Emergency Management of Obstructive Colorectal Cancer - A Retrospective Study of Efficacy and Safety in Self-expanding Metallic Stents and Trans-anal Tubes

BACKGROUND/AIM

The self-expanding metallic stent (SEMS) has recently been used for obstructive colorectal cancer (OCRC), and reports of its use are increasing. However, the long-term results of OCRC after using SEMS remain unclear. This study investigated the characteristics of SEMS compared to trans-anal tube (TAT) and clarified the long-term results and efficacy of SEMS for OCRC.

PATIENTS AND METHODS

We analyzed 48 patients who required SEMS or TAT for emergent decompression of OCRC and underwent resection for OCRC between 2007 and 2019. The perioperative factors and long-term results in the two groups were evaluated.

RESULTS

Patients with OCRC were divided into the SEMS (n=23) and the TAT group (n=25). No significant differences were seen in background factors, complications and the 5-year overall survival after surgery (p=0.3500) between the two groups. The clinical success of decompression (p=0.0072), oral intake (p<0.0001) and change in serum albumin (p<0.0001) from decompression to surgery were significantly better in the SEMS compares to the TAT group.

CONCLUSION

The long-term outcomes in the SEMS group were not significantly different than in the TAT group, and nutritional status was better in patients with SEMS, suggesting that SEMS is very effective and may be the first-line treatment of OCRC.

A tale of three stents: aortic stenting prior to oesophagectomy after oesophageal stents

The use of endoluminal stents to treat anastomotic leaks post oesophagogastric resection remains controversial. While some advocate stents to expedite recovery, others advise caution due to the risk of major morbidity and mortality. We describe a case of anastomotic leak following total gastrectomy for adenocarcinoma treated with a self-expanding metallic stent. Complications with the initial stent were treated with a further stent, which compromised the function of the oesophagus and eroded into the aorta, necessitating a colonic reconstruction and endovascular aortic stenting.

Endoscopic ultrasound-guided transmural drainage of walled-off pancreatic necrosis in patients with portal hypertension and intra-abdominal collaterals

BACKGROUND

Acute necrotizing pancreatitis (ANP) is complicated with segmental portal hypertension (PHT) and formation of venous collaterals. Presence of collaterals in vicinity of endoscopic transmural tract can lead to potentially catastrophic situation. Here, we report safety and outcome of EUS-guided transmural drainage of walled-off pancreatic necrosis (WOPN) in patients with PHT and intra-abdominal collaterals.

METHODS

Retrospective analysis of collected database of patients (n=18; age 40.94±8.43 years; 17 males) who underwent EUS-guided transmural drainage of WOPN and had PHT with collaterals.

RESULTS

Etiology of ANP: alcohol in 14 and gallstones in 3 patients. Mean size of collection was 10.7±3.5 cm, and all 18 patients had splenic vein thrombosis with 1 patient also having portal vein thrombosis. Drainage was not feasible in 1 patient as no window free of collaterals could be found. One patient with gastric variceal bleeding underwent drainage after successful obliteration of varix with glue. Multiple plastic stents were placed in 15 patients and fully covered self-expanding metallic stent (FCSEMS) in 1 patient and 1 patient required direct endoscopic necrosectomy (DEN). Mean procedures required were 3 ± 0.79 and time to resolution was 4.4 ± 1.3 weeks. One patient had post-drainage bleeding that was successfully managed with intravenous terlipressin and intermittent irrigation via nasocystic catheter. Successfully treated patients have been asymptomatic over follow up period of 15.65±12.2 weeks.

CONCLUSION

EUS-guided drainage of WOPN seems to be safe and effective in patients with portal hypertension and intra-abdominal collaterals.

Safety and efficacy of angioembolisation followed by endoscopic ultrasound guided transmural drainage for pancreatic fluid collections associated with arterial pseudoaneurysm

BACKGROUND AND AIMS

Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC's) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients.

AIM

To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC's associated with pseudoaneurysms.

METHODS

Retrospective analysis of data base of eight patients (all males; mean age: 36.9 + 9.2 years; age range: 26-51 years) who underwent angioembolisation of pseudoaneurysm followed by EUS guided transmural drainage of the PFC's.

RESULTS

The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gall stones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastro-duodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolisation. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC's resolved in 3.9 + 2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient.

CONCLUSIONS

Arterial pseudoaneurysms associated with PFC's can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage.

Outcomes of Self-Expanding Metal Stents in Malignant Colonic Obstruction are Independent of Location or Length of the Stenosis: Results of a Retrospective, Single-Center Series

AIM

To evaluate the length and location of stenosis in the colon as predictors of technical and clinical outcomes of stent placement in patients presenting with obstructive colorectal cancer.

METHODS

A prospective single-center cohort study of patients treated with a colonic stent for malignant obstruction, regardless of stenosis length or location. Stenosis length was assessed globally on the appropriate CT slice as well as by 3D CT reconstruction. We analyzed whether outcomes were different in patients with a right sided-tumor and/or a stenosis >4 cm long.

RESULTS

One hundred forty-one patients were evaluated, 63 with a stenosis >4 cm, 48 with a stenosis proximal to the splenic flexure. Technical failure (n = 9) was mainly caused because of looping or due to the difficulty in engaging the stenosis precluding analysis of the relation between the stenosis length and technical success. Both measurement methods showed good agreement. Clinical outcomes were not associated with stenosis length or location.

CONCLUSION

Clinical outcomes of stenting did not differ between groups regardless of stenosis length or location. Measuring stenosis length more precisely using 3D CT reconstructions is not of help.

Endoscopic ultrasound guided transmural drainage of walled off pancreatic necrosis using a "step - up" approach: A single centre experience

BACKGROUND

Walled off necrosis (WON) can be treated endoscopically using multiple transmural plastic stents or fully covered self-expandable metallic stent (FCSEMS) and direct endoscopic necrosectomy (DEN). We evaluated the efficacy of "step-up" endoscopic transmural approach for treatment of WON.

METHODS

Retrospective analysis of data of 86 patients with WON who were treated with attempted endoscopic ultrasound (EUS) guided "step up" transmural drainage during last 5 years was done. Initially multiple plastic stents were placed and patients not responding underwent FCSEMS placement and/or DEN.

RESULTS

Patients presented 10.8 ± 2.8 weeks after an acute attack of acute pancreatitis and mean size of WON was 10.7 ± 2.9 cm. EUS guided transmural drainage was technically successful in 85/86 (98.8%) patients and 70 (82.4%) were drained with multiple 7/10Fr plastic stents alone while DEN was needed in 9 (10.6%) and FCSEMS was inserted in 6 (7%) patients. All patients had successful outcome with none requiring surgery. The patients who needed DEN/FCSEMS presented earlier and had large size collection with more solid necrotic debris as compared to patients treated with multiple plastic stents alone. The complications were pneumoperitoneum (n = 1), bile leak following cholecystecomy (n = 1), development of external pancreatic fistula following percutaneous drainage (n = 1) and gastrointestinal bleed (n = 1).

CONCLUSIONS

"Step up" endoscopic transmural drainage using multiple plastic stents as an initial therapy is safe and effective treatment of WON and avoids more aggressive DEN in majority of patients. Large size WON with more necrotic debris may require DEN.

Radiologic Placement of Uncovered Stents for the Treatment of Malignant Colonic Obstruction Proximal to the Descending Colon

PURPOSE

To evaluate the safety, feasibility, and patency rates of radiologic placement of uncovered stents for the treatment of malignant colonic obstruction proximal to the descending colon.

MATERIALS AND METHODS

This was a retrospective, single-center study. From May 2003 to March 2015, 53 image-guided placements of uncovered stents (44 initial placements, 9 secondary placements) were attempted in 44 patients (male:female = 23:21; mean age, 71.8 years). The technical and clinical success, complication rates, and patency rates of the stents were also evaluated. Technical success was defined as the successful deployment of the stent under fluoroscopic guidance alone and clinical success was defined as the relief of obstructive symptoms or signs within 48 h of stent deployment.

RESULTS

In total, 12 (27.3 %) patients underwent preoperative decompression, while 32 (72.7 %) underwent decompression with palliative intent. The technical success rate was 93.2 % (41/44) for initial placement and 88.9 % (8/9) for secondary placement. Secondary stent placement in the palliative group was required in nine patients after successful initial stent placement due to stent obstruction from tumor ingrowth (n = 7) and stent migration (n = 2). The symptoms of obstruction were relieved in all successful cases (100 %). In the palliative group, the patency rates were 94.4 % at 1 month, 84.0 % at 3 months, 64.8 % at 6 months, and 48.6 % at 12 months.

CONCLUSIONS

The radiologic placement of uncovered stents for the treatment of malignant obstruction proximal to the descending colon is feasible and safe, and provides acceptable clinical results.

Preoperative drainage for malignant biliary strictures: is it time for self-expanding metallic stents?

Palliation of jaundice improves the general health of the patient and, therefore, surgical outcomes. Because of the complexity and location of strictures, especially proximally, drainage has been accompanied by increased morbidity due to sepsis. Another concern is the provocation of an inflammatory and fibrotic reaction around the area of stent placement. Preoperative biliary drainage with self-expanding metallic stent (SEMS) insertion can be achieved via a percutaneous method or through endoscopic retrograde cholangiopancreatography. A recently published multicenter randomized Dutch study has shown increased morbidity with preoperative biliary drainage. A Cochrane meta-analysis has also shown a significantly increased complication rate with preoperative drainage. However, few of these studies have used a SEMS, which allows better biliary drainage. No randomized controlled trials have compared preoperative deployment of SEMS versus conventional plastic stents. The outcomes of biliary drainage also depend on the location of the obstruction, namely the difficulty with proximal compared to distal strictures. Pathophysiologically, palliation of jaundice will benefit all patients awaiting surgery. However, preoperative drainage often results in increased morbidity because of procedure-related sepsis. The use of SEMS may change the outcome of preoperative biliary drainage dramatically.

Endoscopic removal of a self-expanding metallic airway stent: A case report

Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from the airway can pose extreme challenges for both clinical airway management as well as for the administration of general anesthesia. We report on a 61-year-old man with a complex cardiac history presenting for endoscopic stent removal necessitated by the formation of extensive granulation tissue. Comorbidities included a history of myocardial infarction, an ischemic cardiomyopathy with severe left heart failure (ejection fraction of 25%), mild right heart failure, 2+ tricuspid regurgitation status post tricuspid valve repair, and atrial fibrillation. An automatic external (wearable) cardiac defibrillator (Zoll Life Vest) was also in place. Induction of anesthesia was carried out using etomidate, with maintenance of anesthesia carried out with a propofol infusion (total intravenous anesthesia). Rocuronium was used for neuromuscular blockade. A size 4 iGel supraglottic airway and, later, rigid bronchoscopy formed the basis for airway management. Stable conditions were met through the 2-h procedure, and the patient recovered uneventfully. Our successful experience in this case leads us to propose further use of a supraglottic airway in conjunction with total intravenous anesthesia for these procedures.

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.

A temporary self-expanding metallic stent for malignant colorectal obstruction

AIM: To investigate the clinical safety and efficacy of a temporary self-expanding metallic stent (SEMS) for malignant colorectal obstruction.

METHODS: From September 2007 to June 2012, 33 patients with malignant colorectal obstruction were treated with a temporary SEMS. The stent had a tubular configuration with a retrieval lasso attached inside the proximal end of the stent to facilitate its removal. The SEMS was removed one week after placement. Clinical examination, abdominal X-ray and a contrast study were prospectively performed and both initial and follow-up data before and at 1 d, 1 wk, and 1 mo, 3 mo, 6 mo and 12 mo after stent placement were obtained. Data collected on the technical and clinical success of the procedures, complications, need for reinsertion and survival were analyzed.

RESULTS: Stent placement and removal were technically successful in all patients with no procedure-related complications. Post-procedural complications included stent migration (n = 2) and anal pain (n = 2). Clinical success was achieved in 31 (93.9%) of 33 patients with resolution of bowel obstruction within 3 d of stent removal. Eleven of the 33 patients died 73.81 ± 23.66 d (range 42-121 d) after removal of the stent without colonic re-obstruction. Clinical success was achieved in another 8 patients without symptoms of obstruction during the follow-up period. Reinsertion of the stent was performed in the remaining 12 patients with re-obstruction after 84.33 ± 51.80 d of follow-up. The mean and median periods of relief of obstructive symptoms were 97.25 ± 9.56 d and 105 ± 17.43 d, respectively, using Kaplan-Meier analysis.

CONCLUSION: Temporary SEMS is a safe and effective approach in patients with malignant colorectal obstruction due to low complication rates and good medium-term outcomes.

The learning curve for colorectal stent insertion for the treatment of malignant colorectal obstruction

Background/Aims

We aimed to assess the effectiveness of self-expanding metal stent (SEMS) insertion by evaluating the learning curve in relation to the experience of an endoscopist.

Methods

We retrospectively analyzed the outcomes of 120 SEMS insertion procedures performed by one endoscopist in patients with malignant colorectal obstruction. We compared the technical and clinical success rates, complication rates, and duration of the procedures by quartiles.

Results

The mean age of the patients (76 men and 44 women) was 64.6 years. The overall technical success rate was 95.0% (114/120), and the clinical success rate was 90.0% (108/120). The median procedure duration was 16.2 minutes (range, 3.4 to 96.5 minutes). From the first to the last quartile, the technical success rates were 90.0%, 96.7%, 96.7%, and 96.7% (p=0.263), and the clinical success rates were 90.0%, 90.0%, 96.7%, and 83.3% (p=0.588), respectively. Procedure-related complications were observed in 28 patients (23.3%). The complication rates for SEMS insertion when patients were divided by quartiles were 26.7%, 23.3%, 10.0%, and 33.3% (p=0.184), respectively. Moreover, the number of stents per procedure was 1.13, 1.03, 1.00, and 1.00 (p=0.029), respectively. The median duration of SEMS insertion decreased significantly, 20.9 to 14.8 minutes after the first 30 procedures (p=0.005).

Conclusions

An experienced endoscopist was able to perform the SEMS insertion procedure easily and effectively after performing 30 SEMS insertions.

Self-expanding metallic stents drainage for acute proximal colon obstruction

AIM: To clarify the usefulness of the self-expanding metallic stents (SEMS) in the management of acute proximal colon obstruction due to colon carcinoma before curative surgery.

METHODS: Eighty-one colon (proximal to spleen flex) carcinoma patients (47 males and 34 females, aged 18-94 years, mean = 66.2 years) treated between September 2004 and June 2010 for acute colon obstruction were enrolled to this study, and their clinical and radiological features were reviewed. After a cleaning enema was administered, urgent colonoscopy was performed. Subsequently, endoscopic decompression using SEMS placement was attempted.

RESULTS: Endoscopic decompression using SEMS placement was technically successful in 78 (96.3%) of 81 patients. Three patients’ symptoms could not be relieved after SEMS placement and emergent operation was performed 1 d later. The site of obstruction was transverse colon in 18 patients, the hepatic flex in 42, and the ascending colon in 21. Following adequate cleansing of the colon, patients’ abdominal girth was decreased from 88 ± 3 cm before drainage to 72 ± 6 cm 7 d later, and one-stage surgery after 8 ± 1 d (range, 7-10 d) was performed. No anastomotic leakage or postoperative stenosis occurred after operation.

CONCLUSION: SEMS placement is effective and safe in the management of acute proximal colon obstruction due to colon carcinoma, and is considered as a bridged method before curative surgery.

Temporary self-expanding metallic stents for achalasia: A prospective study with a long-term follow-up

AIM: To compare the efficacy of self-expanding metallic stents (SEMSs) for the long-term clinical treatment of achalasia.

METHODS: Ninety achalasic patients were treated with a temporary SEMS with a diameter of 20 mm (n = 30, group A), 25 mm (n = 30, group B) or 30 mm (n = 30, group C). Data on clinical symptoms, complications and treatment outcomes were collected, and follow-up was made at 6 mo and at 1, 3-5, 5-8, 8-10 and > 10 years, postoperatively.

RESULTS: Stent placement was successful in all patients. Although chest pain occurrence was high, stent migration was less in group C than in groups A and B. The clinical remission rate at 5-8, 8-10 and > 10 years in group C was higher than that in the other two groups. The treatment failure rate was lower in group C (13%) than in groups A (53%) and B (27%). SEMSs in group C resulted in reduced dysphagia scores and lowered esophageal sphincter pressures, as well as normal levels of barium height and width during all the follow-up time periods. Conversely, these parameters increased over time in groups A and B. The primary patency in group C was longer than in groups A and B.

CONCLUSION: A temporary SEMS with a diameter of 30 mm is associated with a superior long-term clinical efficacy in the treatment of achalasia compared with a SEMS with a diameter of 20 mm or 25 mm.