Treatment of obstructive colorectal cancer / 中华胃肠外科杂志

Obstructive colorectal cancer is a common malignant bowel obstruction. Colostomy or colostomy following tumor resection may be the first choice for emergency surgery. The intestinal and systemic conditions of patients undergoing emergency surgery are often poor, and patients need to undergo multiple operations, which increase the surgical risk and economic burden and reduce the quality of life of patients. Poor intraoperative visualization may also affect the radical operation of emergency surgery. Transanal decompression tube (TDT) can rapidly decompress and drain the obstructed bowel, effectively relieve obstruction symptoms, and improve the success rate of primary radical resection. The TDT squeeze the tumor lightly, causing no spread of tumor cells, and is cheap, but the cavity of transanal decompression tube is small and easily blocked, and requires tedious flushing or regular replacement. Self-expanding metallic stents (SEMS) can relieve intestinal obstruction effectively, provide sufficient preparation time for preoperative examination and improvement of nutritional status. By improving patient's tolerance to radical surgery, SEMS might be used as an important treatment strategy choice for obstructive colorectal cancer. However, SEMS may squeeze the tumor, leading to the spread of tumor cells, increase the recurrence rate and metastasis rate, and reduce the survival rate. Moreover, intestinal wall edema still existed during the operation following SEMS, and the rate of ostomy after anastomosis was as high as 34%. We hypothesized that prolonging the interval between stent insertion and surgery to 2 months, with neoadjuvant chemotherapy administered during this interval (SEMS-neoadjuvant chemotherapy strategy), would help improve outcomes. The SEMS-neoadjuvant chemotherapy strategy is a safe, effective, and well tolerated treatment approach with a high laparoscopic resection rate, low stoma formation rate and improvement in the overall survival for patients with left-sided colon cancer obstruction. The patient physical status is improved, the primary tumor is downstaged, and intestinal wall edema is relieved during the relatively longer interval between SEMS placement and surgery. The SEMS-neoadjuvant chemotherapy strategy may be a preferred therapeutic strategy for obstructive left colon cancer.

Seguridad y eficacia del uso de prótesis metálicas autoexpandibles en el manejo de estenosis malignas de la vía biliar irresecables / Safety and efficacy of the use of self-expanding metal stents in the management of unresectable malignant biliary stenosis

Antecedentes: En los últimos años se ha producido un incremento del uso de prótesis metálicas autoexpandibles (SEMS) en pacientes con estenosis malignas irresecables de la vía biliar. Sin embargo, en Perú no se cuentan con reportes sobre la seguridad y eficacia de este procedimiento. Objetivo: Evaluar la seguridad y eficacia del uso de las SEMS en el manejo paliativo de las estenosis malignas de la vía biliar. Materiales y métodos: Cohorte retrospectiva. Se incluyeron a todos los pacientes referidos para colocación de SEMS biliar como parte de un tratamiento paliativo entre enero del 2016 y agosto del 2018. Se obtuvieron las tasas de colocación exitosa de las SEMS, de paliación adecuada de la obstrucción y de complicaciones asociadas al procedimiento. Se evaluó la patencia de la prótesis durante el seguimiento. Se determinó la supervivencia luego de la colocación de la prótesis. Resultados: Se incluyeron 32 pacientes con indicación de manejo paliativo debido a una estenosis maligna irresecable de la vía biliar. El cáncer de páncreas (56,25%) seguido del colangiocarcinoma (31,25%) fueron las etiologías más frecuentes. Se alcanzó una tasa de colocación exitosa en primera intención de 96,97%. La paliación adecuada de la obstrucción biliar se alcanzó en el 100% de los pacientes (p<0,05). Dos SEMStc migraron durante el seguimiento (6,25%) siendo manejados con la colocación de una nueva SEMSnc. Conclusiones: La colocación de SEMS constituye una estrategia segura, con alta tasa de éxito terapéutico en el manejo paliativo de los pacientes con obstrucción maligna de la vía biliar.

Background: In recent years there has been an increase in the use of self-expanding metallic stents (SEMS) in patients with unresectable malignant stenosis of the bile duct. However, in Peru there are no reports on the safety and efficacy of this procedure. Objective: To evaluate the safety and efficacy of the use of SEMS in the palliative management of malignant stenosis of the bile duct. Materials and methods: Retrospective cohort. All patients referred for placement of biliary SEMS as part of a palliative treatment between January 2016 and August 2018 were included. Rates of successful placement of SEMS, adequate palliation of the obstruction, and complications associated with the procedure were obtained. The patency of the prosthesis was evaluated during follow-up. Survival was determined after placement of the prosthesis. Results: We included 32 patients with indication of palliative management due to an unresectable malignant stenosis of the bile duct. Pancreatic cancer (56.25%) followed by cholangiocarcinoma (31.25%) were the most frequent etiologies. A successful first-time placement rate of 96.97% was achieved. Adequate palliation of biliary obstruction was achieved in 100% of patients (p<0.05). Two SEMStc migrated during follow-up (6.25%) being managed with the placement of a new SEMSuc. Conclusions: The placement of SEMS is a safe and effective therapeutic strategy in the palliative management of patients with malignant obstruction of the biliary tract.

Experiencia con los stents metálicos autoexpandibles para el manejo de cáncer gástrico distal / Auto-expandable metal stent in the management of distal stomach cancer

Objetivos: Establecer la eficacia y seguridad de los stents metálicos antroduodenales para el tratamiento del síndrome pilórico en pacientes con cáncer gástrico distal. Materiales y métodos: Se obtuvo datos de 31 pacientes mayores de 18 años que tenían diagnóstico de cáncer gástrico distal entre el año 2009 y el año 2017, quienes presentaban síndrome pilórico asociado a estenosis antroduodenal documentada por endoscopia o radiografía de vías digestivas altas, siendo manejados con stent metálico autoexpandible antroduodenal en la unidad de gastroenterología del Hospital Universitario San Ignacio (HUSI) de Bogotá D.C, Colombia. Resultados: El principal síntoma documentado que motivó a consultar fue la presencia de vómito en el 45,1%, seguido por pérdida de peso 16,13% y hemorragia de vías digestivas altas 19,35%, realizándose el diagnóstico en el 74,19% de los casos con endoscopia de vías digestivas altas. El 96,7% de los pacientes presentaban metástasis al momento del diagnóstico de síndrome pilórico. El 100% de los pacientes tuvo éxito técnico en relación al implante del stent con posterior resolución de síntomas en el 96,77%, siendo la complicación más frecuente el desplazamiento en un 16,13%. Conclusiones: Los stents metálicos autoexpandibles para el manejo de la obstrucción al tracto de salida gástrico secundario a cáncer gástrico distal es un método seguro y eficaz como tratamiento paliativo, mejorando la morbilidad y mortalidad en comparación con el manejo quirúrgico.

Objectives: To establish the efficacy and safety of antroduodenal metal stents for the treatment of pyloric syndrome in patients with distal gastric cancer. Materials and methods: Data were obtained from 31 patients older than 18 years who had a diagnosis of distal gastric cancer between 2009 and 2017, who presented pyloric syndrome associated with antroduodenal stenosis documented by endoscopy or X-ray of upper digestive tract, being managed with an antroduodenal auto-expandable metal stent in the gastroenterology unit of the San Ignacio University Hospital (HUSI) in Bogotá DC, Colombia. Results: The main documented symptom that led to consultation was the presence of vomiting in 45.1%, followed by weight loss 16.13% and upper digestive tract bleeding 19.35%, the diagnosis being made in 74.19 % of cases with endoscopy of upper digestive tract. 96.7% of the patients presented metastases at the time of diagnosis of pyloric syndrome. 100% of patients had technical success in relation to stenting with subsequent resolution of symptoms in 96.77%, the most frequent complication being displacement in 16.13%. Conclusions: Auto-expandable metal stents for the management of gastric outlet tract obstruction secondary to distal gastric cancer is a safe and effective method as a palliative treatment, improving morbidity and mortality compared to surgical management.

Double Penetrated Duodenal Wall during Endoscopic Ultrasound-Guided Choledochoduodenostomy

No abstract available.

A Unique Use of a Double-Pigtail Plastic Stent: Correction of Kinking of the Common Bile Duct Due to a Metal Stent

A 72-year-old man with jaundice by ampullary adenocarcinoma was treated at our hospital. For biliary decompression, a transpapillary, fully covered, self-expandable metal stent (FCSEMS) was deployed. Four days later, the patient developed acute cholangitis. Endoscopic carbon dioxide cholangiography revealed kinking of the common bile duct above the proximal end of the FCSEMS. A 7-F double-pigtail plastic stent was therefore placed through the FCSEMS to correct the kink, straightening the common bile duct (CBD) and improving cholangitis. This is the first report of a unique use of a double-pigtail plastic stent to correct CBD kinking. The placement of a double-pigtail plastic stent can correct CBD kinking, without requiring replacement or addition of a FCSEMS, and can lead to cost savings.

Prótesis endoluminal autoexpandible en una oclusión aguda por tumor del colon izquierdo / Self-expanding endoluminal prosthesis in an acute occlusion due to left colon tumor

Se describe la utilización endoscópica de prótesis autoexpandibles en dos pacientes con oclusión mecánica aguda del colon izquierdo, tratados en el servicio de urgencias, lo que permitió mejorar el estado hidroelectrolítico y sintomático de los pacientes, así como la preparación del colon. Esto último evitó una cirugía de urgencia y colostomía descompresiva, y la intervención quirúrgica se programó para los 5 posteriores. No hubo complicaciones posoperatorias. El resultado anatomopatológico confirmó sendos adenocarcinomas de colon en anillo de sellos, en un paciente en el colon descendente y en el otro en el colon sigmoides(AU)

Endoscopic use of self-expanding prostheses is described in two patients with acute mechanical occlusion of left colon, treated in the emergence service of our center allowing us to improve the hydroelectric symptomatic status of patients, as well as the colon preparation. This latter avoided an emergence surgery and decompression colostomy; surgery was programmed for the subsequent five ones. Anatomical-pathological results confirmed the presence of large seal-ring colon's adenocarcinomas in the descendent colon in a patient, and in the sigmoid colon in another one(AU)