Colonic stents: the modern treatment of colonic obstruction

Malignant obstruction in the ileocecal region treated by self-expandable stent placement under the fluoroscopic guidance: A case report

BACKGROUND

Malignant tumors of the ileocecal region often cause intestinal obstruction. Emergency surgery is the main treatment for patients presenting with an obstruction. However, this procedure is associated with a high mortality rate and frequent complications. The placement of colon stents is commonly performed for obstructions in the distal colon and is a less invasive and safer procedure. However, obstructions in the proximal colon are more challenging to treat by stent placement due to the increased distance from the anus.

CASE SUMMARY

This case report concerns an 88-year-old man with malignant intestinal obstruction in the ileocecal region. He was contraindicated for general anesthesia and surgical enterostomy. The placement of a self-expandable metallic stent seems an alternative to surgery, although stenting in this area is thought to be difficult and few studies have been reported so far. After three attempts at different interventional approaches, a stent was successfully placed in the obstructed segment under fluoroscopic guidance. After the procedure, the patient's abdominal distension and abdominal pain were significantly better than before.

CONCLUSION

For patients with proximal colonic obstruction, self-expandable metallic stent placement under fluoroscopic guidance could be considered as a feasible treatment to relieve abdominal distension and pain in patients with acute bowel obstruction. It has the characteristics of high safety and high patient tolerance. However, further study is still needed.

Minimally Invasive Management of Diverticular Disease

Traditionally, management of complicated diverticular disease has involved open damage control operations with large definitive resections and colostomies. Studies are now showing that in a subset of patients who would typically have undergone an open Hartmann's procedure for Hinchey III/IV diverticulitis, a laparoscopic approach is equally safe, and has better outcomes. Similar patients may be good candidates for primary anastomosis to avoid the morbidity and subsequent reversal of a colostomy. While most operations for diverticulitis across the country are still performed open, there has been an incremental shift in practice toward minimally invasive approaches in the elective setting. The most recent data from large trials, most notably the SIGMA trial, found laparoscopic sigmoid colectomy is associated with fewer short-term and long-term complications, decreased pain, improvement in length of stay, and maintains better cost-effectiveness than open resections. Some studies even demonstrate that robotic sigmoid resections can maintain a similar if not more reduction in morbidity as the laparoscopic approach while still remaining cost-effective. Intraoperative approaches also factor into improving outcomes. One of the most feared complications in colorectal surgery is anastomotic leak, and many studies have sought to find ways to minimize this risk. Factors to consider to minimize incidence of leak are the creation of tension-free anastomoses, amount of contamination, adequacy of blood supply, and a patient's use of steroids. Techniques supported by data that decrease anastomotic leaks include preoperative oral antibiotic and mechanical bowel prep, intraoperative splenic flexure mobilization, low-tie ligation of the inferior mesenteric artery, and use of indocyanine green immunofluorescence to assess perfusion. In summary, the management of benign diverticular disease is shifting from open, morbid operations for a very common disease to a minimally invasive approach. In this article, we review those approaches shown to have better outcomes, greater patient satisfaction, and fewer complications.

Biopsy sampling during self-expandable metallic stent placement in acute malignant colorectal obstruction: a narrative review

BACKGROUND

Histopathology is a crucial part of diagnosis and treatment guidance of colorectal cancer. In Denmark, it is not routine to biopsy during self-expandable metallic stent (SEMS) placement as a treatment option for acute colorectal obstruction of unknown etiology. This is due to lack of knowledge about the risks of hemorrhage, and thus the risk to aggravate the deteriorating overview conditions. Therefore, the aim of this study is to investigate whether there is evidence to avoid biopsy sampling during acute SEMS placement.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched for relevant studies. Studies were included if they described biopsy sampling in relation to SEMS placement. Additionally, national and international guidelines were scrutinized on Google and by visiting the websites of national and international gastrointestinal societies.

RESULTS

In total, 43 studies were included in the review. Among these, one recommended biopsy during SEMS placement, three advised against biopsy, 23 just reported biopsy was performed during the procedure, and 16 reported biopsy before or after the procedure, or the timing was not specified. Among the 12 included guidelines, only two described biopsy during SEMS placement.

CONCLUSION

The literature on the subject is limited. In 24 of the 43 included studies, biopsy sampling was done during SEMS placement without reporting a decrease in the technical success rate. The included guidelines were characterized by a general lack of description of whether biopsy during SEMS placement should be performed or not. Prospective studies are needed in order to establish the real risk of hemorrhage, if any, when a biopsy is obtained.

Comparing the mechanical properties of a self-expandable metallic stent for colorectal obstruction: Proposed measurement method of axial force using a new measurement machine

OBJECTIVES

Colorectal stenting is widely performed using self-expandable metallic stents (SEMSs), but the mechanical properties have not been evaluated. Therefore, we conducted an in vitro study to evaluate the mechanical properties of colorectal SEMSs.

METHODS

Eighteen individual types and sizes of uncovered SEMSs were evaluated for their mechanical properties. Radial force was measured using a measurement machine. Axial force (AF) was measured by two methods: a conventional manual method and a new method using a measurement machine. The correlation of these two methods was evaluated. We also proposed an "AF zero border" that was defined as the angle at which the torque force disappeared.

RESULTS

Radial force versus diameter curves and AF versus angle curves were influenced by the structure and the size of each stent. There was excellent correlation of AFs measured by the new and conventional manual method (y = 21.434x, R = 0.881, P < 0.0001). Colorectal SEMSs could be categorized into five subgroups according to the mechanical properties. Most hook-wired SEMSs had the AF of zero border.

CONCLUSIONS

This is the first report to evaluate the mechanical properties of colorectal SEMSs, and these data may provide useful information for the clinical use and development of colorectal SEMS. Furthermore, the new measurement machine might standardize the measuring method of AF.

Development and In Vitro Evaluation of 5-Fluorouracil-Eluting Stents for the Treatment of Colorectal Cancer and Cancer-Related Obstruction

Self-expanding metal stents (SEMSs) are currently the gold standard for the localised management of malignant gastrointestinal (GI) stenosis and/or obstructions. Despite encouraging clinical success, in-stent restenosis caused by tumour growth is a significant challenge. Incorporating chemotherapeutic drugs into GI stents is an emerging strategy to provide localised and sustained release of drugs to intestinal malignant tissues to prevent tumour growth. Therefore, the aim of this work was to develop and evaluate a local GI stent-based delivery system that provides a controlled release of 5-fluorouracil (5FU) over a course of several weeks to months, for the treatment of colorectal cancer and cancer-related stenosis/obstructions. The 5FU-loaded GI stents were fabricated via sequential dip-coating of commercial GI stents with a drug-loaded polyurethane (PU) basecoat and a drug-free poly(ethylene-co-vinyl acetate) (PEVA) topcoat. For comparison, two types of commercial stents were investigated, including bare and silicone (Si) membrane-covered stents. The physicochemical properties of the 5FU-loaded stents were evaluated using photoacoustic Fourier-transform infrared (PA-FTIR) spectroscopy, X-ray diffraction (XRD), X-ray photoelectron spectroscopy (XPS), scanning electron microscopy (SEM), and thermal analysis. In vitro release studies in biological medium revealed that the 5FU-loaded stents provided a sustained release of drug over the period studied (18 d), and cell viability, cell cycle distribution and apoptosis assays showed that the released 5FU had comparable anticancer activity against human colon cancer cells (HCT-116) to pure 5FU. This study demonstrates that dip-coating is a facile and reliable approach for fabricating drug-eluting stents (DESs) that are promising candidates for the treatment of GI obstructions and/or restenosis.

Uncovered self-expandable metal stents for the treatment of refractory benign colorectal anastomotic stricture

Self-expandable metal stent (SEMS) placement has been suggested as a therapeutic modality for treating benign colorectal strictures. Covered stents are generally used, given the concerns regarding the efficacy and safety of uncovered stents. Hence, few studies have evaluated the efficacy and safety of uncovered SEMSs (UCSEMSs) in patients with refractory benign colorectal anastomotic strictures. In this study, 12 patients with postoperative benign symptomatic anastomotic strictures refractory to pneumatic dilation (range, 2–9) and transient indwelling-covered SEMSs were treated using UCSEMS. All enrolled patients were men (mean age, 61 years). Stent placement was successful in all 12 patients, and early clinical success was achieved in 11 (92%) patients. Four patients (25%) showed successful clinical outcomes without further intervention, but eight patients (75%) were clinically unsuccessful, and showed stricture recurrence or functional obstructive symptoms. Three patients underwent surgery, and the remaining five patients required repeat stent procedures. Despite the high reobstruction rate, the median follow-up period after UCSEMS placement was 16.7 months, demonstrating that UCSEMS may be able to achieve medium-term symptom relief without any complications. Therefore, UCSEMS may be an alternative option in exceptional circumstances in carefully selected patients, where invasive surgical treatments, such as stoma diversion, are not an option, thereby improving patients’ quality of life.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.

Clinical effect of double coaxial self-expandable metallic stent in management of malignant colon obstruction

PURPOSE

We aimed to evaluate the clinical effectiveness and safety of double coaxial self-expandable metallic stent (DCSEMS) in management of malignant colonic obstruction as a bridge to surgery or palliation for inoperable patients.

METHODS

Between April 2006 and December 2012, 49 patients (27 males and 22 females; median age, 68 years; age range, 38-91 years) were selected to receive decompressive therapy for malignant colonic obstruction by implanting a DCSEMS. Application of DCSEMS was attempted in 49 patients under fluoroscopic guidance. The obstruction was located in the transverse colon (n=2), descending colon (n=7), sigmoid colon (n=24), rectosigmoid junction (n=6), and the rectum (n=10). The intended use of DCSEMS was as a bridge to elective surgery in 23 patients and palliation in 26 patients.

RESULTS

Clinical success, defined as >50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 48 of 49 patients (98%). The stent was properly inserted in all patients. No immediate major procedure-related complications occurred. One patient in the bridge-to-surgery group had colon perforation three days after DCSEMS application. Four patients had late migrations of the double stent.

CONCLUSION

Application of DCSEMS is safe and effective in management of malignant colonic obstruction; it prevents stent migration and tumor ingrowth and lowers perforation rate during the stent application.

Self-Expanding Metal Stenting in the Management of a Benign Colonic Stricture

Colonic postanastomotic strictures occur in 1.5–8% of patients following colorectal surgery. Traditionally, colonic strictures were treated by multiple modalities including endoscopic dilatation. Self-expanding metal stents (SEMS) have been indicated in the management of benign colonic strictures; however, there are limited available data with regard to their efficacy. We present the case of a 68-year-old male who had perforated sigmoid diverticulitis followed by Hartmann's procedure with eventual reanastomosis 6 months later. He subsequently developed benign colonic stricture, which was treated with a metal stent. SEMS are associated with a low mortality rate and are appropriate in treating acute colonic obstruction as a result of benign stricture in the setting of postanastomosis.

Self-expandable metallic stent as a bridge to elective surgery versus emergency surgery for acute malignant colorectal obstruction

BACKGROUD

The efficacy and safety of self-expandable metallic stents (SEMSs) as a bridge for patients with acute malignant colorectal obstructions (AMCOs) are still controversial. We conducted this study to evaluate the outcomes of patients with AMCOs treated by different strategies.

METHODS

From January 2010 to March 2014, a total of 171 patients with AMCOs from Zhongshan Hospital were retrospectively enrolled in this study. One hundred twenty patients successfully received stent placement followed by one-stage laparoscopic or open resection in the stent group, and 51 patients received emergency operations in the emergency group.

RESULTS

The operation duration and postoperative hospital stay were significantly shorter in the stent group (114.51 ± 28.65 vs. 160.39 ± 58.94 min, P < 0.001; 8.00 ± 3.97 vs. 12.59 ± 9.07 days, P = 0.001). The stent group also had significantly reduced intraoperative blood loss and the incidence of postoperative complications compared with the emergency group (61.00 ± 43.70 vs. 121.18 ± 85.90 ml, P < 0.001; 16.7 vs. 37.3%, P = 0.003). Kaplan-Meier survival curves showed that the median survival time in the stent group was significantly longer than that in the emergency group (53 vs. 41 months, P = 0.034). In subgroup analysis of stent group, the stent laparoscopy group had significantly decreased postoperative complications (P = 0.025), and similar long-term survival (P = 0.81).

CONCLUSIONS

Stent placement as a bridge to surgery is a safe and feasible procedure and provides significant advantages in terms of short-term outcomes and favorable prognoses for patients with AMCOs. Laparoscopic surgery could be considered as an optimal treatment after stent placement.

Clinical efficacy of endoscopic treatment for benign colorectal stricture: balloon dilatation versus stenting

BACKGROUND/AIMS

There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes.

METHODS

Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed.

RESULTS

Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5±13.3 months vs. 2.0±0.6 months, p=0.031).

CONCLUSIONS

Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.

Outcomes of the use of fully covered esophageal self-expandable stent in the management of colorectal anastomotic strictures and leaks

Introduction. Colorectal anastomotic leak or stricture is a dreaded complication leading to significant morbidity and mortality. The novel use of self-expandable metal stents (SEMS) in the management of postoperative colorectal anastomotic leaks or strictures can avoid surgical reintervention. Methods. Retrospective study with particular attention to the indications, operative or postoperative complications, and clinical outcomes of SEMS placement for patients with either a colorectal anastomotic stricture or leak. Results. Eight patients had SEMS (WallFlex stent) for the management of postoperative colorectal anastomotic leak or stricture. Five had a colorectal anastomotic stricture and 3 had a colorectal anastomotic leak. Complete resolution of the anastomotic stricture or leak was achieved in all patients. Three had recurrence of the anastomotic stricture on 3-month flexible sigmoidoscopy follow-up after the initial stent was removed. Two of these patients had a stricture that was technically too difficult to place another stent. Stent migration was noted in 2 patients, one at day 3 and the other at day 14 after stent placement that required a larger 23 mm stent to be placed. Conclusions. The use of SEMS in the management of colorectal anastomotic leaks or strictures is feasible and is associated with high technical and clinical success rate.

Stenting for Emergency Colorectal Obstruction: An Analysis of 204 Patients in Relation to Predictors of Failure and Complications

Background and Aims:

Self-expanding metallic stents are increasingly used in the management of malignant and benign colorectal obstructions. We aimed to identify relevant predictive factors for stent failure and stent-related complications.

Material and Methods:

We conducted a retrospective single-center analysis of 204 consecutive patients who underwent emergency colorectal stenting procedures because of symptomatic bowel obstructions from 1996 to 2011 at the Sisters of Charity Hospital Linz, Austria.

Results:

A total of 204 patients (median age 74 years) with 36 (17.7%) benign and 168 (82.3%) malignant obstructions were included in the study. Technical success was achieved in 92.5% and clinical success in 86.8% of the cases. Major complications occurred in 2.9% and minor ones in 19.6%. Overall mortality during a median follow-up period of 4.3 years was 73% (149 patients). Relevant predictors of increased risk of complications were extracolonic obstruction (p = 0.001), complete obstruction (p = 0.066), and inflammatory bowel disease (p = 0.05). Stent localization at the splenic flexure, a stenosis of >8 cm in length, and the need for endoscopic guidance were associated with higher rates of technical and/or clinical stenting failure.

Conclusion:

Colorectal stenting is less invasive than other means of emergency treatment for large bowel obstruction; it is generally safe and effective in different types of colorectal obstruction. However, relevant rates of failure and complications were recorded and predictors could be determined.

Outcome of emergency one-stage resection and anastomosis procedure for patients with obstructed colorectal cancer

PURPOSES

The purpose of this study was to verify the outcome of the emergency one stage resection and anastomosis procedure for patients with obstructed colorectal cancer.

METHODS

An emergency one stage resection and anastomosis procedure was performed for 40 patients with obstructive colorectal cancer. The outcome was verified and compared dividing into two groups. 17 patients under the age of 70 in (Group A), 23 patients 70 years and over in (Group B).

RESULTS

The operative mortality rate in both groups was 0%. As a result, postoperative complications were not significantly different between the two groups. The overall survival rate after a 5-year period in both groups was 41.8%, regarding all patients and the survival curves for the two groups, was not significantly different. The 5 year survival rate in stage II or III showed no differences between the two groups.

CONCLUSION

The one-stage resection and anastomosis of the large bowel could be applied safely to emergency patients, which in turn allows for excellent short-term operative results in both groups mentioned. This particular procedure should be positively enforced, even in elderly patients in their 70's.

Uncovered Self-Expanding Metal Stent (SEMS) Four Years After Placement for Long-Term Treatment of a Benign Colonic Obstruction

Self-expanding metal stents (SEMS) have emerged as an alternative to surgery in the treatment of malignant colorectal obstructions. There is limited data about their use for benign colonic obstructions, especially in regards to safety and long-term patency. We present a case in which long-term SEMS placement proved to be a durable option for over 4 years in a patient with a benign colonic stricture.

Perforation in colorectal stenting: a meta-analysis and a search for risk factors

BACKGROUND

Recent studies suggest that there is a substantial risk of perforation after colorectal stent placement.

OBJECTIVE

To identify risk factors for perforation from colonic stenting.

DESIGN

A meta-analysis of 86 studies published between 2005 and 2011.

SETTING

Multicenter review.

PATIENTS

All patients who underwent colorectal stent placement.

INTERVENTION

Colorectal stent placement.

MAIN OUTCOME MEASUREMENTS

The occurrence of perforation with subgroup analyses for stent design, stricture etiology, stricture dilation, and concomitant chemotherapy, including the use of bevacizumab.

RESULTS

A total of 4086 patients underwent colorectal stent placement; perforation occurred in 207. Meta-analysis revealed an overall perforation rate of 7.4%. Of the 9 most frequently used stent types, the WallFlex, the Comvi, and the Niti-S D-type had a higher perforation rate (>10%). A lower perforation rate (<5%) was found for the Hanarostent and the Niti-S covered stent. Stenting benign strictures was associated with a significantly increased perforation rate of 18.4% compared with 7.5% for malignant strictures. Dilation did not increase the risk of perforation: 8.5% versus 8.5% without dilation. The subgroup of post-stent placement dilation had a significantly increased perforation risk of 20.4%. With a perforation rate of 12.5%, bevacizumab-based therapy was identified as a risk factor for perforation, whereas the risk for chemotherapy without bevacizumab was 7.0% and not increased compared with the group without concomitant therapies during stent therapy (9.0%).

LIMITATIONS

Heterogeneity; a considerable proportion of data is unavailable for subgroup analysis.

CONCLUSIONS

The perforation rate of colonic stenting is 7.4%. Stent design, benign etiology, and bevacizumab were identified as risk factors for perforation. Intraprocedural stricture dilation and concomitant chemotherapy were not associated with an increased risk of perforation.

Acute obstruction

Acute obstruction of the gastrointestinal or biliary tract represents a common problem for acute care surgeons. It is with appropriate clinical evaluation, planning, and physical examination follow-up that acute care surgeons are able to appropriately diagnose, manage, and resolve this difficult group of surgical problems and minimize the morbidity associated with each.

Colorectal stenting as first-line treatment in acute colonic obstruction

Tumoral obstructions in almost the entire gastrointestinal tract can be resolved with interventional digestive endoscopy techniques. Self-expanding metal stent (SEMS) insertion in the obstructed colon is a minimally invasive and relatively simple procedure providing an effective first-line treatment for relief of acute malignant obstruction symptoms and serving either as a preoperative or “bridge to surgery” procedure or as palliative definitive care. This technique was introduced in the early 1990s. Although there is still debate about its real value, a lot of reports have been published since then and the procedure is advocated by many surgical groups as the method of choice for the initial treatment of left-sided tumoral colonic obstruction. Before the procedure, colonic obstruction has to be diagnosed by abdominal radiographs, water contrast enema and/or a computed tomography scan. The greatest information is provided by the latter and it is perhaps the method of choice prior to stenting. Skills and training are mandatory, as in all interventional procedures. The key step for success is to cross the malignant stricture with a guidewire. Care must be taken not to over insufflate an obstructed colon during the procedure. SEMS slide over the guidewire through the endoscope working channel or in parallel, outside the endoscope. An average 7% perforation rate has been reported during the procedure and other minor complications can appear in the follow up. However, as a whole, this technique seems to compare favorably with surgery.

Self-expandable metallic stent placement plus laparoscopy for acute malignant colorectal obstruction

AIM: To investigate the clinical advantages of the stent-laparoscopy approach to treat colorectal cancer (CRC) patients with acute colorectal obstruction (ACO).

METHODS: From April 2008 to April 2012, surgery-related parameters, complications, overall survival (OS), and disease-free survival (DFS) of 74 consecutive patients with left-sided CRC presented with ACO who underwent self-expandable metallic stent (SEMS) placement followed by one-stage open (n = 58) or laparoscopic resection (n = 16) were evaluated retrospectively. The stent-laparoscopy group was also compared with a control group of 96 CRC patients who underwent regular laparoscopy without ACO between January 2010 and December 2011 to explore whether SEMS placement influenced the laparoscopic procedure or reduced long-term survival by influencing CRC oncological characteristics.

RESULTS: The characteristics of patients among these groups were comparable. The rate of conversion to open surgery was 12.5% in the stent-laparoscopy group. Bowel function recovery and postoperative hospital stay were significantly shorter (3.3 ± 0.9 d vs 4.2 ± 1.5 d and 6.7 ± 1.1 d vs 9.5 ± 6.7 d, P = 0.016 and P = 0.005), and surgical time was significantly longer (152.1 ± 44.4 min vs 127.4 ± 38.4 min, P = 0.045) in the stent-laparoscopy group than in the stent-open group. Surgery-related complications and the rate of admission to the intensive care unit were lower in the stent-laparoscopy group. There were no significant differences in the interval between stenting and surgery, intraoperative blood loss, OS, and DFS between the two stent groups. Compared with those in the stent-laparoscopy group, all surgery-related parameters, complications, OS, and DFS in the control group were comparable.

CONCLUSION: The stent-laparoscopy approach is a feasible, rapid, and minimally invasive option for patients with ACO caused by left-sided CRC and can achieve a favorable long-term prognosis.

Palliative stenting of the digestive tract: a case series of a single centre

BACKGROUND AND AIM

Obstruction of the gastrointestinal tract due to cancer can be treated with stenting. The aim was to review the local experience with endoscopic stenting. All patients treated with stenting in a ten years period from 2001-2010 were studied.

RESULTS

Fifty one patients received 57 stents because of oesophageal cancer. Mean survival after stent placement was 141 days. No case of perforation occurred. In nine cases (17%) clogging with food occurred. Tumour overgrowth was noted in four cases. Twenty four patients received 28 stents in their colon or rectum. The stents were placed in the rectum (n=6), the sigmoid (n=14), the descending colon (n=1), and the transverse colon (n=3). Mean survival was 276 days. Perforation did not occur. Tumour ingrowth was seen in two patients. One patient received a second stent. Dislocation occurred in two cases. There were two cases of clogging (8%) by stool. Fourteen patients received a total of 18 stents because of obstructing stomach cancer. Mean survival after placement was 121 days. There was no perforation, one case of clogging, and four cases of tumour ingrowth. Eight patients had stent placement in their duodenum. Mean survival after stent placement was 84 days. No perforation or clogging occurred. But three cases of tumour ingrowth were seen.

CONCLUSIONS

The present series shows that placement of expandable stents in the digestive tract in normal daily practice is feasible, safe, with a low number of complications, and provides good palliation for their remaining life.

Factors influencing quality of bowel preparation for colonoscopy

Recent technological advances in colonoscopy have led to improvements in both image enhancement and procedural performance. However, the utility of these technological advancements remain dependent on the quality of bowel preparation during colonoscopy. Poor bowel preparation has been shown to be associated with lower quality indicators of colonoscopy performance, such as reduced cecal intubation rates, increased patient discomfort and lower adenoma detection. The most popular bowel preparation regimes currently used are based on either Polyethylene glycol-electrolyte, a non-absorbable solution, or aqueous sodium phosphate, a low-volume hyperosmotic solution. Statements from various international societies and several reviews have suggested that the efficacy of bowel preparation regimes based on both purgatives are similar, although patients’ compliance with these regimes may differ somewhat. Many studies have now shown that factors other than the type of bowel preparation regime used, can influence the quality of bowel preparation among adult patients undergoing colonoscopy. These factors can be broadly categorized as either patient-related or procedure-related. Studies from both Asia and the West have identified patient-related factors such as an increased age, male gender, presence of co-morbidity and socio-economic status of patients to be associated with poor bowel preparation among adults undergoing routine out-patient colonoscopy. Additionally, procedure-related factors such as adherence to bowel preparation instructions, timing of bowel purgative administration and appointment waiting times for colonoscopy are recognized to influence the quality of colon cleansing. Knowledge of these factors should aid clinicians in modifying bowel preparation regimes accordingly, such that the quality of colonoscopy performance and delivery of service to patients can be optimised.

Simultaneous surgery for primary colorectal cancer and metastatic lesions?

Approximately 20-25% of patients with colorectal cancer present with liver metastases at the time of diagnosis. Traditionally, resection of the primary tumor has been advocated in order to prevent complications of the primary tumor colorectal cancer in patients with synchronous liver metastases. The published data concerning long-term prognosis in this group of patients are discordant. Although some of the reports show survival benefits from resection of the primary tumor, these studies are retrospective with small number of patients and using single drug chemotherapy. For patients with resectable liver metastases, new studies indicate that progression-free survival is best in patients receiving perioperative chemotherapy. In patients with synchronous nonresectable liver metastases and colorectal cancer, there is no published prospective randomized study comparing initial surgery of the primary tumor with neoadjuvant chemotherapy. However, recent publications show that in patients receiving chemotherapy based on oxaliplatin or irinotecan combined with targeted treatments, the complications associated with the primary tumor are less than 10%. The conclusion should be that today prophylactic surgery of asymptomatic primary colorectal cancer in patients with liver metastases cannot be recommended.