The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction

Endoscopic Management of Colonic Obstruction

Large bowel obstruction is a serious event that occurs in approximately 25% of all intestinal obstructions. It is attributed to either benign, malignant, functional (pseudo-obstruction), or mechanical conditions. Benign etiologies of colonic obstructions include colon volvulus, anastomotic strictures, radiation injury, ischemia, inflammatory processes such as Crohn's disease, diverticulitis, bezoars, and intussusception.

Percutaneous endoscopic cecostomy for management of Ogilvie's syndrome: a case series and literature review with an update on current guidelines (with video)

INTRODUCTION

Percutaneous endoscopic cecostomy (PEC) is a viable treatment option for patients with persistent or recurrent acute colonic pseudo-obstruction (ACPO; Ogilvie's syndrome). It should be generally considered in patients that are refractory to pharmacologic and endoscopic decompression, especially those not amenable to surgical intervention due to an increased perioperative risk. Physicians are rather unfamiliar with this approach given the limited number of reports in the literature and paucity of guideline resources, although guidelines concerning ACPO and covering the role of endoscopy were recently published by three major expert societies, all within the last 2 years.

PATIENTS AND METHODS

We retrospectively identified three consecutive patients who underwent PEC placement at a Czech tertiary referral center between May 2018 and December 2021: all for recurrent ACPO. In addition, we summarized the current guidelines in order to present the latest knowledge related both to the procedure and management approach in patients with ACPO.

RESULTS

The placement of PEC was successful and resulted in clinical improvement in all cases without any adverse events.

CONCLUSION

The results of our experience are in line with previous reports and suggest that PEC may become a very useful tool in the armamentarium of modalities utilized to treat ACPO. Furthermore, the availability of guideline resources now offers comprehensive guidance for informed decision-making and the procedural aspects.

Self-expanding metal stents versus decompression tubes as a bridge to surgery for patients with obstruction caused by colorectal cancer: a systematic review and meta-analysis

BACKGROUND

Using self-expanding metal stents (SEMS) and decompression tubes (DT) as a bridge-to-surgery (BTS) treatment may avoid emergency operations for patients with colorectal cancer-caused obstructions. This study aimed to evaluate the efficacy and safety of the two approaches.

METHODS

We systematically retrieved literature from January 1, 2000, to May 30, 2023, from the PubMed, Embase, Web of Science, SinoMed, Wanfang Data, Chinese National Knowledge Infrastructure, and Cochrane Central Register of Clinical Trials databases. Randomized controlled trials (RCTs) or cohort studies of SEMS versus DT as BTS in colorectal cancer obstruction were selected. Risks of bias were assessed for RCTs and cohort studies using the Cochrane Risk of Bias tool version 2 and Risk of Bias in Nonrandomized Studies of Interventions. Certainty of evidence was determined using the Graded Recommendation Assessment. Odds ratio (OR), mean difference (MD), and 95% confidence interval (95% CI) were used to analyze measurement data.

RESULTS

We included eight RCTs and eighteen cohort studies involving 2,061 patients (SEMS, 1,044; DT, 1,017). Pooled RCT and cohort data indicated the SEMS group had a significantly higher clinical success rate than the DT group (OR = 1.99, 95% CI 1.04, 3.81, P = 0.04), but no significant difference regarding technical success (OR = 1.29, 95% CI 0.56, 2.96, P = 0.55). SEMS had a shorter postoperative length of hospital stays (MD = - 4.47, 95% CI - 6.26, - 2.69, P < 0.00001), a lower rates of operation-related abdominal pain (OR = 0.16, 95% CI 0.05, 0.50, P = 0.002), intraoperative bleeding (MD = - 37.67, 95% CI - 62.73, - 12.60, P = 0.003), stoma creation (OR = 0.41, 95% CI 0.23, 0.73, P = 0.002) and long-term tumor recurrence rate than DT (OR = 0.47, 95% CI 0.22, 0.99, P = 0.05).

CONCLUSION

SEMS and DT are both safe as BTS to avoid emergency surgery for patients with colorectal cancer obstruction. SEMS is preferable because of higher clinical success rates, lower rates of operation-related abdominal pain, intraoperative bleeding, stoma creation, and long-term tumor recurrence, as well as a shorter postoperative length of hospital stays. Trial registration CRD42022365951 .

WSES consensus guidelines on sigmoid volvulus management

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus.

Colonic stent for bridge to surgery for acute left-sided malignant colonic obstruction: A review of the literature after 2020

It has been found that 8%-29% of colorectal cancers are obstructive. The use of “stent as bridge to surgery” is one of the most debated topics in obstructive left-sided colorectal cancer management. The endoscopic placement of a self-expanding metallic stent as bridge to surgery (BTS) could turn an emergency surgery to an elective one, increasing the number of primary anastomoses instead of stoma and facilitating the laparoscopic approach instead of an open one. However, in recent years the possible risk of perforations and microperforations facilitating cancer spread related to the use of self-expanding metallic stent for BTS has been highlighted. Therefore, despite the useful short-term outcomes related to BTS, the recent literature has focused on long-term outcomes investigating the disease-free survival, the recurrence rate and the overall survival. Due to discordant data, international guidelines are still conflicting, and the debate is still open. There is not agreement about using self-expanding metallic stent for BTS as the gold standard.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.

When to Perform a Colonoscopy in Diverticular Disease and Why: A Personalized Approach

Colonoscopy is a crucial diagnostic tool in managing diverticular disease (DD). Diverticulosis can often be an unexpected diagnosis when colonoscopy is performed in asymptomatic subjects, generally for colorectal cancer screening, or it could reveal an endoscopic picture compatible with DD, including acute diverticulitis, in patients suffering from abdominal pain or rectal bleeding. However, alongside its role in the differential diagnosis of colonic diseases, particularly with colon cancer after an episode of acute diverticulitis or segmental colitis associated with diverticulosis, the most promising use of colonoscopy in patients with DD is represented by its prognostic role when the DICA (Diverticular Inflammation and Complication Assessment) classification is applied. Finally, colonoscopy plays a crucial role in managing diverticular bleeding, and it could sometimes be used to resolve other complications, particularly as a bridge to surgery. This article aims to summarize “when” to safely perform a colonoscopy in the different DD settings and “why”.

Acute Colonic Pseudo-Obstruction

Acute colonic pseudo-obstruction (ACPO) is a functional disorder of the large intestine distinguished by colonic dysmotility resulting in colonic distension in the absence of mechanical obstruction. The underlying pathophysiology of ACPO remains unclear despite technological advances in understanding the physiology of colonic motility, such as spatio-temporal mapping and high-resolution manometry. In many ways, the management of ACPO has remained relatively unchanged for 40 years. Patients with perforation or suspected ischemia undergo operative intervention, while patients without undergo initial conservative management with bowel rest, correction of electrolyte disturbances, and mobilization. Patients who fail conservative management or have prominent cecal dilatation undergo decompression with either neostigmine or colonoscopy. A subset of patients with ACPO will have recurrent symptoms despite endoscopic and medical management. For these patients who are difficult to manage, an underlying colonic functional disorder, such as slow-transit dysmotility or chronic intestinal pseudo-obstruction may be considered. The following review of ACPO aims to provide a concise update of the causes, diagnosis, and management of this emergency surgical condition.

A Rare Case of a Failed AngioVac Procedure Used to Debride Tricuspid Vegetation Complicated by Ogilvie Syndrome

Ogilvie syndrome is a rare disorder characterized by dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. Its etiology is likely multifactorial with high mortality if left untreated. Here, we report for the first time a case of Ogilvie syndrome secondary to the AngioVac procedure. Because our patient had a high operative risk, we used the AngioVac system to debulk tricuspid valve vegetations to reduce bacterial load. Although AngioVac is considered safe overall, publications describing its side effects, safety, and efficacy are limited. Providers should be aware of this rare but potentially fatal complication and the importance of close clinical monitoring and serial abdominal examinations following AngioVac procedures.

Advances in gastrointestinal surgical endoscopy

Surgeons have a role in observing, detect abnormalities, disease, and other deficiencies in function which could be treated. Diagnosing and treating back days were challenging for many reasons. However, technology's innovation enhances surgeons' ability to treat their patients. The term endoscopy refers to the Greek prefix endo- ("within") and the verb skopein ("to view or observe"). Endoscopy is practical both in the diagnosis and treatment of various pathologies. Technological advances, especially in endoscopy, gradually progress and discover many possibilities which allow rapid advancement. Endoscopy development aims to assess human orifice that has not been inspected, probed, and examined over the centuries. Endoscopy over these decades is improving, which led to new problem solving using advanced technological approaches. Thus, a surgeon can solve any issues from examination, diagnosis, and treatment using progressive endoscopy evolution. This review delivers a brief history of advances in surgical endoscopy and describes current endoscopy development.

Acute colonic pseudo-obstruction (Ogilvie syndrome) leading to respiratory compromise and death

Here, we present an unusual case of acute colonic pseudo-obstruction (ACPO), also known as Ogilvie syndrome, which resulted in respiratory failure and sudden death. The patient was a 19-year-old man with a history of cerebral palsy (CP) and severe autism who experienced marked abdominal distension that progressed over several days in his skilled nursing facility. He developed shortness of breath and episodic diarrhea, before having an unwitnessed cardiac arrest and subsequently expiring after prehospital and emergency department care. Autopsy revealed developmental deformities consistent with CP, rectal prolapse, and significant abdominal distension. Postmortem radiography showed diffuse bowel distension with bilateral upward displacement of the diaphragm and consequent lung compression. Thorough examination of the gastrointestinal tract failed to reveal any perforation or obstruction. The cause of death was determined to be respiratory compromise secondary to diaphragmatic compression as a result of ACPO, a condition defined as colonic distension without a mechanical explanation for obstruction. This case highlights the challenges that ACPO can pose to a forensic pathologist at autopsy, and serves as a teaching point to clinicians on the warning signs and treatment measures for ACPO.

An Unusual Cause of Large Bowel Obstruction in a Patient With Ulcerative Colitis

Endometriosis is a rare cause of large bowel obstruction and has been infrequently reported in patients with inflammatory bowel disease. We present an unusual case of a young woman with ulcerative colitis, who presented with a large bowel obstruction with colonic stricture and peripancreatic mass concerning for malignancy. The evaluation revealed endometriosis, and her large bowel obstruction was successfully managed with leuprolide and colonic stenting.

Considerations in the Management of Malignant Bowel Obstruction

Malignant bowel obstruction is a challenging clinical problem encountered in patients with advanced abdominal and pelvic malignancies. Although medical therapies form the foundation of management, some patients may be suitable candidates for surgical and procedural interventions. The literature is composed primarily of retrospective single-institution experiences and the results of prospective trials are pending. Given the high symptom burden and limited life expectancy of these patients, management may be best informed by multidisciplinary teams with relevant expertise.

Efficacy and Safety of Neostigmine and Decompressive Colonoscopy for Acute Colonic Pseudo-Obstruction: A Single-Center Analysis

Background

Acute colonic pseudo-obstruction (ACPO) is characterized by acute colonic dilation in the absence of anatomical obstruction. Neostigmine is an acetylcholinesterase inhibitor recommended as first-line salvage therapy for uncomplicated ACPO. Decompressive colonoscopy is recommended if neostigmine is contraindicated or unsuccessful. There is a need to better characterize relative efficacy and factors impacting treatment choice. The aim of the study was to examine the use, efficacy, and safety of neostigmine and decompressive colonoscopy in the management of ACPO at a single academic center.

Methods

Patients ≥ 18 years of age meeting established criteria for uncomplicated ACPO and with cecal diameter ≥ 10 cm on imaging between 1999 and 2019 were identified. Individuals were categorized as having received supportive care alone or subsequent trials of neostigmine or decompressive colonoscopy. Demographics and pre- and post-intervention data were collected, including indication and contraindication to intervention used, time to intervention, initial response, and adverse events.

Results

In 46 cases of ACPO (N = 42 patients), all but one individual received initial supportive care. Seven responded to conservative measures alone. Of the patients failing supportive care, 15 cases were initially treated with neostigmine (response rate 86.7%) and 24 initially underwent decompressive colonoscopy (response rate 95.8%) (P = 0.390). One episode of transient bradycardia, resolved with atropine, occurred in the neostigmine group. One patient experienced respiratory instability during colonoscopy.

Conclusions

Both neostigmine and decompressive colonoscopy appear effective for treating uncomplicated ACPO in individuals failing conservative therapy. Adverse events were infrequent in both cohorts. Future prospective studies examining treatment for ACPO should focus on whether either intervention is superior to the other.

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

Risk factors affecting failure of colonoscopic detorsion for sigmoid colon volvulus: a single center experience

PURPOSE

Colonoscopic detorsion (CD) is the first treatment option for uncomplicated sigmoid volvulus (SV). We aim to examine the factors affecting the failure of CD.

METHODS

The files of patients, treated after diagnosis of SV between January 2015 and September 2020, were retrospectively reviewed. Patients' demographic data, comorbidities, endoscopy reports, and surgical and other treatments were recorded. Patients were divided into two groups, as the successful CD group and unsuccessful CD group. The data were compared between the groups, and multivariate analysis of statistically significant variables was performed.

RESULTS

There were 21 patients in the unsuccessful CD group and 52 patients in the successful CD group. The unsuccessful CD rate was found to be 28.76%; this is likely a function of more neuropsychiatric disease, more accompanying sigmoid diverticulum, previous abdominal surgery, abdominal tenderness, onset of symptoms for more than 48 h, higher mean intra-abdominal pressure (IAP), IAP over 15 mmHg, larger mean diameter of the cecum, the cecum diameter over 10 cm, and higher mean C-reactive protein (CRP) values as statistically significant. In the multivariate analysis, previous abdominal surgery and cecum diameter over 10 cm were seen as predictive factors for failure of CD (p=0.049, OR=0.103, and p = 0.028, OR=10.540, respectively).

CONCLUSIONS

CD failure rate was significantly associated with previous abdominal surgery and a cecum diameter over 10 cm. We found that patients with these factors will tend to need more emergency surgery.

Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis

BACKGROUND

With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients.

METHODS

We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates.

RESULTS

We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I² = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I² = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I² = 79.3%, P < 0.001).

CONCLUSION

The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Colonic Stent Use by Indication and Patient Outcomes: A Nationwide Inpatient Sample Study

BACKGROUND

Colonic stent placement can avoid urgent surgery for large bowel obstruction in selected patients. Population-wide stent utilization patterns and outcomes are unknown.

MATERIALS AND METHODS

Using retrospective, population-based, Nationwide Inpatient Sample data, we studied patients with colonic stents discharged during 2010-2015. The primary outcome was ostomy creation during the same hospitalization. Other outcomes were perforation or peritonitis, and in-hospital death. Associations of outcomes with stent indication were investigated, adjusting for patient-, admission-, and hospital characteristics. We estimated annual population-wide stent use volumes.

RESULTS

Of 4257 patients with stent placement (52% male, mean age 64.6 years), 9.9% had non-metastatic colon cancer, 12.9% metastatic colon cancer, 37.8% extracolonic malignancy (ECM), and 39.3% had benign obstruction. In 8.1% of patients, ostomy creation surgery was performed. Perforation or peritonitis occurred in 16.7%, and in-hospital death in 4.5%. Relative to ECM, ostomy creation was several-fold more likely among nonmetastatic colon cancer (adjusted odds ratio (OR) 3.4; 95%CI, 2.1-5.5), metastatic colon cancer (adjusted OR 2.5; 95%CI, 1.7-3.7), and benign obstruction patients (adjusted OR 3.1; 95%CI, 2.1-4.7). Benign obstruction was associated with high risk of perforation/peritonitis (adjusted OR 3.1 relative to non-metastatic CC (95%CI, 2.1-4.5)). Perforation/peritonitis was highly associated with inpatient death (adjusted OR 6.8 (95%CI, 4.9-9.5)). Annually, about 3,580 patients underwent stent placement, with benign obstruction showing an increasing trend (P=0.0002).

CONCLUSIONS

Over 75% of stent placements were done for patients with benign disease and ECM obstruction. Subsequent ostomy creation during the hospitalization was least likely among ECM patients. Rates of perforation/peritonitis in benign obstructions were concerningly high. (22.2%).

Appraisal of the Current Guidelines for Management of Malignant Left-Sided Colonic Obstruction Using the Appraisal of Guidelines Research and Evaluation II Instrument

INTRODUCTION

Colorectal cancer (CRC) is the fourth leading cause of death with 1.4 million new cases occurring annually worldwide. High-quality clinical practice guidelines are needed to tailor high-quality individualized treatment. The aim of the present study was to evaluate the methodological quality of the current guidelines for the management of acute malignant left-sided colonic bowel obstruction.

METHODS

A systematic search of the literature was carried out using electronic databases. The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess the quality of each guideline.

RESULTS

Search results returned a total of 14 guidelines appropriate for assessment. Both domain I (scope and purpose) and domain VI (editorial independence) were assessed with the same median score of 83%. The lowest scoring domain was domain V (applicability), scoring only 43%. The 2 guidelines that had the highest score were the National Institute for Health and Care Excellence (NICE) and Scottish Intercollegiate Guidelines Network (SIGN), each scoring 100%. However, there were significant variations in terms of quality. The NICE and New Zealand guidelines were voted unanimously for use unchanged, whilst 8 other guidelines were voted for use with modifications.

CONCLUSION

Variation in guideline quality in CRC is a concern despite some clearly excellent published guidelines. All guidelines score poorly when it comes to describing how the guidelines could be applied. Lack of patient participation in guideline development is also a shortcoming that requires urgent redress.

Endoscopic Decompression in Colonic Distension

Background

Acute colonic distension is a medical emergency with high morbidity and mortality. Clinically important causes of colonic distension are acute colonic pseudo-obstruction, colonic volvulus, and malignant obstruction. Endoscopic decompression is one established therapeutic strategy.

Summary

This therapeutic review will give an overview of possible therapeutic strategies based on the recently published literature, focusing on endoscopic decompression and summarizing the other therapeutic possibilities. The review discusses separately the therapeutic options of acute colonic pseudo-obstruction, colonic volvulus, and malignant obstruction, providing an evidence-based orientation for clinical use.

Key Messages

Endoscopic decompression of colonic distension is an established therapy with high clinical success. The technique and its position in the therapy sequence differ depending on the medical condition, the trigger of the colonic distension, and the local expertise.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in emergency colorectal surgery

AIM

There is a requirement for an expansive and up to date review of the management of emergency colorectal conditions seen in adults. The primary objective is to provide detailed evidence-based guidelines for the target audience of general and colorectal surgeons who are responsible for an adult population and who practise in Great Britain and Ireland.

METHODS

Surgeons who are elected members of the Association of Coloproctology of Great Britain and Ireland Emergency Surgery Subcommittee were invited to contribute various sections to the guidelines. They were directed to produce a pathology-based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. Each author was asked to provide a set of recommendations which were evidence-based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after two votes were included in the guidelines.

RESULTS

All aspects of care (excluding abdominal trauma) for emergency colorectal conditions have been included along with 122 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence-based summary of the current surgical knowledge in the management of emergency colorectal conditions and should serve as practical text for clinicians managing colorectal conditions in the emergency setting.

Short- and long-term outcomes of self-expanding metallic stent placement vs. emergency surgery for malignant colorectal obstruction

The European Society of Gastrointestinal Endoscopy does not recommend self-expanding metal stent (SEMS) placement as a bridge to surgery (BTS) for malignant colorectal obstruction (MCRO). However, no universally accepted consensus has been determined. The present study aimed to evaluate the short- and long-term outcomes of SEMS placement vs. emergency surgery (ES) for MCRO. Surgical resection of colorectal cancer was performed in 3,840 patients between April 2001 and June 2016. Of these, 93 patients had MCRO requiring emergency decompression. Only patients in whom the colorectal lesion was ultimately resected were included; thus, the present study included 62 patients treated with MCRO via SEMS placement as a BTS (n=25) or via ES (n=37). The rates of laparoscopic surgery, primary anastomosis, stoma formation, lymph node dissection, adverse events, 30-day mortality and disease-free survival were evaluated. The clinical success rate of SEMS placement was 92.0% (23/25). Compared with the ES group, the SEMS group had higher rates of laparoscopic surgery (68.0 vs. 2.7%; P<0.001) and primary anastomosis (88.0 vs. 51.4%; P=0.003), a greater number of dissected lymph nodes (30 vs. 18; P=0.001), and lower incidences of stoma formation (24.0 vs. 67.6%; P=0.002) and overall adverse events (24.0 vs. 62.2%; P=0.004). The 30-day mortality and disease-free survival of the SEMS group were not significantly different to that of the ES group (0 vs. 2.7%; P=1.000; log-rank test; P=0.10). In conclusion, as long as adverse events such as perforation are minimized, SEMS placement as a BTS could be a first treatment option for MCRO. The present study is registered in the University Hospital Medical Network Clinical Trials Registry (UMIN R000034868).

Acute colonic pseudo-obstruction with bowel rupture after caesarean section in HELLP syndrome: a case report

Background

Ogilvie syndrome, also known as acute colonic pseudo-obstruction (ACPO), can occur postpartum after caesarean section (C-section), often resulting in caecal dilatation. The incidence rate is approximately 100 cases in 100,000 patients per year (Ross et al., Am Surg 82:102-11, 2016). Without proper diagnosis and treatment, it may progress to intestinal perforation or other fatal complications.

Case presentation

A 39-year-old pregnant woman underwent emergency low-segment C-section due to complications of Haemolysis, Elevated Liver enzymes and Low Platelets syndrome (HELLP) syndrome. ACPO was suspected on the third day after C-section based on inability to pass flatus, evident abdominal distension, slight abdominal pain, and computed tomography (CT) scan revealing severe, diffuse colonic distention with caecal dilatation of approximately 9 cm. Based on these findings, conservative treatment was implemented. However, 6 days after C-section, her symptoms worsened, and CT showed possible intestinal perforation; thus, an emergency laparotomy was performed. Due to a 3-cm (diameter) laceration in the anterolateral wall of the ascending colon and a 5-cm tear in the ileocecal junction, in combination with mucosal eversion in the colon, resection of the ileocecum, distal closure of the ascending colon, and a terminal ileostomy were performed. The patient was discharged 2 weeks post-laparotomy and continued to undergo nursing care for the incision and stoma. Ileostomy was performed 4 months later.

Conclusion

Ogilvie syndrome after C-section is an extremely rare but severe condition, which warrants early recognition and treatment to prevent potentially fatal complications, especially in patients with poor health status.

Pseudoobstrucción colónica aguda (Sindrome de Ogilvie) posterior a una nefrectomía radical: Reporte de caso

El Sindrome de Ogilvie se caracteriza por una dilatación masiva del colon y una clínica sugestiva de obstrucción intestinal mecánica, sin causa orgánica. Presentamos un caso de dilatación aguda idiopática del colon secundaria a una cirugía abdominal.

El objetivo de este reporte fue la descripción de una patología urológica inusual que puede pasarse por alto o tratarse como un íleo adinámico y, la revisión de la literatura relacionada con la definición, factores de riesgos, etiología, fisiopatología y el tratamiento de la misma.

Paciente masculino de 61 años con antecedente de nefrectomía radical izquierda por tumor renal que, a las 48hs del alta hospitalaria, consultó por presentar distensión abdominal aguda. Se solicitó una radiografía abdominal y una tomografía computada que evidenciaba importante dilatación intestinal y un diámetro cecal mayor a 12cm.

Se practicó una laparotomía exploradora de urgencia constatándose dilatación colónica del colon transverso y ascendente con un cambio de diámetro a nivel del ángulo esplénico, sin causa osbtructiva. Finalmente, se realizó colostomía en asa.

A los 6 meses de seguimiento, la videocolonoscopía no mostró lesiones endoluminales concluyendo en un Sindrome de Ogilvie secundario a la nefrectomía. Finalmente, se efectuó reconstrucción del tránsito con buena evolución posterior.

En nuestro caso, el Sindrome de Ogilvie fue una complicación postoperatoria y como fallaron las terapias conservadoras iniciales instauradas, este reporte provee una modalidad de tratamiento alternativo. Si se reconoce temprano y se trata adecuadamente, la pseudoobstrucción se resolverá en la mayoría de los pacientes y la tasa de mortalidad posterior será menor.

Obstructing Left-Sided Colonic Cancer: Is Endoscopic Stenting a Bridge to Surgery or a Bridge to Nowhere?

For the 8-29% colorectal cancers that initially manifest with obstruction, emergency surgery (ES) was traditionally considered the only available therapy, despite high morbidity and mortality rates and the need for colostomy creation. More recently, malignant obstruction of the left colon can be temporized by endoscopic placement of a self-expanding metallic stent (SEMS), used as bridge to surgery (BTS), facilitating a laparoscopic approach and increasing the likelihood that a primary anastomosis instead of stoma would be used. Despite these attractive outcomes, the superiority of the BTS approach is not clearly established. Few authors have stressed the potential cancer risk associated with perforations that may occur during endoscopic stent placement, facilitating neoplastic spread and negatively impacting prognosis. For this reason, the current literature focuses on long-term oncologic outcomes such as disease-free survival, overall survival and recurrence rate that do seem not to differ between the ES and BTS approaches. This lack of consensus has spawned differing and sometimes discordant guidelines worldwide. In conclusion, 20 years after the first description of a colonic stent as BTS, the debate is still open, but the growing number of articles about the use of SEMS as a BTS signifies a great interest in the topic. We hope that these data will finally converge on a single set of recommendations supporting a management strategy with well-demonstrated superiority.

Case Report of Ogilvie's Syndrome Following Emergency Haemostatic Subtotal Abdominal Hysterectomy at University Teaching Hospital of Butare, Rwanda

Background

Acute colonic pseudo-obstruction or Ogilvie's syndrome is a rare condition that usually develops due to a dysregulated autonomic nervous system following a medical or surgical condition. With delayed diagnosis, it may lead to bowel ischemia and perforation with poor prognosis.

Case

We report a case of a 33 years old female, Gravida 1, Para1, who developed severe abdominal distension following abdominal haemostatic hysterectomy due to a severe postpartum haemorrhage and shock requiring epinephrine infusion after a spontaneous vaginal delivery. The postpartum haemorrhage was due to both atony and posterior cervical tear. Two initial administrations of neostigmine 2 mg mixed with atropine 0.5 mg were unsuccessful, but an insertion of a flexible recto-sigmoid cannula allowed a slight decompression. A subsequent third dose of neostigmine 2 mg mixed with atropine 0.5 mg was followed with a remarkable flatus evacuation and complete decompression.

Conclusion

Prompt diagnosis and management of Ogilvie's syndrome is crucial in order to avoid subsequent complications. In case of postoperative cecal and colonic distension without mechanical obstruction, Ogilvie's syndrome should be suspected as this will ensure timely and adequate management of patients at risk including obstetric patients.

Endoscopic Detorsion Results in Sigmoid Volvulus: Single-Center Experience

Endoscopic detorsion is the first-line recommended treatment modality in sigmoid volvulus patients who have no peritoneal irritation signs on admission. In this paper, we present the results of endoscopic detorsion procedures applied at the time of presentation with the diagnosis of sigmoid volvulus and review the current literature about this topic.

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.

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.

Endoscopic Management of Malignant Colonic Obstruction

Advanced colorectal cancer can cause acute colonic obstruction, which is a life-threatening condition that requires emergency bowel decompression. Malignant colonic obstruction has traditionally been treated using emergency surgery, including primary resection or stoma formation. However, relatively high rates of complications, such as anastomosis site leakage, have been considered as major concerns for emergency surgery. Endoscopic management of malignant colonic obstruction using a self-expandable metal stent (SEMS) was introduced 20 years ago and it has been used as a first-line palliative treatment. However, endoscopic treatment of malignant colonic obstruction using SEMSs as a bridge to surgery remains controversial owing to short-term complications and longterm oncological outcomes. In this review, the current status of and recommendations for endoscopic management using SEMSs for malignant colonic obstruction will be discussed.

Colonic Decompression Reduces Proximal Acute Colonic Pseudo-obstruction and Related Symptoms

BACKGROUND

Colonoscopic decompression is performed in inpatients for management of acute colonic pseudo-obstruction. Evidence for its efficacy is limited to small descriptive studies published before the use of neostigmine for acute colonic pseudo-obstruction. Furthermore, therapeutic end points were not defined.

OBJECTIVE

The aim was to compare the effectiveness of colonic decompression with standard medical therapy (supportive and pharmacologic therapy) to standard medical therapy alone.

DESIGN

This is a retrospective, propensity-matched study.

SETTING

The study was conducted at a tertiary care center.

PATIENTS

Inpatients with first diagnosis of acute colonic pseudo-obstruction between 2000 and 2016 were selected.

INTERVENTIONS

The intervention group received colonic decompression as well as supportive and/or pharmacologic therapy. The control group did not receive colonic decompression.

MAIN OUTCOME MEASURES

The primary outcome was the resolution of overall colonic dilation on imaging 48 hours following colonic decompression or the initiation of standard medical therapy alone. Secondary outcomes included symptom improvement, colonic segment diameter percentage change, perforation, 30-day readmission, and all-cause mortality.

RESULTS

The standard medical therapy and colonic decompression groups included 61 and 83 patients. Of the patients who underwent colonic decompression, 47.7% had complete resolution of acute colonic pseudo-obstruction versus 19.9% of patients who underwent standard medical therapy (p < 0.001). There were no significant differences in mid or distal colon diameter reduction between groups. The 30-day readmission rate was 15.7% in the colonic decompression group versus 26.2% in the standard medical therapy group. No immediate adverse events were noted in either group. Thirty-day all-cause mortality was 8.4% for the colonic decompression group and 14.8% in the standard medical therapy group.

LIMITATIONS

The study was a retrospective review on a highly comorbid population.

CONCLUSIONS

Colonic decompression is effective compared to standard medical therapy alone for proximal colonic dilation or symptoms associated with acute colonic pseudo-obstruction. On segmental analysis, colonic decompression does not provide any additional benefit over standard medical therapy in improving transverse or distal colonic dilation. See Video Abstract at http://links.lww.com/DCR/B32. LA DESCOMPRESIÓN COLÓNICA REDUCE LA PSEUDOOBSTRUCCIÓN COLÓNICA AGUDA PROXIMAL Y LOS SÍNTOMAS RELACIONADOS.: La descompresión colonica se realiza en pacientes hospitalizados para el tratamiento de la pseudoobstrucción colónica aguda. La evidencia de su eficacia se limita a pequeños estudios descriptivos antes del uso de neostigmina para la pseudoobstrucción colónica aguda. Además, los puntos finales terapéuticos no se definieron.El objetivo fue comparar la efectividad de la descompresión colónica mas el tratamiento médico estándar (tratamiento de apoyo y farmacológico) contra el tratamiento médico estándar solamente.Este es un estudio retrospectivo de propensión coincidente.El estudio se realizó en un centro de atención de tercer nivel.Pacientes hospitalizados con diagnóstico de pseudoobstrucción colónica aguda entre 2000 y 2016.El grupo de intervención recibió descompresión colónica, así como tratamiento de apoyo o farmacológica. El grupo control no recibió descompresión colónica.La medida de resultado primaria fue la resolución de la dilatación colónica general en la imagen 48 horas después de la descompresión colónica o el inicio del tratamiento médico estándar solo. Los resultados secundarios incluyeron mejoría de los síntomas, cambio porcentual en el diámetro del segmento colónico, perforación, reingreso a los 30 días y mortalidad por cualquier causa.La terapia médica estándar y los grupos de descompresión colónica incluyeron 61 y 83 pacientes, respectivamente. El 47,7% de los pacientes con descompresión colónica tuvieron una resolución completa de la pseudoobstrucción colónica aguda frente al 19,9% de los pacientes con terapia médica estándar (p < 0,001). No hubo diferencias significativas en la reducción del diámetro del colon medio o distal entre los grupos. La tasa de reingreso a los 30 días fue del 15,7% en el grupo de descompresión colónica frente al 26,2% en el grupo de tratamiento médico estándar. No se observaron eventos adversos inmediatos en ninguno de los dos grupos. La mortalidad por cualquier causa a los 30 días fue del 8.4% para la descompresión del colon y del 14.8% en los grupos de terapia médica estándar.El estudio fue una revisión retrospectiva en una población altamente comórbida.La descompresión colónica es efectiva en comparación con el tratamiento médico estándar solo para la dilatación del colon proximal o los síntomas asociados con la pseudoobstrucción colónica aguda. En el análisis segmentario, la descompresión colónica no proporciona ningún beneficio adicional sobre el tratamiento médica estándar para mejorar la dilatación colónica transversal o distal. Vea el resumen del video en http://links.lww.com/DCR/B32.

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.

Robot-assisted laparoscopic surgery after placing a self-expanding metallic stent for malignant rectal obstruction: a case report

BACKGROUND

Approximately 20% of colorectal cancer patients show complete or incomplete bowel obstruction as an early symptom. Preoperative nonsurgical decompression such as placing a self-expanding metallic stent for malignant colorectal obstruction has been shown to be effective for reducing perioperative morbidity and mortality. However, there is a lack of published studies reporting robot-assisted laparoscopic surgery (RALS) after self-expanding metallic stent (SEMS) placement for malignant rectal obstruction (MRO). To our knowledge, this is the first report to do so.

CASE PRESENTATION

An 80-year-old man with incomplete paralysis of the lower limbs as well as bladder-rectal disorder due to a spine fracture sustained in a fall accident 26 years ago presented with lower abdominal pain and vomiting. Abdominal multi-detector computed tomography revealed an obstructive rectal tumor with distended bowel on the oral side. Emergency colonoscopy was performed, and an SEMS placed. The patency of SEMS and decompression of the distended bowel was confirmed, and elective RALS was performed 29 days after SEMS placement. To our knowledge, this is the first report of RALS after decompression with SEMS placement for MRO.

CONCLUSIONS

RALS after SEMS placement is a safe and feasible therapeutic strategy for MRO.

Endoscopic Management of Benign Colonic Obstruction and Pseudo-Obstruction

There are a variety of causes of intestinal obstruction, with the most common cause being malignant diseases; however, volvulus, inflammatory bowel disease or diverticulitis, radiation injury, ischemia, and pseudo-obstruction can also cause colonic obstruction. These are benign conditions; however, delayed diagnosis of acute intestinal obstruction owing to these causes can cause critical complications, such as perforation. Therefore, high levels of clinical suspicion and appropriate treatment are crucial. There are variable treatment options for colonic obstruction, and endoscopic treatment is known to be a less invasive and an effective option for such. In this article, the authors review the causes of benign colonic obstruction and pseudo-obstruction and the role of endoscopy in treating them.

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.

Optimal management of malignant left-sided large bowel obstruction: do international guidelines agree?

Background

Approximately 20% of patients diagnosed with colorectal cancer will present with left-sided large bowel obstruction. The optimal management of this cohort of patients remains unclear. We aimed to review international guidelines to see if there was a consensus on the treatment of this surgical emergency.

Methods

The PubMed and Medline databases were searched for guidelines on the management of left-sided, malignant large bowel obstruction (MBO) between 2010 and 2018.

Results

Nineteen guidelines were identified spanning a range of continents. There was no clear consensus on the management of potentially resectable disease. Eight guidelines (42%) suggested primary surgery, two guidelines (11%) suggested stenting as a bridge to surgery and nine guidelines (47%) suggested surgery or stenting could be performed. Primary resection with or without anastomosis was the most frequently recommended procedure (n = 6 35%), but over a third of guidelines gave no operative recommendations. There was very limited detail on the stenting procedure and how long elective surgery should be deferred. In the palliative situation, there was general agreement that stents should be offered in preference to surgery.

Conclusion

International guidelines offer limited and contrasting recommendations on the management of left-sided MBO. There is a lack of high-quality evidence to support whether emergency surgery or stenting as a bridge to surgery is the optimal procedure in terms of morbidity, mortality and long-term oncological outcome.

Subcutaneous neostigmine appears safe and effective for acute colonic pseudo-obstruction (Ogilvie's syndrome)

BACKGROUND

Intravenous neostigmine is a well-established treatment for acute colonic pseudo-obstruction (ACPO). Its use is hampered by the perceived requirement for continuous cardiac monitoring, and patients are often transferred to high-dependency units for close observation during treatment. Subcutaneous neostigmine has the potential to minimize adverse cardiovascular effects while maintaining efficacy. This study aims to assess the safety of subcutaneous neostigmine on ward inpatients with ACPO monitored with standard nursing care.

METHODS

This is a retrospective case series of 30 patients with ACPO who were treated with subcutaneous neostigmine between August 2008 and October 2012. Data were collected prospectively. All patients were diagnosed using clinical examination and radiology and were assessed for contraindications to neostigmine. Patients were treated on regular wards and monitored with standard nursing observations. The main outcomes were time to flatus and bowels working and complications.

RESULTS

No serious complications such as clinically evident bradycardia were encountered. Ninety-three percent of patients had clinically successful resolution of ACPO. Two patients (7%) developed caecal tenderness and proceeded to colonoscopic decompression, which was successful in both instances.

CONCLUSIONS

Subcutaneous neostigmine appears to be safe for the treatment of ACPO. No clinically evident serious adverse events occurred, meaning continuous cardiac monitoring as a routine may not be necessary. In our cohort, we achieved similar success rates compared with reported rates using intravenous neostigmine.

Fluoroscopy-guided trans-anal decompression tube placement in the treatment of acute colonic pseudo-obstruction: a single center experience

PURPOSE

Acute colonic pseudo-obstruction (ACPO or Ogilvie's syndrome) is a rare but often fatal disease; timely colonic decompression may be essential for successful treatment. This study describes a technique of placing a trans-anal tube via fluoroscopy-guiding and investigates the effect of colon decompression on ACPO.

METHODS

Patients undergoing colonic decompression via fluoroscopy-guided trans-anal tube placement from April 2015 to May 2017 were included. The technical and clinical successes of this procedure were evaluated. Clinical features and long-term outcomes are described.

RESULTS

Decompression was successful in 72.73% (16/22) of the patients; the procedure was considered a clinical success in 50% (11/22) of the patients. 31.82% (7/22) of the patients underwent elective surgery, and only 18.19% (4/22) of the patients need emergency surgery.

CONCLUSIONS

Fluoroscopy-guided trans-anal decompression tube placement was an easy and efficient method for treating ACPO. Additionally, ACPO once required emergency surgery, but now may only require elective surgery in certain instances.

Oncological emergency surgery for metachronous large and small bowel metastases after pancreaticoduodenectomy for pancreatic cancer: a case report

Background

A surgical case of metachronous metastases of pancreatic head cancer (PC) to the large and small bowel is extremely rare. Therefore, there are only a few reports about surgery for intestinal metastases from PC. An oncologic emergency is defined as an acute, potentially life-threatening condition in a cancer patient that developed directly or indirectly because of the malignant disease or cancer treatment.

Case presentation

A 63-year-old man with PC underwent pancreaticoduodenectomy after receiving neoadjuvant chemotherapy with gemcitabine and S-1. Histopathologically, the tumor was diagnosed as poorly differentiated, tubular adenocarcinoma, with pT2, N0, pStage IB according to the UICC classification, seventh edition. R0 was achieved. Three months after pancreatoduodenectomy, blood tests showed coagulation derangements with high C-reactive protein (CRP 11.30 mg/dl). Computed tomography (CT) scan revealed a 55-mm mass alongside the transverse colon. During 2 weeks of follow-up, the coagulation derangement and elevated CRP persisted. Repeat CT showed that the tumor enlarged to 65 mm, and an additional mass, 25 mm in diameter, was detected in the jejunum. He was hospitalized due to abdominal pain and diarrhea with persistent high fever and was inspected; however, there was no evidence for infections. With the understanding that his life-threatening symptoms were secondary to the underlying malignancy, extirpation of the tumors combined with partial resection of the transverse colon and the jejunum was performed on the eighth day of hospitalization, on an emergency basis.

The lesions were identified as large and small bowel metastases from PC because histopathological examination revealed morphological features similar to the primary disease.

Immediately after the emergency surgery, the fever resolved and the CRP level normalized. He was discharged and received nab-paclitaxel with gemcitabine chemotherapy for 2 months postoperatively. He selected for best supportive care after this. The patient died due to a relapse with mesenteric lymph node metastasis 7 months after the emergency surgery.

Conclusion

Surgery as an oncological emergency for selected patients could sometimes contribute to improving patient’s quality of life.

Top Ten Tips Palliative Care Clinicians Should Know About Interventional Symptom Management Options When Caring for Patients with Gastrointestinal Malignancies

Patients diagnosed with advanced stages of gastrointestinal (GI) malignancies are often quite symptomatic, with symptoms primarily related to anatomic sites of obstruction. Endoscopic approaches to the palliation of GI malignancies have begun to overtake surgical approaches as first line in interventional management. We brought together a team of interventional gastroenterologists and palliative care experts to collate practical pearls for the types of endoscopic interventions used for symptom management in patients with GI malignancies. In this article, we use a "Top 10" format to highlight issues that may help palliative care physicians recognize common presentations of advanced GI malignancies, address interventional approaches to improve symptom burden, and improve the quality of shared decision making and goals-of-care discussions.

Recurrent Volvulus during Pregnancy: Case Report and Review of the Literature

Introduction

Sigmoid colon volvulus (SV) represents the most common etiology of antepartum gastrointestinal obstruction, with repetitive antepartum episodes rarely reported.

Case Presentation

A 25-year-old multiparous patient with history of SV at 26 weeks in her previous pregnancy presented with recurrent episodes of SV at 32 0/7, 32 4/7, 37 0/7, and 38 1/7 weeks successfully managed with colonoscopic decompression. Labor was successfully induced at 38 4/7 weeks, and she experienced two further episodes on postpartum days #1 and #32 also treated with colonoscopic decompression, followed by laparoscopic resection.

Conclusion

Successful treatment of antepartum SV with colonoscopic decompression does not preclude recurrence later in gestation and in future pregnancies.