Endoscopic laser therapy for palliation of patients with distal colorectal carcinoma: analysis of factors influencing long-term outcome

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.

A systematic review of the effectiveness of palliative interventions to treat rectal tenesmus in cancer

BACKGROUND

Rectal tenesmus is a distressing symptom in patients with advanced cancer and challenging to treat. There is lack of consensus on the appropriate management of tenesmus in this patient population.

AIM

To identify and examine the effectiveness of interventions to palliate rectal tenesmus caused by advanced cancer when surgery, radiotherapy or chemotherapy are no longer treatment options.

DESIGN

A systematic review of the literature following standard systematic review methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance.

DATA SOURCES

A comprehensive search of the electronic databases MEDLINE, EMBASE and the Cochrane Library was conducted from date of inception to April 2016. PubMed 'related articles' search, grey literature search and hand-searches of the bibliographies of relevant papers and textbooks were also performed. Non-cancer patients were excluded. Any studies involving surgery or radiotherapy to treat tenesmus were excluded. Studies involving interventions to treat pelvic pain syndromes without specific outcome measures on severity of tenesmus were excluded. The quality of the studies was assessed using a National Institute for Health and Clinical Excellence-recommended quality assessment tool.

RESULTS

From 861 studies, 9 met full criteria and were selected. All were case series investigating the use of pharmacological interventions (diltiazem, nifedipine, methadone, mexiletine hydrochloride, lidocaine and bupivacaine), anaesthetic interventions (lumbar sympathectomy, neurolytic superior hypogastric plexus block), and endoscopic laser interventions. The included studies showed substantial heterogeneity, and therefore, a meta-analysis was not feasible.

CONCLUSION

From this review, we identified a significant gap in research into the palliation of rectal tenesmus. A multimodal approach may be necessary due to the complexity of the pathophysiology of tenesmus. Future research should focus on randomised controlled trials of drug therapies whose potential effectiveness is suggested by case series.

Ablative therapies for colorectal polyps and malignancy

Endoscopic techniques are gaining popularity in the management of colorectal polyps and occasionally superficial cancers. While their use is in many times palliative, they have proven to be curative in carefully selected patients with polyps or malignancies, with less morbidity than radical resection. However, one should note that data supporting local and ablative therapies for colorectal cancer is scarce and may be subject to publication bias. Therefore, for curative intent, these techniques should only be considered in highly select cases as higher rates of local recurrences have also been reported. The aim of this review is to explain the different modalities of local and ablative therapies specific to colorectal neoplasia and explain the indications and circumstances where they have been most successful.

Status and literature review of self-expandable metallic stents for malignant colorectal obstruction

Use of colorectal stents has increased dramatically over the last decades. Colorectal stents offer an alternative way to relieve fatal intestinal obstruction and can take place of emergency surgery, which associated with significant morbidity and mortality and a high incidence of stoma creation, to elective resection. Although there remain a few concerns regarding the use of stents as a bridge to surgical resection, use of self-expandable metallic stents for palliation in patients with unresectable disease has come to be generally accepted. Advantages of colorectal stents include acute restoration of luminal patency and allowance of time for proper staging and surgical optimization, and the well-known disadvantages are procedure-related complications including perforation, migration, and stent failure. General indications, procedures, and clinical outcomes as well as recent evidences regarding the use of colorectal stents will be discussed in this review.

Evaluation of an endorectal electrode for performing focused irreversible electroporation ablations in the Swine rectum

PURPOSE

To study the feasibility of a novel endorectal electrode for the creation of focal ablations of the rectal wall with the use of irreversible electroporation (IRE).

MATERIALS AND METHODS

A monopolar electrode with a grounding pad (10 ablations in five pigs) and a bipolar electrode (two ablations in one pig) were evaluated in healthy swine rectum. A two-dimensional model of the electrode in the rectum was created and used to solve the Laplace equation to determine field strength. Simulation was used to identify treatment settings for superficial ablation (mucosal layers) or transmural ablation of rectal wall. Animals were euthanized within 4 hours after treatment.

RESULTS

Treatment was successfully completed without treatment-related complications. Eleven of 12 lesions were successfully located and extracted for pathologic analysis. All lesions were characterized by necrotic cell death with mild inflammation and hyperemia, with a sharp demarcation between ablated and adjacent normal tissue. Depth of lesions corresponded with numeric simulation. Histologic analysis and measurements indicated that lesion creation with the superficial treatment setting resulted in ablation of mucosal and submucosal layers with superficial or no injury to the muscularis propria (9.97 mm ± 0.31 length, 3.3 mm ± 2.92 depth), and that lesion creation with the transmural treatment setting resulted in full-thickness ablation (12.43 mm ± 3.85 length, 4.97 mm ± 2.89 depth) of the rectal wall.

CONCLUSIONS

An endorectal electrode can be used to deliver IRE and create limited focal ablations in the rectal wall. Treatment parameters can be determined through numeric modeling to control the depth of penetration of ablation.

Expandable metal stents for malignant colorectal strictures

The surgical management of malignant colorectal obstruction is still controversial and has higher associated mortality and complication rates compared with elective surgery. Placement of self-expanding metallic stents (SEMS) has been proposed as an alternative therapeutic approach for colonic decompression of patients with acute malignant obstruction. SEMS placement may be used both as a bridge to surgery in patients who are good candidates for curative resection and for palliation of those patients presenting with advanced stage disease or with severe comorbid medical illnesses.

Determinants of morbidity and survival after elective non-curative resection of stage IV colon and rectal cancer

PURPOSE

The benefit of elective primary tumor resection for non-curable stage IV colorectal cancer (CRC) remains largely undefined. We wanted to identify risk factors for postoperative complications and short survival.

METHODS

Using a prospective database, we analyzed potential risk factors in 233 patients, who were electively operated for non-curable stage IV CRC between 1996 and 2002. Patients with recurrent tumors, resectable metastases, emergency operations, and non-resective surgery were excluded. Risk factors for increased postoperative morbidity and limited postoperative survival were identified by multivariate analyses.

RESULTS

Patients with colon cancer (CC = 156) and rectal cancer (RC = 77) were comparable with regard to age, sex, comorbidity, American Society of Anesthesiologists score, carcinoembryonic antigen levels, hepatic spread, tumor grade, resection margins, 30-day mortality (CC 5.1%, RC 3.9%) and postoperative chemotherapy. pT4 tumors, carcinomatosis, and non-anatomical resections were more common in colon cancer patients, whereas enterostomies (CC 1.3%, RC 67.5%, p < 0.0001), anastomotic leaks (CC 7.7%, RC 24.2%, p = 0.002), and total surgical complications (CC 19.9%, RC 40.3%, p = 0.001) were more frequent after rectal surgery. Independent determinants of an increased postoperative morbidity were primary rectal cancer, hepatic tumor load >50%, and comorbidity >1 organ. Prognostic factors for limited postoperative survival were hepatic tumor load >50%, pT4 tumors, lymphatic spread, R1-2 resection, and lack of chemotherapy.

CONCLUSIONS

Palliative resection is associated with a particularly unfavorable outcome in rectal cancer patients presenting with a locally advanced tumor (pT4, expected R2 resection) or an extensive comorbidity, and in all CRC patients who show a hepatic tumor load >50%. For such patients, surgery might be contraindicated unless the tumor is immediately life-threatening.

Clinical application of self-expandable metallic stent for treatment of colorectal obstruction caused by extrinsic invasive tumors

PURPOSE

The purpose of this study was to extend the application of self-expandable metallic stents by investigating their usefulness in treating colorectal obstructions caused by unresectable extrinsic tumors.

METHODS

From January 2000 to November 2005, a total of 60 colorectal stenting procedures were performed, and 57 stents were deployed in 39 patients with extrinsic tumors. The success rate and complications were analyzed retrospectively.

RESULTS

The most common etiology and location of obstruction were advanced gastric cancer and transverse colon. Technical success was 34 of 39 patients (87.2 percent). The causes of technical failure were immediate stent migration (n = 1), technical problems (n = 1), and access failure because of bowel immobilization (n = 3). Clinical success was 32 of 34 technical successes (82.1 percent). The two patients without clinical success had multifocal strictures of the bowel. Complications occurred in 22 of 57 stents (38.6 percent), including stent reobstruction (n = 14) and stent migration (n = 5). All of stent migrations except one developed with covered stents.

CONCLUSIONS

In patients with colonic obstruction caused by extrinsic tumors, stent insertion provided effective symptom relief and can be a reasonable alternative choice to a colostomy. An uncovered stent might be more preferable, considering less migration and remaining short life expectancy, compared with a covered stent.

Ultraflex precision colonic stent placement for palliation of malignant colonic obstruction: a prospective multicenter study

BACKGROUND

Many patients who develop obstructive colonic symptoms secondary to inoperable colorectal cancer will require palliative treatment. A minimally invasive and potentially long-lasting approach is placement of nitinol self-expanding metal stents (SEMS).

OBJECTIVE

To determine the effectiveness and safety of a nitinol SEMS designed for colorectal use in the palliative treatment of malignant colonic obstruction.

DESIGN

Prospective multicenter clinical study.

SETTING

Nine European study centers.

PATIENTS

Forty-four patients with malignant colonic obstruction.

INTERVENTIONS

Placement of nitinol SEMS designed for colorectal use.

MAIN OUTCOME MEASURES

Technical success, defined as accurate SEMS deployment with adequate stricture coverage, and clinical success, defined as decompression and relief of obstructive colonic symptoms maintained without intervention or serious device-related complications.

RESULTS

Technical success was attained in 95% of patients, with 95% CI 85%-99%. After 6 months, the rate of clinical success was 81%, 95% CI 69%-96%. Survival at 6 months was 67%, 95% CI 54%-84%. Clinical success was maintained until death in 86% of the nonsurvivors. No perforations or SEMS-related deaths occurred.

LIMITATION

This investigation was nonrandomized and did not include a control group.

CONCLUSIONS

In a large prospective investigation, palliative placement of a nitinol SEMS designed for colorectal use was accomplished with a high rate of technical success. Durable clinical success was achieved in a high proportion of patients with low morbidity.

The role of primary tumour resection in patients with stage IV colorectal cancer

OBJECTIVE

The management of stage IV colorectal cancer is controversial. Resection of the primary tumour to prevent obstruction, bleeding or perforation is the traditional approach, although survival benefit is undetermined. Management consisting of diverting ostomy, enteric bypass, laser recanalization or endoscopic stenting is an alternative to radical resection. The purpose of this study was to determine the role of resection of the primary tumour in patients with stage IV colorectal cancer, with specific attention paid to survival benefit and safety.

METHOD

This was a retrospective review of all stage IV colon and rectal cancer patients in our tumour registry between 1991 and 2002. Data collected included patient demographics, presenting symptoms, detail from the hospital course including diagnostic data and operative management, complications and survival time (days). Survival analysis was performed to assess the effect of primary tumour resection on long-term survival.

RESULTS

109 patients were studied. Sixty-two (57%) patients (group I) underwent resection of the primary tumour, whereas 47 (43%) patients (group II) were managed without resection. Median survival times for groups I and II were 375 (IQR: 179-759) and 138 (IQR: 35-262) days respectively (P < 0.0001). After controlling for age, sex, tumour location and level of liver involvement as well as liver function, patients who underwent resection still survived longer (HR = 0.34, 95% CI: 0.21-0.55).

CONCLUSION

Palliative resection of the primary tumour plays an essential role in the management of stage IV colorectal cancer. Resection can offer increased survival and is indicated in certain patients with incurable disease. Limited metastatic tumour burden of the liver was associated with better survival in such patients.

Operative colonoscopy in cancer patients

Gastrointestinal endoscopy has experienced tremendous developments in technology and equipment over the past decades. It is not only a diagnostic tool, but it also allows some interventional treatments in benign and malignant digestive diseases. Operative colonoscopy has been used to perform curative treatment of various kinds of polyps, flat and carpet-like adenomas and early colorectal carcinomas. Endoscopic palliative treatment strategies, such as the placement of self-expandable metal stents (SEMS), laser ablation, photodynamic therapy (PDT), argon plasma coagulation (APC), electrocoagulation, and injection therapy, have been proved to effectively alleviate advanced colorectal cancer (CRC) associated symptoms and maintain or improve the quality of the patient's remaining life.

Retrospective review of laser therapy for palliation of colorectal tumours

Patients with inoperable colorectal tumours will often require symptomatic relief due to the nature of extensive disease spread or existing co-morbidities. The use of laser treatment for palliation of tumours in the lower gastrointestinal tract has become an attractive treatment option for such patients. This paper presents the results of a retrospective review of 58 case notes in order to determine the effectiveness of laser therapy in palliating symptoms of colorectal tumours. In addition, the paper aims to identify which colorectal symptoms laser is best used to palliate. The study was conducted in a regional coloproctology unit at the Western General Hospital in Edinburgh. The main findings show that 52% (n=30) of patients had successful (complete/good) resolution of symptoms, 36% (n=21) had a poor response and 12% (n=7) had no resolution of symptoms from laser therapy. Of all documented symptoms, this study found that laser is most effective at palliating obstructive symptoms. It also has beneficial application in the palliation of bleeding and mucous discharge. It is less effective for the anal symptoms of tenesmus and pain and for stool related symptoms such as diarrhoea, constipation, frequency and incontinence.

Endoscopic approaches for palliation of luminal gastrointestinal obstruction

Much of the workload of a typical gastroenterologist is devoted to screening patients for gastrointestinal malignancies. Efforts such as colorectal cancer screening via colonoscopy and endoscopic surveillance of patients with Barrett's esophagus are widespread and widely endorsed. In recent years, the armamentarium of endoscopy has broadened considerably and now affords physicians a variety of nonsurgical means to palliate malignant obstruction of the gastrointestinal tract. This article reviews endoscopic techniques to treat malignant esophageal, biliary, small bowel, and colonic obstruction.

Management of malignant colonic obstruction

Malignant large bowel obstruction remains a clinical entity that is commonly encountered despite our advances in screening for colorectal cancer. Patients with malignant large bowel obstruction usually have advanced colorectal cancer and are often poor operative candidates, yet these patients are in need of treatment and colonic decompression. Surgical therapies are available and can offer good outcomes in selected patients. Patients who have curative or palliative surgeries planned should routinely undergo preoperative endoscopic decompression. Available options for decompression include the placement of colonic decompression tubes, ablative methods such as the use of lasers, argon plasma coagulators, and the use of self-expanding metal stents. The author favors the use of self-expanding metal stents, as these devices provide rapid colonic decompression, create a wide luminal diameter, and are applicable in patients requiring preoperative decompression and bowel preparation as well as in patients undergoing palliative therapy only. Patients who go on to surgery can have the stent and tumor removed en bloc at the time of the procedure, whereas patients who are only candidates for palliation can have the stents left in place as permanent decompressive devices with minimal morbidity and mortality.

ASGE guideline: the role of endoscopy in the diagnosis, staging, and management of colorectal cancer

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

Endoscopic methods (other than stents) for palliation of rectal carcinoma

Patients with unresectable or metastatic rectal cancer may have symptoms of obstruction, bleeding, pain, or tenesmus. Insertion of a self-expandable metal stent is the most durable nonsurgical method for relieving obstruction and has been reviewed in the previous article. Other endoscopic methods of palliating obstruction have been largely replaced by expandable metal stent placement. However, laser ablation is still a useful therapy for some patients, particularly when the predominant symptom is rectal bleeding. The indications and results of endoscopic laser therapy along with other endoscopic treatments for the palliation of rectal cancer will be reviewed here.

Definitive palliation for neoplastic colonic obstruction using enteral stents: Personal case-series with literature review

Acute colonic obstruction due to malignancies is an emergency that requires surgical treatment. Elderly patients or inoperable tumors require intestinal decompression that is a simple colostomy in almost all cases. This “manoeuvre” leads the patient to a percentage of mortality/morbidity and to a bad quality of life due to acceptance of stoma. The introduction of enteral metal stent inserted endoscopically has, in our opinion, provided a new way to obtaining the definitive palliation of inoperable colo-rectal cancer with a simple method. We reported our case-series and we analyzed the current literature and costs of treatments.

The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: technique, indications, and contraindications

Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy has a broad range of indications, including evaluating lower GI symptoms such as lower GI bleeding, evaluating abnormal radiographic findings, and screening and surveillance for colon cancer. Colonoscopy is increasingly being used therapeutically. Patient evaluation, patient instructions, and colonic preparation before colonoscopy are essential for safe and efficient colonoscopy. Intravenous sedation reduces patient pain and anxiety during colonoscopy, but requires monitoring by pulse oximetry and automated measurements of vital signs. An experienced colonoscopist can complete colonoscopy in 90% or more of cases, using maneuvers to maintain the colonic lumen in view, straighten the colonoscope, and avoid looping during colonic intubation.

Surgical management of colon cancer

The primary mode of therapy for colon cancer continues to be surgery. Although little has changed in the technical aspects of colonic resection, a great deal of research has taken place to develop procedures that enhance staging of disease, optimize postoperative recovery, and improve outcomes in obstructed patients without compromising cancer-related morbidity and mortality. This review explores the current use of laparoscopy, sentinel node biopsy, intraoperative ultrasound, and colonic stents in the elective and emergent management of colon cancer.