Colonic Stenting Alessandro Repici, MD Digestive Endoscopy Unit Department of Gastroenterology IRCCS Istituto Clinico Huma...
Large Bowel Obstruction (LBO)
Large Bowel Malignant Obstruction <ul><li>Serious medical and surgical emergency </li></ul><ul><li>Older patients </li></u...
 
LBO: the management <ul><li>Curative  Surgery </li></ul><ul><li>Palliative or decompressive  Surgery </li></ul><ul><li>Ste...
S. Breitenstein, et al; Systematic evaluation of surgical strategies for acute malignant left-sided colonic  obstruction; ...
Colonic Stenting <ul><li>Relief of colonic obstruction </li></ul><ul><li>Allows patient’s evaluation </li></ul><ul><li>Bet...
Technical issues <ul><li>Working team </li></ul><ul><li>Emergency Room Physicians </li></ul><ul><li>Radiologists </li></ul...
The Technique <ul><li>Radiology suite </li></ul><ul><li>Mild sedation and analgesia </li></ul><ul><li>Therapeutic scope </...
<ul><li>Anatomy is cumbersome (long, large, angled and looped tube) </li></ul><ul><li>Colonic wall is thinner than other G...
 
Baron TH, Endoscopy 2010
first 25-30 cm Rest of colon OTW STENT TTS STENT
 
 
Pooled analysis of clinical and technical success rates   (54 trials – 1198 patients) Sebastian S et al. Am J Gastroentero...
Br J Surgery 2007
Arch Surg 2009
Repici A et al GIE 2008  Long-term palliation
SEMS-related complications <ul><li>Perforation </li></ul><ul><li>Migration </li></ul><ul><li>Re-obstruction </li></ul>
There is concern about risk of perforation Van Hooft J et al Endoscopy 2008
Author Journal Pts Palliation/ BTS Type of stent Complications (%) Perforations (%) Law WL Colorectal Dis 2010 130 101/29 ...
Small AJ et al. GIE 2010 Bevacizumab-based therapies and  Colonic perforation after SEMS placement Is it time for a warnin...
Cennamo V et al Clin Gastroenterol Hepatol 2009
49 y old lady: Feb-July 2009  FOLFOX4   Sept 2009-Jan 2010  FOLFIRI+Bevacizumab Feb 02 2010 Feb 04 2010 March 11 2010
Hapani S, et al Lancet Oncology 2009
Proper selection of patients for palliation with metal stents is a key-factor <ul><li>Stage of the disease </li></ul><ul><...
Conclusions: Colonic Stenting <ul><li>Multidisciplinary team to face with a medical and surgical emergency </li></ul><ul><...
Upcoming SlideShare
Loading in...5
×

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

982

Published on

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
982
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
0
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

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

  1. 1. Colonic Stenting Alessandro Repici, MD Digestive Endoscopy Unit Department of Gastroenterology IRCCS Istituto Clinico Humanitas, Milano, Italy
  2. 2. Large Bowel Obstruction (LBO)
  3. 3. Large Bowel Malignant Obstruction <ul><li>Serious medical and surgical emergency </li></ul><ul><li>Older patients </li></ul><ul><li>More comorbities </li></ul><ul><li>More advanced disease </li></ul>
  4. 5. LBO: the management <ul><li>Curative Surgery </li></ul><ul><li>Palliative or decompressive Surgery </li></ul><ul><li>Stenting as bridge to Surgery </li></ul><ul><li>Palliative Stenting </li></ul>
  5. 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 <ul><li>Mortality rate 5-14% </li></ul><ul><li>Morbidity rate 15-28% </li></ul><ul><li>One-stage surgery in less than 25% of cases </li></ul><ul><li>Temporary ileostomies will be not closed in ¼ of the patients </li></ul><ul><li>Permanent stoma do report a significant lower health-related </li></ul><ul><li>quality of life </li></ul>Surgical management of malignant LBO
  6. 7. Colonic Stenting <ul><li>Relief of colonic obstruction </li></ul><ul><li>Allows patient’s evaluation </li></ul><ul><li>Better staging of the disease </li></ul><ul><li>Time to elective surgery (avoid stoma) </li></ul><ul><li>Provide long-term palliation </li></ul>
  7. 8. Technical issues <ul><li>Working team </li></ul><ul><li>Emergency Room Physicians </li></ul><ul><li>Radiologists </li></ul><ul><li>Therapeutic Endoscopists </li></ul><ul><li>Anesthesiologists </li></ul><ul><li>Surgeons </li></ul>
  8. 9. The Technique <ul><li>Radiology suite </li></ul><ul><li>Mild sedation and analgesia </li></ul><ul><li>Therapeutic scope </li></ul><ul><li>5 Fr catheter and floppy guide wire </li></ul><ul><li>Contrast injection to define the stricture </li></ul><ul><li>Super-stiff guide wire </li></ul><ul><li>Stent deployed under fluoro and endo </li></ul><ul><li>control </li></ul>
  9. 10. <ul><li>Anatomy is cumbersome (long, large, angled and looped tube) </li></ul><ul><li>Colonic wall is thinner than other GI tract </li></ul><ul><li>The stricture can be very difficult to be accessed </li></ul><ul><li>Over-insufflation can be very dangerous </li></ul><ul><li>Pre-stenting dilation increases the risk of perforation </li></ul><ul><li>Surgical team ready to go </li></ul>To me, emergency colorectal stenting may be one of the most challenging operative procedures in GI endoscopy The Technique
  10. 12. Baron TH, Endoscopy 2010
  11. 13. first 25-30 cm Rest of colon OTW STENT TTS STENT
  12. 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
  13. 17. Br J Surgery 2007
  14. 18. Arch Surg 2009
  15. 19. Repici A et al GIE 2008 Long-term palliation
  16. 20. SEMS-related complications <ul><li>Perforation </li></ul><ul><li>Migration </li></ul><ul><li>Re-obstruction </li></ul>
  17. 21. There is concern about risk of perforation Van Hooft J et al Endoscopy 2008
  18. 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
  19. 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
  20. 24. Cennamo V et al Clin Gastroenterol Hepatol 2009
  21. 25. 49 y old lady: Feb-July 2009 FOLFOX4 Sept 2009-Jan 2010 FOLFIRI+Bevacizumab Feb 02 2010 Feb 04 2010 March 11 2010
  22. 26. Hapani S, et al Lancet Oncology 2009
  23. 27. Proper selection of patients for palliation with metal stents is a key-factor <ul><li>Stage of the disease </li></ul><ul><li>Life expectancy </li></ul><ul><li>Previous or future therapies </li></ul><ul><li>Surgical risk </li></ul>
  24. 28. Conclusions: Colonic Stenting <ul><li>Multidisciplinary team to face with a medical and surgical emergency </li></ul><ul><li>High technical success despite it’s a technically demanding maneuver </li></ul><ul><li>Very effective for bridge-to-surgery patients </li></ul><ul><li>Careful selection of patients for long-term palliation (Bevacizumab alert) </li></ul>

×