in these years.There is significant controversy regarding the best surgical treatment and the role of SEMS in obstructive CRC. Urgent surgery in these patients is associated with high morbidity and mortality rates (30–60% and of 7–22%, respectively), both significantly higher than those observed in elective surgery.<a class="elsevierStyleCrossRef" href="#bib0145">2</a> If the goal of “bridge to surgery” stenting is to decrease the stoma rate, our study suggests that SEMS placement is an acceptable option. In fact, in 76% of patients, a single-stage surgery intervention was achieved in the “bridge to surgery” group and Hartmann's procedure was done in only 14.5% of patients. Our data are consistent with previous data that showed success rates for one-stage elective operation of 60–85% when SEMS were used as a bridge to surgery.<a class="elsevierStyleCrossRefs" href="#bib0255">24–27</a> There is also interest regarding the role of SEMS for palliative care. In such cases, the duration of palliation is critical. In our series, among patients in which SEMS were placed for palliation, only 70% maintained relief of obstruction until death or the end of the follow-up period. These results suggest that SEMS could be useful in this setting; although, all available options should be carefully discussed with the patient. The implantation of SEMS for palliative purposes can improve quality of life of patients with relative low rates of early complications. But, because the long-term outcomes of SEMS insertion continue to be a matter of controversy, surgical treatment can be taken into account in patients with a long life expectancy or suitables for chemotherapy. More studies regarding the quality of life after definitive SEMS placement and the cost-effectiveness of this strategy should be carried out before a definitive conclusion can be made.Finally, very few studies have assessed which factors may influence the survival of patients treated with a SEMS. We performed a survival analysis and the OS time was determinated from the date of the diagnosis to the date of death of patient from any cause or last contact. In our study, multivariate analysis identified three prognostic factors that independently impacted on survival in our cohort of patients: tumor stage IV, Charlson index>4 and presence of complications. Older age, comorbidity, and advanced tumor stage are well known co-related factors, since older patients frequently present more comorbidities and age is the most significant risk factor for colorectal carcinogenesis. A larger sample size would be necessary to confirm if other variables such as the time to surgery or clinical failure are risk or confounding factors.To our knowledge, the present study represents one of the largest cohorts of patients with colorectal obstruction and SEMS placement. We demonstrated that SEMS implantation is a feasible alternative to colostomy in acute colorectal occlusion. However, it has pros and cons and is far from being the perfect alternative. The rate of patients requiring surgery after a definitive (at least in theory) palliative SEMS placement is too high (30%) from our perspective. Although, SEMS placement can decrease the number of patients needing a stoma when used as a “bridge to surgery”. Survival of patients after SEMS placement depends on tumor stage, comorbidity and stent complications. In addition, our results suggest that SEMS placement by ER may be safer than the XR method and may be the method of choice, although this needs to be confirmed in other larger studies.Author's contributionsAll authors meet the three required conditions: a. Substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; b. Drafting the article or revising it critically for important intellectual content; c. Final approval of the version to be published.Financial supportThe present investigation has not received any specific grant from agencies of the public, commercial, or non-profit sectors.Conflict of interestThe authors have no conflict of interest regarding this paper." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1164410" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1089783" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1164411" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1089784" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Procedures" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Definitions" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analyses" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Patients demographics" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Technical and clinical outcomes and comparison of insertion techniques" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Requirement of emergency surgery in the “bridge to surgery” group and requirement of surgery in the “palliative” group" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Survival and predictors of survival" ] ] ] 7 => array:2 [ "identificador" => "sec0060" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Author's contributions" ] 9 => array:2 [ "identificador" => "sec0070" "titulo" => "Financial support" ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack397749" "titulo" => "Acknowledgments" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-06" "fechaAceptado" => "2018-07-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1089783" "palabras" => array:5 [ 0 => "Bridge to surgery" 1 => "Colorectal cancer" 2 => "Colorectal obstruction" 3 => "Palliation" 4 => "Self-expandable metal stent" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1089784" "palabras" => array:5 [ 0 => "Puente a la cirugía" 1 => "Cancer colorrectal" 2 => "Obstrucción colorrectal" 3 => "Paliación" 4 => "Prótesis metálica autoexpandible" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Objectives(1) To evaluate the short- and long-term clinical outcomes of patients after colorectal stent placement and (2) to assess the safety and efficacy of the stents for the resolution of colorectal obstruction according to the insertion technique. MethodsRetrospective cohort study which included 177 patients with colonic obstruction who underwent insertion of a stent. ResultsA total of 196 stents were implanted in 177 patients. Overall, the most common cause of obstruction was colorectal cancer (89.3%). Ninety-two stents (47%) were placed by radiologic technique and 104 (53%) by endoscopy under fluoroscopic guidance. Technical success rates were 95% in both groups. Clinical success rates were 77% in the radiological group and 81% in the endoscopic group (p>0.05). The rate of complications was higher in the radiologic group compared with the endoscopic group (38% vs 20%, respectively; p=0.006). Among patients with colorectal cancer (158), 65 stents were placed for palliation but 30% eventually required surgery. The multivariate analysis identified three factors associated with poorer long-term survival: tumor stage IV, comorbidity and onset of complications. ConclusionsStents may be an alternative to emergency surgery in colorectal obstruction, but the clinical outcome depends on the tumor stage, comorbidity and stent complications. The rate of definitive palliative stent placement was high; although surgery was eventually required in 30%. Our study suggests that the endoscopic method of stent placement is safer than the radiologic method." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "Objetivos1) Evaluar los resultados clínicos a corto y largo plazo de los pacientes después de la colocación de una prótesis a nivel colorrectal y 2) Evaluar la eficacia y la seguridad de las prótesis en la resolución de la obstrucción en función de la técnica de inserción. MétodosEstudio de cohortes retrospectivo que incluyó 177 pacientes con obstrucción cólica que fueron tratados incialmente con colocación de prótesis. ResultadosSe colocaron 196 prótesis en 177 pacientes. La causa más frecuente de obstrucción fue el cáncer colorrectal (89,3%). Noventa y dos prótesis (47%) se colocaron mediante técnica radiológica y 104 (53%) mediante endoscopia bajo guía fluoroscópica. Las tasas de éxito técnico fueron del 95% en ambos grupos. Las tasas de éxito clínico fueron del 77% en el grupo radiológico y del 81% en el grupo endoscópico (p>0,05). La tasa de complicaciones fue mayor en el grupo radiológico en comparación con el grupo endoscópico (38 vs. 20%, respectivamente; p=0,006). Entre los pacientes con cáncer colorrectal (158), 65 prótesis se colocaron con un fin paliativo, pero el 30% requirió finalmente cirugía. El análisis multivariante identificó 3 factores asociados a una peor supervivencia: estadio tumoral IV, comorbilidad y aparición de complicaciones. ConclusionesLas prótesis pueden ser una alternativa a la cirugía urgente en la obstrucción colorrectal, pero el resultado clínico depende del estadio tumoral, de la comorbilidad y de las complicaciones de la prótesis. La tasa de colocación de prótesis paliativa definitiva fue alta; aunque en un 30% se requirió cirugía, finalmente. Nuestro estudio sugiere que el método de implantación con visión endoscópica es más seguro que el método radiológico." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 982 "Ancho" => 2333 "Tamanyo" => 185018 ] ] "descripcion" => array:1 [ "en" => "Flowchart of patients with obstructive CRC and SEMS placement." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient demographics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">177 patients n (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">102 (57.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Age (years)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean±standard deviation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71.7±12.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73.4 (63.8–79.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Charlson Comorbidity Score (age adjusted)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean±standard deviation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.5±2.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.0 (3.0–5.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Etiology of obstruction</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">158 (89.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diverticulitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (4.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical anastomosis stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (2.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extrinsic compression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (1.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Location of obstruction</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rectum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (14.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sigmoid colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100 (56.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Descending colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (12.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Splenic flexure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17 (9.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transverse colon \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatic flexure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ascending colon or cecum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgery anastomosis without location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Not defined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1987550.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographics of patients with SEMS implantation." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CRC: colorectal cancer." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient demographics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Obstructive CRC (n=158) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (male) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92 (58.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Age (years)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean±standard deviation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">71.9±11.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73.8 (64.2–80.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Charlson Comorbidity Score (age adjusted)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean±standard deviation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.4±1.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Median (interquartile range) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.0 (3.0–6.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Tumor stages (TNM)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (13.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (2.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (1.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIIA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (0.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIIB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 (16.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IIIC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8 (5.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 (46.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TxNxM0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 (3.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (10.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1987549.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographics of patients with obstructive CRC." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Pat: patient; Insert tech: insertion technique; SEMS: self expandable metal stent; CRC: colorectal cancer; CS: clinical success; TS: technical success; RX: radiologic; ER: endoscopic under fluoroscopic guidance." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Insert tech. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology of obstruction \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aim of SEMS (occlusion by CRC) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes of failure of first stent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes of failure of second stent \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Is emergent surgery necessary? \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Failure expansion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No CS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bridge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Failure expansion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diverticulitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anastomotic stricture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">RX \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No CS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No CS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Palliative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bridge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No CS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bridge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No TS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ER \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anastomotic stricture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1987547.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Use of a second SEMS." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SEMS: self expandable metal stent." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes of surgery \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">“Bridge to surgery” group (emergency surgery) n=15 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Palliative SEMS group (surgery) n=20 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Technical failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical failure with unknown etiology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No long term clinical success \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perforation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Re-obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Migration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obstruction in other location \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1987548.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Causes of non-elective surgery after SEMS placement." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of surgery</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">“Bridge to surgery” group</th><th class="td" title="table-head " align="left" valign="top" scope="col">Palliative group \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Emergency surgery (n=15) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Elective surgery (n=68) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery (n=20) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palliative stoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (35%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palliative stoma with second resection surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (13.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resection with primary anastomosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (33.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 (85.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (20%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hartmann's procedure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (46.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (7.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (30%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resection (it is unknown if primary anastomosis takes place) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (10%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perforation suture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exploratory laparotomy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (5.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1987546.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Type of surgery." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib0140" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current management of acute malignant large bowel obstruction: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Frago" 1 => "E. Ramirez" 2 => "M. Millan" 3 => "E. Kreisler" 4 => "E. del Valle" 5 => "S. Biondo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjsurg.2013.07.027" "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "2014" "volumen" => "207" "paginaInicial" => "127" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24124659" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0145" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Oncologic outcomes of self-expanding metallic stent insertion as a bridge to surgery in the management of left-sided colon cancer obstruction: comparison with nonobstructing elective surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.S. Kim" 1 => "H. Hur" 2 => "B.S. Min" 3 => "S.K. Sohn" 4 => "C.H. Cho" 5 => "N.K. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00268-009-0007-5" "Revista" => array:6 [ "tituloSerie" => "World J Surg" "fecha" => "2009" "volumen" => "33" "paginaInicial" => "1281" "paginaFinal" => "1286" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19363580" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0150" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "New method: endoscopic implantation of rectal stent in palliative treatment of malignant stenosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24443824/0000004200000003/v1_201903150620/S2444382419300586/v1_201903150620/en/main.assets" "Apartado" => array:4 [ "identificador" => "48441" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004200000003/v1_201903150620/S2444382419300586/v1_201903150620/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382419300586?idApp=UINPBA00004N"]

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Original article

Short- and long-term clinical outcomes of self-expandable metal stents inserted for colorectal obstruction and efficacy of different insertion techniques

Resultados a corto y largo plazo de la colocación de prótesis metálicas autoexpandibles en la obstrucción colorrectal y eficacia de las diferentes técnicas de inserción

Carla J. Gargalloa,b,

Corresponding author

carlajerusalen@hotmail.com

Corresponding author.

, Angel Ferrandeza,b, Patricia Carrerac, Miguel Angel Simona,d, Julio Duconsa, Angel Lanasa,b,c,d

a Department of Gastroenterology, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain

b Instituto de Investigación Sanitaria Aragón (ISS Aragón), Zaragoza, Spain

c CIBER Enfermedades Hepáticas y digestivas (CIBERehd), Spain

d Universidad de Zaragoza, Zaragoza, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Colorectal obstruction is an abdominal emergency associated with high mortality and morbidity rates&#46; Large bowel obstructions results from intrinsic or extrinsic factors&#44; with colorectal cancer &#40;CRC&#41; by far the most common cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;2</span></a> It is unclear whether stent or surgery is the most appropriate modality for managing colorectal obstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3&#44;4</span></a> Several uncontrolled studies have suggested that the placement of self-expandable metal stent &#40;SEMS&#41; in malignant large bowel obstruction could improve patients&#8217; clinical conditions before elective surgery&#44; leading to a decrease in mortality&#44; morbidity&#44; and the number of colostomies&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">1&#44;5&#8211;7</span></a> It may also allow accurate tumor staging and serve as permanent palliation&#44; allowing patients with not resectable disease and short life expectancy or unacceptable surgical risk to avoid surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">8&#8211;10</span></a> The role of SEMS for benign colonic lesions or extracolonic causes is not clear&#44; as the majority of studies are case reports or case series&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">11&#44;12</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The technical success &#40;TS&#41; and clinical success &#40;CS&#41; rates of SEMS vary widely between studies&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> A recent meta-analysis reported a high mean success rate of 76&#46;9&#37; &#40;46&#46;7&#8211;100&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> However&#44; there are also potential disadvantages as major complications or uncertainty regarding long-term outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;15&#8211;18</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Finally&#44; there are essentially two different SEMS insertion techniques&#58; radiologic &#40;XR&#41; and endoscopic under fluoroscopic guidance &#40;ER&#41;&#46; In both cases&#44; SEMS are placed under fluoroscopic guidance&#44; but endoscopic assistance is only used in the ER technique&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> However&#44; very few studies have analyzed differences in the efficacy of these methods&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">To address these issues&#44; we aimed to asses&#58; &#40;1&#41; the short and long term clinical outcomes&#44; including survival&#44; of patients after SEMS placement and factors that could impact such outcomes and &#40;2&#41; the safety and efficacy of the stents to resolve the obstruction according to the insertion technique used &#91;XR or ER&#93;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">The Endoscopy Unit at University Clinical Hospital&#44; Zaragoza&#44; has used SEMS as a therapeutic option for patients with acute colonic occlusion &#40;especially malignant obstruction&#41; since January 2008&#46; The Interventional Radiology Unit has also performed this procedure in this hospital since 1991&#46; In our study&#44; we included all patients with a SEMS implantation via XR between January 2002 and January 2010 that were registered in the Hospital database and all patients with a SEMS implantation via ER between January 2008 and January 2013&#46; The characteristics of the SEMS of XR group were obtained from the medical histories and the characteristics of SEMS of ER group were collected from a proprietary database&#46; Medical records of all patients were reviewed retrospectively&#46; The study was terminated on September 2013 or upon the death of the patient&#44; whichever occurred first&#46; The vital status was confirmed by the medical records or via telephone contact when needed&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Procedures</span><p id="par0030" class="elsevierStylePara elsevierViewall">All patients provided informed consent before the placement of SEMS&#46; All patients underwent at least an abdominal computed tomography scan prior to insertion of the stent to diagnose the cause of the obstruction and to perform tumor staging in patients with malignant obstruction&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In the ER group</span>&#46; Expert endoscopists performed SEMS placement with the same through-the-scope technique&#46; A therapeutic endoscope was advanced until tumoral stricture was found&#46; Wallflex<span class="elsevierStyleSup">TM</span> Colonic Stents &#40;Boston Scientific&#41;&#44; 6&#44; 9 or 12<span class="elsevierStyleHsp" style=""></span>cm in length and 2&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter&#44; were used in most patients&#46; Hanarostents<span class="elsevierStyleSup">TM</span> Esophagus stents &#40;M&#46;I&#46; Tech&#46;&#41; were used in two patients&#46; Image intensification was used during the endoscopic placement&#46; Biopsies were taken from the lesion when possible&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">In the XR group</span>&#46; An expert interventional radiologist<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;13</span></a> worked with two types of stents&#58; the Wallstent<span class="elsevierStyleSup">TM</span> &#40;Boston Scientific&#41;&#44; 5&#8211;9<span class="elsevierStyleHsp" style=""></span>cm in length and 1&#46;6&#8211;2&#46;5<span class="elsevierStyleHsp" style=""></span>cm in diameter and SX-ELLA intestinal stent &#40;Ella&#41;&#44; 8&#46;2&#8211;11&#46;2<span class="elsevierStyleHsp" style=""></span>cm in length and 2&#46;2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm in diameter&#46; The most appropriate size was chosen after visualization with fluoroscopy of the stenosis&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Definitions</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Technical success</span> &#40;TS&#41; was defined as a successful SEMS insertion with correct deployment and precise positioning of the SEMS at the location of the stenosis&#46; The expert endoscopist or radiologist determined the TS of stent placement after radiological confirmation&#46; <span class="elsevierStyleItalic">Clinical success</span> &#40;CS&#41; was defined as successful colonic decompression with disappearance of obstructive symptoms within 72<span class="elsevierStyleHsp" style=""></span>h of stent placement&#46; <span class="elsevierStyleItalic">Complications</span> were defined as any adverse event related to SEMS placement&#44; leading to new symptoms&#44; re-intervention&#44; patient hospital readmission or death&#46; Migration&#44; re-obstruction&#44; perforation&#44; failure to expansion&#44; long-term clinical failure&#44; bleeding and fecal incontenence were considered complications&#46; Long-term clinical failure was considered when the patient had recurrence of colorectal obstructive symptoms&#44; but it was not possible to determine which was the specific cause &#40;reobstruction&#44; migration&#44; tumor growth&#44; etc&#46;&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analyses</span><p id="par0050" class="elsevierStylePara elsevierViewall">An initial exploratory analysis of all clinical variables was carried out&#46; Continuous variables were expressed as the mean and standard deviation or median and interquartile range &#40;IQR&#41;&#59; whereas&#44; qualitative variables were expressed as frequencies and percentages&#46; The relationship between qualitative variables was evaluated with the Chi-square &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#41; test&#46; Student&#39;s <span class="elsevierStyleItalic">t</span>-test or Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test were employed for comparing means of two independent groups&#46; Normality was tested using Kolmogorov&#8211;Smirnov test&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Overall survival &#40;OS&#41; time was calculated from the date of the diagnosis to the date of last contact or death from any cause&#46; In addition&#44; the comorbidities of patients at hospital admission were evaluated using a previously validated adaptation of the Charlson Comorbidity Index&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a> Survival among different factors was calculated using the Kaplan&#8211;Meier method and compared using the Log rank test&#46; Variables shown by univariate analysis to be significantly associated with survival were entered into a Cox proportional hazards regression model for multivariate analysis&#46; For all tests&#44; a two-sided <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05 was considered statistically significant&#46; SPSS software v22&#46;0 for Windows was used for performing statistical analyses&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients demographics</span><p id="par0060" class="elsevierStylePara elsevierViewall">A total of 196 SEMS were placed in 177 patients&#46; Baseline data for these patients are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Males comprised 57&#46;6&#37; of the cohort&#44; the median age was 73&#46;5 &#40;IQR&#58; 63&#46;8&#8211;79&#46;3&#41; years and the median age-adjusted Charlson comorbidity score was 4&#46;0 &#40;IQR&#58; 3&#46;0&#8211;5&#46;0&#41;&#46; Obstruction was distal to splenic flexure in 83&#37; of patients&#46; One patient presented obstruction in two different locations due to synchronous CRC&#46; The most common cause of obstruction was primary CRC &#40;89&#46;3&#37;&#41;&#46; In patients with CRC&#44; tumor stage was known in 142 patients and was stage IV in 51&#46;4&#37; &#40;73&#47;142&#41;&#46; In patients with synchronous CRC&#44; the most advanced CRC stage was chosen&#46; The demographics of patients with CRC included in our study are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Technical and clinical outcomes and comparison of insertion techniques</span><p id="par0065" class="elsevierStylePara elsevierViewall">Ninety-two &#40;46&#46;9&#37;&#41; SEMS were placed by the XR technique and 104 &#40;53&#46;1&#37;&#41; by the ER method&#46; The <span class="elsevierStyleItalic">TS rates</span> were 95&#46;7&#37; &#40;88&#47;92&#41; for SEMS placed by XR and 95&#46;2&#37; &#40;99&#47;104&#41; for those placed by ER &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;87&#41;&#46; The <span class="elsevierStyleItalic">CS rates</span> were 77&#46;3&#37; &#40;68&#47;88&#41; and 80&#46;8&#37; &#40;80&#47;99&#41; for the XR and ER groups&#44; respectively &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;27&#41;&#46; The CS was unknown in 5 patients who were lost to follow-up and attended different hospitals&#46; The rate of <span class="elsevierStyleItalic">complications</span> was higher with XR placement than ER &#40;38&#46;0&#37; vs 20&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46; In the XR group&#44; there were 35 complications&#58; 13 migrations of SEMS&#44; 8 re-obstructions&#44; 8 perforations&#44; 2 failures of expansion of SEMS&#44; and 4 patients with severe rectal symptoms&#46; In the ER group&#44; there were 21 complications&#58; 4 migrations&#44; 6 re-obstructions&#44; 5 perforations&#44; 2 long-term clinical failures&#44; 1 pneumoperitoneum without objectified perforation&#44; 2 failures of expansion&#44; and 1 patient with severe rectal symptoms&#46; Seventeen patients underwent a second SEMS placement attempt after an initial clinical or technical failure &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Requirement of emergency surgery in the &#8220;bridge to surgery&#8221; group and requirement of surgery in the &#8220;palliative&#8221; group</span><p id="par0070" class="elsevierStylePara elsevierViewall">Of the 158 patients with CRC&#44; 85 SEMS were inserted as a &#8220;bridge to surgery&#8221; and 65 SEMS were placed in patients with non-resectable tumors &#40;&#8220;palliative&#8221; group&#41;&#46; In the &#8220;bridge to surgery&#8221; group&#44; 37 &#40;43&#46;5&#37;&#41; SEMS were inserted by the XR technique and 48 &#40;56&#46;5&#37;&#41; by ER method&#46; The indication for SEMS placement&#44; &#8220;bridge to surgery&#8221; or &#8220;palliation&#8221; was determined by the most responsible physician based on the stage of the tumor&#44; the age and the comorbidity of the patient&#46; Eight patients were submitted from other centers and the indication for SEMS placement was not recorded &#40;see <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#41;</span><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleUnderline">&#8220;</span><span class="elsevierStyleBold"><span class="elsevierStyleUnderline">Bridge to surgery&#8221; Group&#46;</span></span> The TS and short-term CS rates were 96&#46;5&#37; &#40;82&#47;85&#41; and 86&#46;6&#37; &#40;71&#47;82&#41;&#44; respectively&#46; Three patients were reevaluated and additional SEMS were implanted &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Emergency surgery was carried out in 15 &#40;17&#46;6&#37;&#41; patients and elective surgery in 68 patients &#40;80&#37;&#41;&#46; Two patients did not undergo surgery&#46; A resection with primary anastomosis could be done in 58 of the elective surgeries &#40;85&#46;3&#37;&#41; and in only 5 of emergency surgeries &#40;33&#46;3&#37;&#41;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#46; Thus&#44; a stoma was not needed in 63 patients &#40;76&#37;&#41;&#46; After excluding emergency surgeries&#44; the mean time to surgery was 32&#46;1 days &#40;95&#37;CI&#58; 15&#46;7&#8211;48&#46;4&#41; &#40;<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold"><span class="elsevierStyleUnderline">Palliative SEMS Group&#46;</span></span> The TS and short-term CS rates were 95&#46;4&#37; &#40;62&#47;65&#41; and 80&#46;6&#37; &#40;50&#47;62&#41;&#44; respectively in this group&#46; Eleven patients had endoscopic or radiological re-intervention and additional SEMS were implanted &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Twenty &#40;30&#37;&#41; patients required surgery due to technical or clinical failure or SEMS complications &#40;<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Survival and predictors of survival</span><p id="par0085" class="elsevierStylePara elsevierViewall">The median follow-up of patients with obstructive CRC &#40;after SEMS placement&#41; was 14&#46;6 months &#40;range&#58; 0&#46;10&#8211;141&#46;8&#41;&#46; The median survival of patients with obstructive CRC&#44; with a SEMS implanted&#44; was 18&#46;6 months &#40;95&#37;CI&#58; 13&#46;3&#8211;23&#46;9&#41;&#59; whereas&#44; the median survival of patients with a SEMS implanted for palliative care was 3&#46;1 months &#40;95&#37;CI&#58; 0&#46;3&#8211;6&#46;0&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Prognostic factors that independently impacted on survival in patients with obstructive CRC and a SEMS implanted&#44; by univariate analysis were&#58; Charlson index<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4 &#91;HR&#58; 2&#46;51 &#40;95&#37;CI&#58; 1&#46;71&#8211;3&#46;70&#41;&#93;&#44; age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>73 years &#91;HR&#58; 2&#46;10 &#40;95&#37;CI&#58; 1&#46;44&#8211;3&#46;09&#41;&#93;&#44; tumor stage IV &#91;HR&#58; 3&#46;27 &#40;95&#37;CI&#58; 2&#46;16&#8211;4&#46;95&#41;&#93;&#44; no CS &#91;HR&#58; 2&#46;46 &#40;95&#37;CI&#58; 1&#46;52&#8211;4&#46;00&#41;&#93;&#44; presence of complications &#91;HR&#58; 1&#46;93 &#40;95&#37;CI&#58; 1&#46;22&#8211;3&#46;06&#41;&#93; and a prolonged time to surgery after SEMS placement &#91;HR&#58; 1&#46;006 &#40;95&#37;CI&#58; 1&#46;002&#8211;1&#46;010&#41;&#93;&#46; However&#44; neither insertion technique &#91;HR&#58; 1&#46;15 &#40;95&#37;CI&#58; 0&#46;79&#8211;1&#46;67&#41;&#93; nor TS &#91;HR&#58; 1&#46;32 &#40;95&#37;CI&#58; 0&#46;48&#8211;3&#46;58&#41;&#93; was related to survival&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Multivariate analysis of the significant variables determined by univariate analysis identified tumor stage IV &#91;HR&#58; 4&#46;78 &#40;95&#37;CI&#58; 2&#46;84&#8211;8&#46;04&#41;&#93;&#44; Charlson index<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4 &#91;HR&#58; 1&#46;97 &#40;95&#37;CI&#58; 1&#46;06&#8211;3&#46;63&#41;&#93; and presence of SEMS complications &#91;HR&#58; 1&#46;75 &#40;95&#37;CI&#58; 1&#46;06&#8211;2&#46;90&#41;&#93; as factors related with survival in our cohort of patients&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">Endoluminal decompression by stent insertion may be an alternative to emergency surgery in colorectal obstruction&#46; In patients with obstructive CRC&#44; SEMS can be used as a &#8220;bridge to surgery&#8221; if CRC is potentially resectable&#44; or as palliative treatment in patients with disseminated disease or unacceptable surgical risk&#46; In our series&#44; the TS and CS rates of SEMS were 95&#46;4&#37; and 79&#37;&#44; respectively&#44; similar to those reported in a recent meta-analysis of randomized controlled trials &#40;mean success rate 76&#46;9&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">10</span></a> and lower than those reported in a recent systematic review of 88 studies &#40;96&#46;2&#37; and 92&#37;&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> Major complications of our series were migrations &#40;8&#46;6&#37;&#41;&#44; re-obstruction &#40;7&#46;1&#37;&#41;&#44; and perforation &#40;6&#46;6&#37;&#41;&#46; Our migration rate is lower than the median rate reported by Watt et al&#46; in their systematic review including 54 studies &#40;11&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> and also lower than reported by Khot et al&#46; in technically successful cases &#40;10&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> However&#44; our rate of perforations is slightly higher than data reported from previous studies&#46; Datye et al&#46;&#44; in their article that included a total of 2287 patients&#44; found an overall perforation rate of 4&#46;9&#37;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> and Watt et al&#46; showed a median rate of 4&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> This difference could be explained by our study including&#44; not only perforations produced by the stent itself&#44; but also perforations secondary to distension that occurred in patients with clinical failure after the procedure&#46; Finally&#44; our re-obstruction rate is lower than the mean rate reported in the review by Khot et al&#46; &#40;10&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The SEMS can be placed using ER or XR&#46; However&#44; very few studies have analyzed if there are differences in the efficacies of these methods&#46; In a recent retrospective study comparing both procedures&#44; ER was more successful than XR method &#40;90&#46;3&#37; vs 74&#46;8&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> In another retrospective study&#44; Kim et al&#46; showed that while the TS rate was significantly higher with the ER than XR &#40;100&#37; vs 92&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;038&#41;&#44; the CS rates were similar with the two insertion techniques &#40;91&#46;8&#37; vs 97&#46;1&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> In our study&#44; the TS and CS rates were similar in both groups &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; However&#44; the complications rate was significantly higher when using XR placement compared with ER &#40;38&#37; vs 20&#46;2&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46; We found a significantly higher number of migrations&#46; It could be speculated that an indirect visualization during the SEMS release could result in a misplacement of the device&#44; even in expert hands&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;13</span></a> These data and those previously published suggest that the ER method is the preferred technique&#46; One of the limitations of our study is that we compared both procedures but in different time frames&#46; It could condition certain biases mainly due to the evolution in the treatments directed to CRC in these years&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">There is significant controversy regarding the best surgical treatment and the role of SEMS in obstructive CRC&#46; Urgent surgery in these patients is associated with high morbidity and mortality rates &#40;30&#8211;60&#37; and of 7&#8211;22&#37;&#44; respectively&#41;&#44; both significantly higher than those observed in elective surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> If the goal of &#8220;bridge to surgery&#8221; stenting is to decrease the stoma rate&#44; our study suggests that SEMS placement is an acceptable option&#46; In fact&#44; in 76&#37; of patients&#44; a single-stage surgery intervention was achieved in the &#8220;bridge to surgery&#8221; group and Hartmann&#39;s procedure was done in only 14&#46;5&#37; of patients&#46; Our data are consistent with previous data that showed success rates for one-stage elective operation of 60&#8211;85&#37; when SEMS were used as a bridge to surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">24&#8211;27</span></a> There is also interest regarding the role of SEMS for palliative care&#46; In such cases&#44; the duration of palliation is critical&#46; In our series&#44; among patients in which SEMS were placed for palliation&#44; only 70&#37; maintained relief of obstruction until death or the end of the follow-up period&#46; These results suggest that SEMS could be useful in this setting&#59; although&#44; all available options should be carefully discussed with the patient&#46; The implantation of SEMS for palliative purposes can improve quality of life of patients with relative low rates of early complications&#46; But&#44; because the long-term outcomes of SEMS insertion continue to be a matter of controversy&#44; surgical treatment can be taken into account in patients with a long life expectancy or suitables for chemotherapy&#46; More studies regarding the quality of life after definitive SEMS placement and the cost-effectiveness of this strategy should be carried out before a definitive conclusion can be made&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; very few studies have assessed which factors may influence the survival of patients treated with a SEMS&#46; We performed a survival analysis and the OS time was determinated from the date of the diagnosis to the date of death of patient from any cause or last contact&#46; In our study&#44; multivariate analysis identified three prognostic factors that independently impacted on survival in our cohort of patients&#58; tumor stage IV&#44; Charlson index<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>4 and presence of complications&#46; Older age&#44; comorbidity&#44; and advanced tumor stage are well known co-related factors&#44; since older patients frequently present more comorbidities and age is the most significant risk factor for colorectal carcinogenesis&#46; A larger sample size would be necessary to confirm if other variables such as the time to surgery or clinical failure are risk or confounding factors&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">To our knowledge&#44; the present study represents one of the largest cohorts of patients with colorectal obstruction and SEMS placement&#46; We demonstrated that SEMS implantation is a feasible alternative to colostomy in acute colorectal occlusion&#46; However&#44; it has pros and cons and is far from being the perfect alternative&#46; The rate of patients requiring surgery after a definitive &#40;at least in theory&#41; palliative SEMS placement is too high &#40;30&#37;&#41; from our perspective&#46; Although&#44; SEMS placement can decrease the number of patients needing a stoma when used as a &#8220;bridge to surgery&#8221;&#46; Survival of patients after SEMS placement depends on tumor stage&#44; comorbidity and stent complications&#46; In addition&#44; our results suggest that SEMS placement by ER may be safer than the XR method and may be the method of choice&#44; although this needs to be confirmed in other larger studies&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Author&#39;s contributions</span><p id="par0125" class="elsevierStylePara elsevierViewall">All authors meet the three required conditions&#58; a&#46; Substantial contributions to conception and design&#44; or acquisition of data&#44; or analysis and interpretation of data&#59; b&#46; Drafting the article or revising it critically for important intellectual content&#59; c&#46; Final approval of the version to be published&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Financial support</span><p id="par0130" class="elsevierStylePara elsevierViewall">The present investigation has not received any specific grant from agencies of the public&#44; commercial&#44; or non-profit sectors&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest regarding this paper&#46;</p></span></span>"
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            1 => "Colorectal cancer"
            2 => "Colorectal obstruction"
            3 => "Palliation"
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            1 => "Cancer colorrectal"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;1&#41; To evaluate the short- and long-term clinical outcomes of patients after colorectal stent placement and &#40;2&#41; to assess the safety and efficacy of the stents for the resolution of colorectal obstruction according to the insertion technique&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Retrospective cohort study which included 177 patients with colonic obstruction who underwent insertion of a stent&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 196 stents were implanted in 177 patients&#46; Overall&#44; the most common cause of obstruction was colorectal cancer &#40;89&#46;3&#37;&#41;&#46; Ninety-two stents &#40;47&#37;&#41; were placed by radiologic technique and 104 &#40;53&#37;&#41; by endoscopy under fluoroscopic guidance&#46; Technical success rates were 95&#37; in both groups&#46; Clinical success rates were 77&#37; in the radiological group and 81&#37; in the endoscopic group &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46; The rate of complications was higher in the radiologic group compared with the endoscopic group &#40;38&#37; vs 20&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;006&#41;&#46; Among patients with colorectal cancer &#40;158&#41;&#44; 65 stents were placed for palliation but 30&#37; eventually required surgery&#46; The multivariate analysis identified three factors associated with poorer long-term survival&#58; tumor stage IV&#44; comorbidity and onset of complications&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Stents may be an alternative to emergency surgery in colorectal obstruction&#44; but the clinical outcome depends on the tumor stage&#44; comorbidity and stent complications&#46; The rate of definitive palliative stent placement was high&#59; although surgery was eventually required in 30&#37;&#46; Our study suggests that the endoscopic method of stent placement is safer than the radiologic method&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">1&#41;</span> Evaluar los resultados cl&#237;nicos a corto y largo plazo de los pacientes despu&#233;s de la colocaci&#243;n de una pr&#243;tesis a nivel colorrectal y <span class="elsevierStyleItalic">2&#41;</span> Evaluar la eficacia y la seguridad de las pr&#243;tesis en la resoluci&#243;n de la obstrucci&#243;n en funci&#243;n de la t&#233;cnica de inserci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes retrospectivo que incluy&#243; 177 pacientes con obstrucci&#243;n c&#243;lica que fueron tratados incialmente con colocaci&#243;n de pr&#243;tesis&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se colocaron 196 pr&#243;tesis en 177 pacientes&#46; La causa m&#225;s frecuente de obstrucci&#243;n fue el c&#225;ncer colorrectal &#40;89&#44;3&#37;&#41;&#46; Noventa y dos pr&#243;tesis &#40;47&#37;&#41; se colocaron mediante t&#233;cnica radiol&#243;gica y 104 &#40;53&#37;&#41; mediante endoscopia bajo gu&#237;a fluorosc&#243;pica&#46; Las tasas de &#233;xito t&#233;cnico fueron del 95&#37; en ambos grupos&#46; Las tasas de &#233;xito cl&#237;nico fueron del 77&#37; en el grupo radiol&#243;gico y del 81&#37; en el grupo endosc&#243;pico &#40;p<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46; La tasa de complicaciones fue mayor en el grupo radiol&#243;gico en comparaci&#243;n con el grupo endosc&#243;pico &#40;38 vs&#46; 20&#37;&#44; respectivamente&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#46; Entre los pacientes con c&#225;ncer colorrectal &#40;158&#41;&#44; 65 pr&#243;tesis se colocaron con un fin paliativo&#44; pero el 30&#37; requiri&#243; finalmente cirug&#237;a&#46; El an&#225;lisis multivariante identific&#243; 3 factores asociados a una peor supervivencia&#58; estadio tumoral IV&#44; comorbilidad y aparici&#243;n de complicaciones&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las pr&#243;tesis pueden ser una alternativa a la cirug&#237;a urgente en la obstrucci&#243;n colorrectal&#44; pero el resultado cl&#237;nico depende del estadio tumoral&#44; de la comorbilidad y de las complicaciones de la pr&#243;tesis&#46; La tasa de colocaci&#243;n de pr&#243;tesis paliativa definitiva fue alta&#59; aunque en un 30&#37; se requiri&#243; cirug&#237;a&#44; finalmente&#46; Nuestro estudio sugiere que el m&#233;todo de implantaci&#243;n con visi&#243;n endosc&#243;pica es m&#225;s seguro que el m&#233;todo radiol&#243;gico&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient demographics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">177 patients <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex &#40;male&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102 &#40;57&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Median &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&#46;4 &#40;63&#46;8&#8211;79&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Charlson Comorbidity Score &#40;age adjusted&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Median &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;0 &#40;3&#46;0&#8211;5&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Etiology of obstruction</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">158 &#40;89&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diverticulitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7 &#40;4&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surgical anastomosis stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;2&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extrinsic compression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;1&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Location of obstruction</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rectum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;14&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sigmoid colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100 &#40;56&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Descending colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">22 &#40;12&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Splenic flexure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17 &#40;9&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Transverse colon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hepatic flexure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ascending colon or cecum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Surgery anastomosis without location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Demographics of patients with SEMS implantation&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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            "identificador" => "at2"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">CRC&#58; colorectal cancer&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient demographics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Obstructive CRC<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>158&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex &#40;male&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92 &#40;58&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">71&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Median &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73&#46;8 &#40;64&#46;2&#8211;80&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Charlson Comorbidity Score &#40;age adjusted&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Median &#40;interquartile range&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;0 &#40;3&#46;0&#8211;6&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Tumor stages &#40;TNM&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 &#40;13&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IIB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;2&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IIC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;1&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IIIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;0&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IIIB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26 &#40;16&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IIIC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">73 &#40;46&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TxNxM0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;3&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;10&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1987549.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Demographics of patients with obstructive CRC&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Pat&#58; patient&#59; Insert tech&#58; insertion technique&#59; SEMS&#58; self expandable metal stent&#59; CRC&#58; colorectal cancer&#59; CS&#58; clinical success&#59; TS&#58; technical success&#59; RX&#58; radiologic&#59; ER&#58; endoscopic under fluoroscopic guidance&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pat&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Insert tech&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Etiology of obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aim of SEMS &#40;occlusion by CRC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes of failure of first stent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes of failure of second stent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Is emergent surgery necessary&#63;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failure expansion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bridge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Failure expansion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Diverticulitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anastomotic stricture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Palliative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bridge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No CS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bridge&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No TS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ER&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anastomotic stricture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 4"
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            "identificador" => "at4"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">SEMS&#58; self expandable metal stent&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Causes of surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#8220;Bridge to surgery&#8221; group &#40;emergency surgery&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Palliative SEMS group &#40;surgery&#41;<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Technical failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical failure with unknown etiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No long term clinical success&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perforation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Re-obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Migration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obstruction in other location&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Causes of non-elective surgery after SEMS placement&#46;</p>"
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      5 => array:8 [
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        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at5"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " rowspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of surgery</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#8220;Bridge to surgery&#8221; group</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Palliative group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Emergency surgery<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Elective surgery<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgery<br>&#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palliative stoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;35&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palliative stoma with second resection surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;13&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resection with primary anastomosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;33&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">58 &#40;85&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hartmann&#39;s procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;46&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;7&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;30&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resection &#40;it is unknown if primary anastomosis takes place&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perforation suture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Exploratory laparotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unknown&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 24443824
Original language: English

DOI:10.1016/j.gastre.2019.02.028

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Year/Month	Html	Pdf	Total

2024 November	5	1	6
2024 October	9	1	10
2024 September	13	9	22
2024 August	15	3	18
2024 July	7	1	8
2024 June	20	2	22
2024 May	29	5	34
2024 April	33	4	37
2024 March	8	3	11
2024 February	9	3	12
2024 January	6	1	7
2023 December	13	3	16
2023 November	10	1	11
2023 October	11	1	12
2023 September	4	0	4
2023 August	9	2	11
2023 July	8	2	10
2023 June	16	0	16
2023 May	29	1	30
2023 April	38	1	39
2023 March	24	2	26
2023 February	20	4	24
2023 January	15	3	18
2022 December	23	1	24
2022 November	23	5	28
2022 October	107	5	112
2022 September	25	4	29
2022 August	32	12	44
2022 July	12	9	21
2022 June	16	5	21
2022 May	12	8	20
2022 April	18	8	26
2022 March	13	6	19
2022 February	13	8	21
2022 January	49	6	55
2021 December	17	8	25
2021 November	23	11	34
2021 October	24	9	33
2021 September	11	6	17
2021 August	15	3	18
2021 July	19	5	24
2021 June	28	10	38
2021 May	12	8	20
2021 April	33	0	33
2021 March	10	2	12

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