Determining the difference in the efficacy and safety of self-expandable metallic stents as a bridge to surgery for obstructive colon cancer among patients in the CROSS 0 group and those in the CROSS 1 or 2 group: a pooled analysis of data from two Japanese prospective multicenter trials.

PURPOSE: This study compared the feasibility and safety of endoscopic placement of self-expandable metallic stents (SEMSs) as a bridge to surgery (BTS) between patients with obstructive colorectal cancer (CRC) classified as ColoRectal Obstruction Scoring System (CROSS) 0 and those with CROSS 1 or 2. METHODS: We conducted a post hoc analysis of two prospective, observational, single-arm multicenter clinical trials and performed a pooled analysis of the data. In total, 336 consecutive patients with malignant colorectal obstruction underwent SEMS placement. The primary endpoint was clinical success, defined as resolution of symptoms and radiological findings within 24 h. Secondary endpoints were technical success and adverse events. RESULTS: High clinical (98.0% vs. 98.4%) and technical (96.7% vs. 97.8%) success rates were observed in both groups (CROSS 0 vs. CROSS 1 or 2). The adverse event rate was low. The mean stricture length was lower (3.8 ± 1.2 cm vs. 4.4 ± 1.8 cm) and laparoscopic surgery more common (56.7% vs 52.2%) in the CROSS 0 group than in the CROSS 1 and 2 group. CONCLUSION: This study was the first to compare the degree of stricture in different CROSS groups and demonstrated comparable results with respect to the short-term efficacy and safety of SEMS placement as a BTS for obstructive CRC in CROSS 0, 1, and 2 patients.

Self-expandable metallic stenting as a bridge to surgery for malignant colorectal obstruction: pooled analysis of 426 patients from two prospective multicenter series.

BACKGROUND: Self-expandable metallic stenting (SEMS) for malignant colorectal obstruction (MCO) as a bridge to elective surgery (BTS) is a widely used procedure. The aim of this study was to assess short-term outcomes of SEMS for MCO as BTS. METHODS: This study analyzed pooled data from BTS patients who were enrolled in two multicenter prospective single-arm observational clinical studies that used different stent types. Both studies were conducted by the Japan Colonic Stent Safe Procedure Research Group (JCSSPRG). The first study evaluated the WallFlex™ colonic stent for BTS or palliative treatment (PAL) from May 2012 to October 2013 and the second evaluated the Niti-S™ colonic stent from October 2013 to May 2014. Fifty-three facilities in Japan participated in the studies. Before each study started, the procedure had been shared with the participating institutions by posting details of the standard methods of SEMS placement on the JCSSPRG website. Patients were followed until discharged after surgery. RESULTS: A total of 723 consecutive patients were enrolled in the two studies. After excluding nine patients, the remaining 714 patients were evaluated as a per-protocol cohort. SEMS placement was performed in 426 patients (312 WallFlex and 114 Niti-S) as BTS and in 288 as PAL. In the 426 BTS patients, the technical success rate was 98.1% (418/426). The clinical success rate was 93.8% (392/418). SEMS-related preoperative complications occurred in 8.5% of patients (36/426), perforations in 1.9% (8/426), and stent migration in 1.2% (5/426). Primary anastomosis was possible in 91.8% of patients (391/426), 3.8% of whom (15/393) had anastomosis leakage. The overall stoma creation rate was 10.6% (45/426). The postoperative complication rate was 16.9% (72/426) and mortality rate was 0.5% (2/426). CONCLUSIONS: SEMS placement for MCO as BTS is safe and effective with respect to peri-procedural outcomes. Further investigations are needed to confirm long-term oncological outcomes.

[Endoscopic stenting for patients with malignant colorectal obstruction in our hospital].

In January 2012, the Wall Flex Colonic Stent (Boston Scientific) for treating patients with malignant colorectal obstruction was included in the National Health Insurance (NHI) price list in Japan, and since July 2012, our hospital has placed this stent in 22 patients(as bridge-to-surgery [BTS] in 14 patients and as palliative treatment in 8 patients). The subjects included 13 men and 9 women, aged 27-94 years. The placement sites were the ileocecal lesion in 1 patient, the ascending colon in 1 patient, the transverse colon in 3 patients, the descending colon in 6 patients, the sigmoid colon in 4 patients, and the rectum in 7 patients. Stent placement was successful in all 22 patients (100%). The primary endpoint was improvement in scores on the ColoRectal Obstruction Scoring System (CROSS). The mean CROSS score before stenting was 1.18. The mean CROSS score after stenting was 3.71. Only 1 patient showed no change in the CROSS score(before versus after stenting). The rate of clinical efficacy was 95.4%. One patient experienced restenosis, an accidental event, requiring re-stenting after 3 days. There was 1 case of stent migration, which occurred 32 days after stenting. Colonic stent placement, as BTS and palliative treatment, is effective in improving the quality of life (QOL) of patients.

[Learning experiences of colorectal ESD in a community general hospital].

Learning how to perform colorectal endoscopic submucosal dissection (ESD) is considered difficult because of different factors including the thin colorectal wall, poor fixation, numerous folds and flexures, and changing conditions over time. A surgeon with experience in performing 25 gastric ESDs began to perform colorectal ESD after fully communicating and consulting with the Department of Surgery and obtaining adequate informed consent. Herein, we examined the results of colorectal ESD performed for 57 lesions between July 2012 and September 2013. Moreover, we selected the first 10 cases (early-phase) and the last 10 cases (late-phase) from 33 colorectal ESD cases to compare the results between the early-phase and late-phase groups. For sites where it was difficult to perform colorectal ESD, it was possible to perform ESD by changing the detachment device, tip attachment, body position, and endoscope. As the surgeon gained experience in performing gastric ESD, the colorectal procedure in the late phase group could be performed with greater speed, and a rising learning curve was observed. An incidental event of delayed perforation occurred in 1 case, for which laparoscopic partial colectomy was performed immediately after the definitive diagnosis had been made.

[Russell body gastritis].

A 63-year-old woman who presented with chest and back pain underwent an upper gastrointestinal endoscopy which revealed elevated legion in the antrum mucosa. Histologic examinations of gastric biopsies were showing monoclonal proliferation plasma cells containing Russell bodies. Differential diagnosis from B-cell lymphoma and plasmacytoma is difficult, because of monoclonality. Molecular analyses of immunoglobulin heavy chain (IgH) gene demonstrated that gene rearrangement was negative. Thus, diagnosis of Russell body gastritis was made. The Giemsa stains were also showing infection of Helicobacter pylori (H.pylori). After eradication therapy for H.pylori, follow-up upper gastrointestinal endoscopy was performed. She then recovered.