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Endoscopy in Gastrointestinal Oncology - Slide 19 - A. Repici - Colorectal stents
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Endoscopy in Gastrointestinal Oncology - Slide 19 - A. Repici - Colorectal stents

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  • 1. Colonic Stenting Alessandro Repici, MD Digestive Endoscopy Unit Department of Gastroenterology IRCCS Istituto Clinico Humanitas, Milano, Italy
  • 2. Large Bowel Obstruction (LBO)
  • 3. Large Bowel Malignant Obstruction
    • Serious medical and surgical emergency
    • Older patients
    • More comorbities
    • More advanced disease
  • 4.  
  • 5. LBO: the management
    • Curative Surgery
    • Palliative or decompressive Surgery
    • Stenting as bridge to Surgery
    • Palliative Stenting
  • 6. S. Breitenstein, et al; Systematic evaluation of surgical strategies for acute malignant left-sided colonic obstruction; British Journal of Surgery 2007; 94: 1451–1460
    • Mortality rate 5-14%
    • Morbidity rate 15-28%
    • One-stage surgery in less than 25% of cases
    • Temporary ileostomies will be not closed in ¼ of the patients
    • Permanent stoma do report a significant lower health-related
    • quality of life
    Surgical management of malignant LBO
  • 7. Colonic Stenting
    • Relief of colonic obstruction
    • Allows patient’s evaluation
    • Better staging of the disease
    • Time to elective surgery (avoid stoma)
    • Provide long-term palliation
  • 8. Technical issues
    • Working team
    • Emergency Room Physicians
    • Radiologists
    • Therapeutic Endoscopists
    • Anesthesiologists
    • Surgeons
  • 9. The Technique
    • Radiology suite
    • Mild sedation and analgesia
    • Therapeutic scope
    • 5 Fr catheter and floppy guide wire
    • Contrast injection to define the stricture
    • Super-stiff guide wire
    • Stent deployed under fluoro and endo
    • control
  • 10.
    • Anatomy is cumbersome (long, large, angled and looped tube)
    • Colonic wall is thinner than other GI tract
    • The stricture can be very difficult to be accessed
    • Over-insufflation can be very dangerous
    • Pre-stenting dilation increases the risk of perforation
    • Surgical team ready to go
    To me, emergency colorectal stenting may be one of the most challenging operative procedures in GI endoscopy The Technique
  • 11.  
  • 12. Baron TH, Endoscopy 2010
  • 13. first 25-30 cm Rest of colon OTW STENT TTS STENT
  • 14.  
  • 15.  
  • 16. Pooled analysis of clinical and technical success rates (54 trials – 1198 patients) Sebastian S et al. Am J Gastroenterol 2004 Group Number Cumulative Range Technical success Overall 1198 93% 64-100 Palliative 791 93% 67-100 Bridge to surgery 407 92% 33-100 Clinical success Overall 1198 89% 55-100 Palliative 791 91% 62-100 Bridge to surgery 407 72% 45-84
  • 17. Br J Surgery 2007
  • 18. Arch Surg 2009
  • 19. Repici A et al GIE 2008 Long-term palliation
  • 20. SEMS-related complications
    • Perforation
    • Migration
    • Re-obstruction
  • 21. There is concern about risk of perforation Van Hooft J et al Endoscopy 2008
  • 22. Author Journal Pts Palliation/ BTS Type of stent Complications (%) Perforations (%) Law WL Colorectal Dis 2010 130 101/29 Esoph.Wallstent Colon Wallflex Choostent Enteral Wallstent Ultraflex 20 1,5 Baraza W. Colorectal Dis 2008 63 56/7 Niti-S Bard Memotherm 25 0 M. Alcantara Tech Coloproctol 2007 95 (103 SEMS) 28/67 Enteral Wallstent Esophacoil Hanaro stent Wallflex 13.7 4.2 Giovannini MD J clin Gastroenterol 2008 36 (52 SEMS) 36/0 Choostent Wallstent Hanaro stent 35 7.5 Brehant O Colorectal Dis 2009 30 0/30 Wallflex 23 7 Min Kyu Jung Surg Endosc 2009 39 39/0 Niti-S Hanarostent Wallflex Early 12.8 Late 11.8 Early 2.6 Late 2.9 S. Mucci-Hennekinne Surg Endosc 2007 67 55/12 Hanarostent ? 6,2 Repici A Gastroint Endosc 2008 42 23/19 Wallflex Early 9.5 Late 14.3 2.4 Jong Pil Im Int J Colorectal Dis 2008 49 pts (51SEMS) 49/0 Hanaro MI Tech 24 2
  • 23. Small AJ et al. GIE 2010 Bevacizumab-based therapies and Colonic perforation after SEMS placement Is it time for a warning? Bevacizumab-based therapies Treated Untreated P 15.4% 6.8% 0.06
  • 24. Cennamo V et al Clin Gastroenterol Hepatol 2009
  • 25. 49 y old lady: Feb-July 2009 FOLFOX4 Sept 2009-Jan 2010 FOLFIRI+Bevacizumab Feb 02 2010 Feb 04 2010 March 11 2010
  • 26. Hapani S, et al Lancet Oncology 2009
  • 27. Proper selection of patients for palliation with metal stents is a key-factor
    • Stage of the disease
    • Life expectancy
    • Previous or future therapies
    • Surgical risk
  • 28. Conclusions: Colonic Stenting
    • Multidisciplinary team to face with a medical and surgical emergency
    • High technical success despite it’s a technically demanding maneuver
    • Very effective for bridge-to-surgery patients
    • Careful selection of patients for long-term palliation (Bevacizumab alert)