Nonsurgical treatment of the primary tumor in four consecutive cases of metastasized colorectal carcinoma

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.

Response of the primary tumor in symptomatic and asymptomatic stage IV colorectal cancer to combined interventional endoscopy and palliative chemotherapy

BACKGROUND

The treatment of the primary tumor in advanced metastatic colorectal cancer (CRC) is still a matter of discussion. Little attention has thus far been paid to the endoscopically observable changes of the primary in non-curatively resectable stage IV disease.

METHODS

20 patients [14 men, 6 women, median age 67 (39-82) years] were observed after initial diagnosis of non-curatively resectable metastasized symptomatic (83%) or asymptomatic (17%) CRC, from June 2002 to April 2009. If necessary, endoscopic tumor debulking was performed. 5-FU based chemotherapy was given immediately thereafter. In 10 patients, chemotherapy was combined with antibody therapy.

RESULTS

Response of the primary was observed in all patients. Local symptoms were treated endoscopically whenever necessary (obstruction or bleeding), and further improved after chemotherapy was started: Four patients showed initial complete endoscopic disappearance of the primary. In an additional 6 patients, only adenomatous tissue was histologically detected. In both these groups, two patients revealed local tumor relapse after interruption of therapy. Local tumor regression or stable disease was achieved in the remaining 10 patients. 15 patients died during the observation time. In 13 cases, death was related to metastatic disease progression. The mean overall survival time was 19.6 (3-71) months. No complications due to the primary were observed.

CONCLUSION

This study shows that modern anti-cancer drugs combined with endoscopic therapy are an effective and safe treatment of the symptomatic primary and ameliorate local complaints without the need for surgical intervention in advanced UICC stage IV CRC.

Treatment of gastrointestinal diseases with second-generation argon plasma coagulation: an analysis of 260 cases

AIM: To investigate the safety and efficacy of the second-generation argon plasma coagulation (VIO APC) for gastrointestinal diseases.

METHODS: During 2007-09-14/2008-10-22, 260 patients were treated using VIO APC in a total of 289 sessions. For various indications, the new VIO APC device was used. Safety and efficacy of VIO APC were recorded after each individual treatment session.

RESULTS: The mean number of treatment sessions required using VIO APC in various indications was 1.11 ± 0.31. In the palliative treatment of gastric adenocarcinoma, it was 2.50; in endoscopic hemostasis, it was 1.23; in the treatment of colorectal polypi, it was 1.15, in the treatment of upper gastrointestinal polypi, it was 1.03, in the management of self-expand stent overgrowth or tumor stenosis, it was 1.17; in the ablation of Barrett's esophagus, it was 1.13; in the ablation of gastric dysplasia, gastritis verrucosa, gastric xanthelasma and gastric or duodenal liparomphalus, only 1 session was needed. Minor complications (pain, dysphagia/odynophagia, asymptomatic gas accumulation in the intestinal wall) were observed in 10.1%-20% sessions, but no major complications (hemorrhage, perforation, stenosis) were observed.

CONCLUSION: VIO APC is effective and safe for various gastrointestinal conditions. It can be widely applied to daily endoscopic treatment.

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.

Colorectal tumors with complete obstruction--endoscopic recovery of passage replacing emergency surgery? A report of two cases

Background

Incomplete or complete obstructive ileus due to colorectal cancer is generally treated by emergency surgery that has higher morbidity and mortality than elective surgery.

Case Presentation

Here we describe an endoscopic technique by which a safe bowel decompression was performed instead of emergency surgery in two patients with complete tumorous obstruction of the colon. By means of a polypectomy snare, a soft wire, an ERCP catheter, a set of endoscopes with different diameters (baby endoscope, gastroscope) and of argon plasma coagulation the tumor mass was reduced and the tumor stenosis was passed. The patients recovered from symptoms of colon obstruction, no procedure-associated complications were observed. One patient had surgery of the sigmoid tumor one week later (UICC-stage III), the other patient (UICC-stage IV) received systemic chemotherapy starting one week after endoscopic decompression.

Conclusion

Complete tumorous obstruction of the colon may be managed by endoscopic tumor debulking avoiding high risk emergency surgery and allowing immediate medical treatment of the primary tumor and of metastases.