Malignant rectal obstruction within 5 cm of the anal verge: is there a role for expandable metallic stent placement?

Impact of self-expanding metal stents on long-term survival outcomes as a bridge to surgery in patients with colon cancer obstruction: Current state and future prospects

Since self-expanding metal stents (SEMS) were first introduced in acute colon cancer obstruction, the increased rate of primary anastomosis and improved quality of life following SEMS placement have been clearly shown. However, it was demonstrated that SEMS are associated with higher recurrence rates. Although several trials have shown that overall and disease-free survival in patients following SEMS placement is similar with patients undergoing emergency surgery, obstruction and a high incidence of recurrence imposed many concerns. The optimal time interval from SEMS to surgery is still a matter of debate. Some studies have recommended a time interval of ~2 weeks between SEMS insertion and elective surgery. A prolonged interval of time from SEMS insertion to elective surgery and the administration of neoadjuvant chemotherapy (NAC) has been proposed. SEMS-NAC might have advantages for improving the surgical and long-term survival outcomes of patients with acute colon cancer obstruction, which is an optional approach in the management of acute colon cancer obstruction.

Four Cases of Proximal Release-Type Colon Stents for Obstructive Rectal Cancer

Malignant colonic obstruction can cause necrosis, bacterial translocation, electrolytic imbalance, and death; therefore, immediate decompression should be performed. Self-expandable metallic colonic stents are an established treatment for the decompression of malignant colonic obstructions. The use of stents that open from the distal side, which have been commonly used until now, requires caution because placing a stent on the dentate line can cause severe pain, and there is a possibility of cutting the stent during rectal resection of the distal side of the tumor. Therefore, we designed a new proximal-release-type colorectal stent for use in our hospital; it is 22 mm in diameter and 70 mm in length, which was placed using the over-the-wire method with a 16 Fr delivery system. We have encountered four cases in which it was appropriate as a bridge to surgical treatment. None of the patients experienced complications, such as bleeding, pain, or other incidents, after stent placement. Additionally, the stents were not affected by the surgical dissection of the rectum on the anorectal side of the tumor. Herein, we presented the four aforementioned cases and discussed the stenting techniques.

Endoscopic Nutrition of Patients with Cancer

The types of endoscopic interventions available for supporting the nutrition of patients with cancer have expanded in recent years to encompass a wide variety of different techniques and procedures. Many of these procedures reflect refinements of technique that have existed for some time, whereas others are implementations of novel technologies and instruments that have only become available in recent years. In this review, the authors seek to summarize the breadth of endoscopic techniques for maintaining nutrition in patients with cancer.

The Deployment of a Newly Developed Proximal Release-Type Colonic Stent Is Feasible for Malignant Colorectal Obstruction near the Anal Verge: A Single-Center Preliminary Study

INTRODUCTION

Colonic self-expandable metallic stents are widely used to treat malignant colorectal obstructions. Stent placement in lesions near the dentate line causes problems, including severe pain due to difficulty in positioning the stent accurately. Therefore, a proximal release-type stent was developed to overcome this issue, and this preliminary study aimed to investigate its efficacy and safety.

PATIENTS AND METHODS

This research enrolled eight patients with malignant colorectal obstructions up to 10 cm from the anal verge who required placement of the newly developed proximal release-type colonic stent. The primary outcome was the clinical success rate, and the secondary outcomes were the technical success and adverse events rates.

RESULTS

The technical and clinical success rates were 87.5% each, and the mean procedure time was 25.5 ± 22.0 min. The mean procedure time in the rectosigmoid colon was significantly longer than that in the rectum. Only one (12.5%) patient had stent migration, and neither anal pain nor tenesmus was observed.

DISCUSSION

The stent was highly effective in treating lesions near the anal verge, and it might contribute to the expansion of indications for colorectal stents for lesions near the dentate line. However, the indications for rectosigmoid colon lesions should be cautiously considered.

Treatment outcome of laparoscopic surgery after self-expandable metallic stent insertion for obstructive colorectal cancer

BACKGROUND

We assessed the technical and oncological safety of self-expandable metallic stent (SEMS) insertion followed by laparoscopic colorectal surgery as a bridge to surgery (BTS) for obstructive colorectal cancer (CRC).

METHODS

A retrospective, single-center study analyzed the short- and long-term outcomes of SEMS insertion followed by laparoscopic colorectal surgery in patients with stage II/III/IV obstructive CRC from 2012 to 2020 at Cancer Institute Hospital.

RESULTS

In 66 patients, including 28 stage IV patients, the clinical success rates of SEMS insertion were 97%. In laparoscopic surgery, primary anastomosis was performed in 61 patients (92%), and open conversion was required in 2 patients (3%). Postoperative complications were seen in 9 patients (13%); however, there was no anastomotic leakage or mortality. Curative resection was achieved in all 38 stage II/III patients and 15 of 28 (54%) stage IV patients. Stage IV patients had a longer operation time and greater blood loss than stage II/III patients; however, the open conversion and postoperative complication rates were similar between the groups. In stage II/III patients, 3-year disease-free survival and 3-year overall survival [OS] were 87.1 and 89.5%, respectively. The median OS of stage IV patients was 34.9 months, and stage IV patients who underwent R0 resection showed a significantly better OS (P = 0.0011) than those with R2 resection.

CONCLUSION

SEMS insertion followed by laparoscopic surgery is a feasible treatment strategy that achieves a high-primary anastomosis rate without severe postoperative complication in not only stage II/III but also stage IV obstructive CRC patients.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

BACKGROUND AND AIMS

Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

METHODS

The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

CONCLUSIONS

The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

[Palliative endoscopy]

Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.

Comparison of survival and perioperative outcome of the colonic stent and the transanal decompression tube placement and emergency surgery for left-sided obstructive colorectal cancer: a retrospective multi-center observational study "The CODOMO study"

PURPOSE

Advances in endoscopic technology have led to the reevaluation of self-expandable metallic stent (SEMS) placement as a bridge-to-surgery (BTS) in patients with obstructive colorectal cancer. In Japan, after inclusion of SEMS placement as a BTS in the medical insurance coverage in 2012, this procedure has been increasingly performed. However, a transanal decompression tube (TADT) placement has been used as a BTS. We aimed to retrospectively evaluate the optimal strategy for obstructive left-sided colorectal cancer (OLCRC) by comparing SEMS and TADT placement with emergency surgery.

METHODS

We included 301 patients with stage II and III OLCRC from 27 institutions. The study patients were divided into Surgery group (emergency surgery, n = 103), SEMS group (BTS by SEMS, n = 113), and TADT group (BTS by TADT, n = 85). We compared the survival and perioperative outcomes of patients in the Surgery group as a standard treatment with those in the SEMS and TADT groups.

RESULTS

The 3-year relapse-free survival rate in patients in the Surgery group was 74.8%, while that in patients in the SEMS group and TADT group were 69.0% (p = 0.39) and 55.3% (p = 0.006), respectively. The technical success rate was not statistically different, but the clinical success rate was significantly higher in the SEMS group than in the TADT group (p = 0.0040). With regard to postoperative complications after curative surgery, the SEMS group had significantly lower of complications (≥ grade 2) than the Surgery group (p = 0.022).

CONCLUSION

Patients who underwent SEMS placement for OLCRC had similar oncological outcomes to patients who underwent emergency surgery.

Colonic stents for malignant bowel obstruction: current status and future prospects

Introduction: Although more than two decades are already passed from the first description of this technique, the debate remains open on the role of self-expanding metal stents (SEMS) placement in the management of malignant bowel obstruction (MBO). According to most recent data, SEMS placement is considered a safe and effective alternative treatment as a bridge to surgery(BTS). In addition, stent placement should be considered as primary option for palliative treatment of obstructing cancer.Areas covered: Current status, indication, technique, oncological outcomes, advantages, and risks of SEMS placement in MBO were reviewed.Expert commentary: The placement of colonic SEMS for palliation and for BTS in patients with MBO has been increasingly reported and it seems to have several advantages over emergency surgery. Substantial concerns of tumor seeding following SEMS placement, especially in case of perforation, have been raised in numerous studies. Actually, no significant differences are reported in oncologic long-term survival between patients undergoing stent placement as a BTS and those undergoing emergency surgery. Considering all the mentioned factors, indication for colorectal stenting should be evaluated only in highly specialized centers, in the context of multidisciplinary approach where risks and benefits of stenting are carefully weighed, especially in the BTS setting.

Current status of colonic stent for obstructive colorectal cancer in Japan; a review of the literature

Colorectal cancer is the most common cancer in Japan. Approximately 10%-20% of the patients with colorectal cancer present with large bowel obstruction, and those who present with malignant colonic obstruction (MCO) require urgent decompression because MCO can cause electrolytic fluid imbalance, colonic necrosis, bacterial translocation, and death. Placement of colonic stents (self-expandable metallic stents) for MCO is a major and standard endoscopic treatment that has been available since 2012 in Japan. This review presents the current conditions and future prospects of this procedure based on the literature. The current indication of colonic stent placement is malignant colorectal stenosis. One of the purposes of using stents is palliative treatment; further, its advantages over emergency surgery with colostomy include avoidance of colostomy, relief of obstruction, shorter hospitalization, and better quality of life. In addition, stent placement can also be used as a bridge to surgery since the duration of the hospitalization is shorter and postoperative complications, colostomy rates, and mortality rates are lower with elective than with emergency surgery. Although recent studies have reported low complication rates related to colonic stents, complications may still occur, highlighting the importance of good preparation, adequate staffing, backup systems, and informed consent. The current major problem related to colonic stents is the lack of evidence on patients' long-term prognoses for bridge to surgery purposes, awaiting the results of ongoing clinical research.

Acute abdominal obstruction: Colon stent or emergency surgery? An evidence-based review

According to the American Cancer Society and Colorectal Cancer Statistics 2017, colorectal cancer (CRC) is one of the most common malignancies in the United States and the second leading cause of cancer death in the world in 2018. Previous studies demonstrated that 8%-29% of patients with primary CRC present malignant colonic obstruction (MCO). In the past, emergency surgery has been the primary treatment for MCO, although morbidity and surgical mortality rates are higher in these settings than in elective procedures. In the 1990s, self-expanding metal stents appeared and was a watershed in the treatment of patients in gastrointestinal surgical emergencies. The studies led to high expectations because the use of stents could prevent surgical intervention, such as colostomy, leading to lower morbidity and mortality, possibly resulting in higher quality of life. This review was designed to provide present evidence of the indication, technique, outcomes, benefits, and risks of these treatments in acute MCO through the analysis of previously published studies and current guidelines.

Clinical Outcomes of Self-Expandable Metal Stents for Malignant Rectal Obstruction

BACKGROUND

Self-expandable metal stents are widely used to treat malignant colorectal obstruction. However, data on clinical outcomes of stent placement for rectal obstruction specifically are lacking.

OBJECTIVE

We aimed to investigate the clinical outcomes of self-expandable metal stents in malignant rectal obstruction in comparison with those in left colonic obstruction and to identify factors associated with clinical failure and complication.

DESIGN

This was a retrospective study.

SETTINGS

The study was conducted at a tertiary care center.

PATIENTS

Between January 2005 and December 2013, medical charts of patients who underwent stent placement for malignant rectal or left colonic obstruction were reviewed retrospectively.

INTERVENTION

Study intervention included self-expandable metal stent placement.

MAIN OUTCOME MEASURES

Technical success, clinical success, and complications were measured.

RESULTS

Technical success rates for the 2 study groups (rectum vs left colon, 93.5% vs 93.1%; p = 0.86) did not differ significantly; however, the clinical success rate was lower in patients with rectal obstruction (85.4% vs 92.1%; p = 0.02). In addition, the complication rate was higher in patients with rectal obstruction (37.4% vs 25.1%; p = 0.01). Patients with rectal obstruction showed higher rates of obstruction because of extracolonic malignancy (33.8% vs 15.8%; p < 0.001) and stent use for palliation (78.6% vs 56.3%; p < 0.001). Multivariate analysis indicated obstruction attributed to extracolonic malignancy and covered stent usage to be independent risk factors for clinical failure. Factors predictive of complications in the palliative group were total obstruction, obstruction because of extracolonic malignancy, and covered stent usage.

LIMITATIONS

This was a retrospective, single-center study.

CONCLUSIONS

The efficacy and safety of stent placement for malignant rectal obstruction were comparable with those for left colonic obstruction. However, obstruction attributed to extracolonic malignancy, use of covered stents, and total obstruction negatively impacted clinical outcomes of self-expandable metal stent placement and must be considered by endoscopists. See Video Abstract at http://links.lww.com/DCR/A417.

Value in palliative cancer surgery: A critical assessment

Emergency operations are associated with increased morbidity, mortality, and cost compared to elective operations. Palliative and emergent surgery for patients with advanced malignancies is associated with additional risk and remains controversial. Emergent or palliative interventions can be broadly categorized according to indication. Tumor related complications (bleeding, obstruction, or perforation) merit specific consideration, as do specific presentations such as pneumoperitoneum, pneumatosis intestinalis, or peritonitis from other causes that may arise during active therapy for malignancies. Although nonoperative, endoscopic, and interventional treatment modalities are frequently available, surgery remains the only effective therapy in selected situations such as small intestinal obstruction and tumor perforation. Selection of patients for surgery requires consideration of factors including overall prognosis, performance status, and patients' priorities. Selection and risk assessment tools underscore the limited capacity of patients' with higher risk features for durable recovery but do not supplant nuanced clinical judgment. J. Surg. Oncol. 2016;114:311-315. © 2016 Wiley Periodicals, Inc.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Role of self expandable stents in management of colorectal cancers

Acute malignant colorectal obstruction is a complication of colorectal cancer that can occur in 7%-29% of patients. Self-expanding metallic stent placement for malignant colorectal obstruction has gained popularity as a safe and effective procedure for relieving obstruction. This technique can be used in the palliation of malignant colorectal obstruction, as a bridge to elective surgery for resectable colorectal cancers, palliation of extracolonic malignant obstruction, and for nonmalignant etiologies such as anastomotic strictures, Crohn’s disease, radiation therapy, and diverticular diseases. Self-expanding metallic stent has its own advantages and disadvantages over the surgery in these indications. During the insertion of the self-expanding metallic stent, and in the follow-up, short term and long term morbidities should be kept in mind. The most important complications of the stents are perforation, stent obstruction, stent migration, and bleeding. Additionally, given the high risk of perforation, if a patient is treated or being considered fortreatmentwith antiangiogenic agents such as bevacizumab, it is not recommended to use self-expanding metallic stent as a palliative treatment for obstruction. Therefore, there is a need for careful clinical evaluation for each patient who is a candidate for this procedure. The purpose of this review was to evaluate self-expanding metallic stent in the management of the obstruction of the colon due to the colorectal and extracolonic obstruction.

Stents for colorectal obstruction: Past, present, and future

Since the development of uncovered self-expanding metal stents (SEMS) in the 1990s, endoscopic stents have evolved dramatically. Application of new materials and new designs has expanded the indications for enteral SEMS. At present, enteral stents are considered the first-line modality for palliative care, and numerous types of enteral stents are under development for extended clinical usage, beyond a merely palliative purpose. Herein, we will discuss the current status and the future development of lower enteral stents.

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.

Enteral stents for the management of malignant colorectal obstruction

Colorectal cancer (CRC) is the 3^rd most common cancer in the United States with more than 10000 new cases diagnosed annually. Approximately 20% of patients with CRC will have distant metastasis at time of diagnosis, making them poor candidates for primary surgical resection. Similarly, 8%-25% of patients with CRC will present with bowel obstruction and will require palliative therapy. Emergent surgical decompression has a high mortality and morbidity, and often leads to a colostomy which impairs the patient’s quality of life. In the last decade, there has been an increasing use of colonic stents for palliative therapy to relieve malignant colonic obstruction. Colonic stents have been shown to be effective and safe to treat obstruction from CRC, and are now the therapy of choice in this scenario. In the setting of an acute bowel obstruction in patients with potentially resectable colon cancer, stents may be used to delay surgery and thus allow for decompression, adequate bowel preparation, and optimization of the patient’s condition for curative surgical intervention. An overall complication rate (major and minor) of up to 25% has been associated with the procedure. Long term failure of stents may result from stent migration and tumor ingrowth. In the majority of cases, repeat stenting or surgical intervention can successfully overcome these adverse effects.

Own experiences of endoscopic self-expandable stent placement for malignant colorectal ileus

Introduction

Acute low neoplasm ileus requires emergency surgery. Nowadays there are increased numbers of patients with comorbidities, which causes higher risk of intra- and postoperative complications.

Aim

To evaluate the clinical usefulness of endoscopic self-expandable stent placement for malignant colorectal ileus.

Material and methods

Twenty-one patients (8 women and 13 men), mean age 66.7 years, with low neoplasm obstruction, underwent endoscopic stenting of the stricture. This procedure was performed as a bridge to the surgery especially for high-risk patients. Eight of them had coagulation system impairment, 5 severe metabolic disorders, 4 circulatory insufficiency, 3 severe malnutrition and 1 patient undiagnosed synchronic rectal tumor. In 10 patients cancer was located in the sigmoid colon, in 7 in the rectum, in 2 in the ascending colon, and the transverse and ascending colon was involved in another 2 patients.

Results

All 21 patients (100%) underwent endoscopic stenting successfully. There were no complications after stent placement. The authors underline that placement of expandable metallic stents for patients with malignant colon obstruction with acute ileus is a safe and effective method. It gives an opportunity for quick balance of fluid, electrolyte, and the coagulation system and improvement of efficiency of the circulatory and respiratory system.

Conclusions

Endoscopic treatment of ileus helps precisely estimate tumor advancement and gives the possibility of a single stage radical surgical procedure.

Novel method of stent insertion for malignant lower rectal obstruction with proximal releasing delivery system (with video)

BACKGROUND

Self-expandable metal stents are an alternative to preoperative and palliative colostomy for patients with malignant colorectal obstruction. However, self-expandable metal stent placement is considered unsuitable or contraindicated for patients with malignant lower rectal obstruction within 5 cm of the anal verge because the exposed stent portion can irritate the distal rectum and cause anal pain and a foreign body sensation.

OBJECTIVE

To describe our experience with 6 patients with malignant lower rectal obstruction who underwent stent insertion with a proximal releasing delivery system (PRDS).

DESIGN

Prospective clinical series outcome study.

SETTING

A tertiary-care referral university hospital.

PATIENTS

This study involved all patients at our center who had a malignant lower rectal obstruction within 5 cm of the anal verge caused by rectal cancer and bladder cancer.

INTERVENTION

Uncovered stent with the PRDS with endoscopic and fluoroscopic guidance.

MAIN OUTCOME MEASUREMENTS

Technical and clinical success rate, adverse event rate, and stent migration rate.

RESULTS

All stents were placed at the expected location. Technical and clinical success rates were 100%. Two patients reported anal pain, which was controlled with analgesics. One case of tumor ingrowth occurred after 5 months and was treated with reinsertion of a stent with the PRDS. After stent insertion, the patients received chemotherapy, chemoradiotherapy, or conservative care.

LIMITATIONS

Small number of patients and no comparison group. Further prospective, randomized, controlled trials are needed.

CONCLUSIONS

Uncovered stent insertion with the PRDS is a feasible, safe, and effective treatment for the patient with malignant lower rectal obstruction within 5 cm from the anal verge.

Acute GI obstruction

Acute gastrointestinal obstruction occurs when the normal flow of intestinal contents is interrupted. The blockage can occur at any level throughout the gastrointestinal tract. The clinical symptoms depend on the level and extent of obstruction. Various benign and malignant processes can produce acute gastrointestinal obstruction, which often represents a medical emergency because of the potential for bowel ischemia leading to perforation and peritonitis. Early recognition and appropriate treatment are thus essential. The typical clinical symptoms associated with obstruction include nausea, vomiting, dysphagia, abdominal pain and failure to pass bowel movements. Abdominal distention, tympany due to an air-filled stomach and high-pitched bowel sounds suggest the diagnosis. The diagnostic process involves imaging including radiography, ultrasonography, contrast fluoroscopy and computer tomography in less certain cases. In patients with uncomplicated obstruction, management is conservative, including fluid resuscitation, electrolyte replacement, intestinal decompression and bowel rest. In many cases, endoscopy may aid in both the diagnostic process and in therapy. Endoscopy can be used for bowel decompression, dilation of strictures or placement of self-expandable metal stents to restore the luminal flow either as a final treatment or to allow for a delay until elective surgical therapy. When gastrointestinal obstruction results in ischemia, perforation or peritonitis, emergency surgery is required.

Evidence-based recommendations on colorectal stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Recently, placement of self-expandable metallic stents has been used for the treatment of colorectal obstruction. As domestic awareness of colorectal cancer has increased, the number of colorectal stenting procedures performed has also increased. We aimed to provide evidence-based recommendations for colorectal stenting to aid gastroenterologists in making informed decisions regarding the management of patients who present with colorectal obstruction. The working group consisted of eight gastroenterologists who actively practice and conduct research in the field of colorectal stenting and are the members of the Stent Study Group of the Korean Society of Gastrointestinal Endoscopy. A literature search was conducted using the PubMed, Embase, KoreaMed, and the Cochrane Library databases to identify relevant articles published between January 2001 and June 2012. Based on the modified Delphi process, 10 recommendation statements regarding indications, usefulness, methodology and complications of colorectal stenting, and alternative treatments for malignant colorectal obstruction were determined. The contents will be widely distributed, and periodically revised to reflect the latest knowledge. These evidence-based recommendations for colorectal stenting will provide gastroenterologists and patients with appropriate and balanced information, and will improve the quality of care.

Angular positioning of stent increases bowel perforation after self-expandable metal stent placement for malignant colorectal obstruction

Background/Aims

Some factors like stent wires, balloon dilatation and use of guide wires seems to increase perforation after self-expandable metal stent (SEMS) placement, but few studies mentioned about the relationship between angulation of malignant stricture and perforation. The present study aimed to confirm that more angular positioning of stents increases perforation.

Methods

This study was conducted with retrospectively evaluation at Digestive Disease Center, CHA Bundang Medical Center, CHA University. Between January 2002 and August 2011, SEMS was inserted in 130 patients with malignant colorectal obstruction. We studied the difference in the angle of stenosis between perforation and non-perforation groups using fluorography images.

Results

SEMS insertion was performed in 130 cases of obstruction due to colon cancer. Perforation occurred in eight patients (6.2%) of them. Thirteen cases were excluded from the analysis due to poor fluoroscopic images. Among the eight patients with perforation, the mean stenosis angle was 109.9° compared to 153.1° in the nonperforation group, indicating that the angle was more acute in the perforation group (p=0.016).

Conclusions

This study shows that more angular positioning of stent increases bowel perforation after SEMS placement for malignant colorectal obstruction.

Successful Self-Expandable Metallic Stent Placement for a Case of Distal Rectal Stenosis due to Gastric Cancer Metastasis

A 47-year-old woman was diagnosed as having advanced gastric cancer with malignant ascites. Despite chemotherapy, recurrent peritoneal dissemination was seen 1.5 years after operation. A computed tomography scan revealed rectal stenosis due to Schnitzler's metastasis. When the distance from the distal end of the obstruction to the anal verge is less than 5 cm, stent replacement has been said to be contraindicated due to the development of anal pain and foreign body sensation. Although the distance from the distal end of the obstruction to the anal verge was 4 cm in this case, a WallFlex^TM colonic stent could be placed. She stayed home, and luminal patency remained until she died 270 days after stent insertion. This report demonstrates that rectal obstruction located less than 5 cm from the anal verge due to Schnitzler's metastasis could be treated by stenting without any symptomatic or technical complications.

Usefulness of a guiding sheath for fluoroscopic colorectal stent placement

Objective

To investigate the technical feasibility, clinical usefulness, and safety of a guiding sheath in fluoroscopic stent placement for patients with malignant colorectal obstructions.

Materials and Methods

Between June 2007 and January 2011, fluoroscopic placement of a dual colorectal stent was attempted in a total of 97 patients with malignant colorectal obstructions. A polytetrafluoroethylene guiding sheath was used in patients in whom a stent delivery system failed to reach the obstruction. Usefulness of the sheath was evaluated depending on whether the sheath could successfully assist the stent delivery system reach its area of interest.

Results

The guiding sheath was needed in 22 patients (15 men, 7 women; age range, 33-77 years; mean age, 59 years). The overall success rate for passing the sheath to the area of interest was 100%. There were no procedure-related deaths or major complications. The majority of the patients reported mild discomfort. In 2 of 22 patients with successful passing of the sheath to the area of interest, stent placement failed because of failure in the negotiation of a guide wire through the obstruction.

Conclusion

Using a guiding sheath seems to be easy, safe and useful in fluoroscopic stent placement for patients with malignant colorectal obstructions.

Endoskopische Möglichkeiten der Behandlung von Nahtinsuffizienzen im Rektum

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen eine gefürchtete Komplikation der kolorektalen Chirurgie dar. Endoskopische Techniken haben sich in der Therapie der Leckagen zunehmend etabliert. In dieser Übersicht möchten wir einen Überblick der wichtigsten endoskopischen Verfahren geben. <b><i>Methode: </i></b>Systematische Recherche der vorhandenen Literatur. <b><i>Ergebnisse: </i></b>Die bedeutendsten endoskopischen Verfahren zur Behandlung der kolorektalen Anastomoseninsuffizienzen stellen die Fibrininjektion, die Vakuumschwammtherapie (Endo-Sponge), spezielle Clip-Systeme (OTSC) sowie die Stentimplantation dar. Der breiten klinischen Anwendung dieser Verfahren steht jedoch eine unzureichende Studienlage gegenüber. <b><i>Schlussfolgerung: </i></b>Die Einschätzung der Wertigkeit der einzelnen endoskopischen Verfahren untereinander und in speziellen therapeutischen Situationen hängt im Wesentlichen von der Erfahrung der Untersucher ab. Es bedarf der Durchführung randomisierter, prospektiver Studien, um diese Erfahrungen zu objektivieren.

Fluoroscopic management of complications after colorectal stent placement

Colorectal self-expanding metal stents have been widely used as a bridge to surgery in patients with acute malignant colonic obstruction by allowing a single-stage operation, or as a definitive palliative procedure in patients with inoperable tumors. Colonic stents are placed under either fluoroscopic or combined endoscopic and fluoroscopic guidance, with similar technical-success and complication rates. Placement of colonic stents is a very safe procedure with a low procedure-related mortality rate, but serious complications can develop and reinterventions are not uncommon. Most of the complications can be treated by minimally invasive or conservative techniques, while surgical interventions are required for most patients with perforation.

Management of recurrent rectal cancer

BACKGROUND

Here we present a concise review on the evaluation and management of locally recurrent rectal cancer, which despite marked reductions in the rate of recurrent rectal cancer remains an important problem.

METHODS

This educational review discusses the diagnosis, evaluation, and management of recurrent rectal cancer.

RESULTS

Despite improvements in both the neoadjuvant and surgical management of rectal cancer, local recurrence is still an important problem, with documented recurrence rates of 4% to 8%. The local management of recurrence requires a team of specialist. Accurate detection and diagnosis followed by chemoradiotherapy and surgical resection may result in 5-year survival rates of up to 35%.

CONCLUSIONS

We discuss the diagnosis, evaluation, and management of locally recurrent rectal cancer. Locally recurrent rectal cancer can be successfully managed with multimodal therapy leading to successful palliation and often cure.

Interventional palliative strategies for malignant bowel obstruction

Malignant bowel obstruction is the luminal narrowing of the small bowel or colon due to direct or indirect cancer growth. Small bowel obstruction usually occurs at the level of the duodenum. Interventional, nonoperative strategies for palliation of malignant bowel obstruction include endoscopic and radiologic techniques. The latter are performed by interventional radiologists. Palliation of luminal small bowel and colonic obstruction primarily is achieved through the use of endoscopically or radiologically placed self-expandable metal stents. Gastrostomy and jejunal tubes also may be placed to provide palliative decompression when other palliative methods are not possible.

Dual-design expandable colorectal stent for malignant colorectal obstruction: comparison of flared ends and bent ends

OBJECTIVE

The purpose of this study was to compare, focusing on colonic perforation and stent migration, the clinical safety and efficacy of dual-design expandable colorectal stents with flared ends with those of stents with bent ends in the treatment of patients with malignant colorectal obstruction.

SUBJECTS AND METHODS

A total of 122 patients with malignant colorectal obstruction underwent implantation of dual-design stents with flared (n = 69) or bent (n = 53) ends.

RESULTS

Stent placement was technically successful in 116 of 122 patients (95.1%), 65 of 69 patients (94.2%) with flared-end stents and 51 of 53 patients (96.2%) with bent-end stents (p > 0.05). Clinical success was achieved within 2 days in 61 of 65 patients (93.8%) with bent-end stents and in 46 of 51 patients (90.2%) with flared-end stents (p > 0.05). Complications included seven cases of colonic perforation (6%), seven cases of stent migration (6%), three cases of tumor overgrowth (2.6%), four cases of severe rectal pain (3.4%), and four cases of bleeding (3.4%). There were no significant differences between the rates of colonic perforation and stent migration in the two groups (6.2% vs 5.9%), and the overall complication rates were similar (p > 0.05).

CONCLUSION

Dual-design expandable colorectal stents with flared ends and those with bent ends are equally safe and effective, having similar perforation and migration rates.

Endoscopic treatment of colonic obstruction

PURPOSE OF REVIEW

Over the past 15 years, great strides have been made in the nonsurgical management of malignant large bowel obstruction. Progress continues, particularly in the area of self-expanding metal stents. The purpose of this review is to assess the available endoscopic techniques for colonic decompression and document the inexorable trend toward supremacy of the self-expanding metal stent in this arena.

RECENT FINDINGS

Stents are being designed with the structure and function of the colon in mind allowing better and longer-lasting palliation. Improvement in the design of the colonic decompression tube allows a low-tech approach to the palliation of colonic obstruction. Argon plasma coagulation is helpful in restoring continuity of the obstructed colonic lumen in certain circumstances.

SUMMARY

As a consequence of technological innovation and growing expertise in the community, gastroenterology is becoming the go to specialty in the early management and palliation of malignant bowel obstruction.