Estreñimiento refractario inducido por opioides con pseudoobstrucción intestinal secundaria resuelto con metilnaltrexona / No disponible

Presentamos el caso de una paciente de 55 años de edad que padecía un adenocarcinoma de pulmón metastático desde hacía dos años manteniendo un excelente estado funcional. La enferma accedió a nuestra Unidad de Cuidados Paliativos para manejo de un dolor difícil óseo incidental, asociado a un dolor neuropático incipiente. Previamente había evidenciado intolerancia a opioides con fracaso terapéutico con tramadol, buprenorfina, fentanilo, oxicodona y morfina oral. La paciente fue tratada inicialmente con radioterapia paliativa junto con rotación opioide a morfina parenteral con buena respuesta analgésica. No obstante, y a pesar de una adecuada optimización del uso de laxantes y enemas, presentaba deposición muy difícil cada 7 días con secuelas tales como hemorroides externas trombosadas y, finalmente, un episodio agudo de una aparente obstrucción intestinal. El cuadro de estreñimiento inducido por opioides refractario fue resuelto con medidas de soporte, junto con metilnaltrexona cada 48 horas y rotación opioide a metadona (AU)

We report the case of a 55-year-old patient with metastatic lung adenocarcinoma for two years who preserved an excellent functional status. She was admitted to our Palliative Care Unit because of challenging pain syndromes caused by incidental bone pain and recently-developed neuropathic pain. She had previously been diagnosed with opioid side effects and analgesic failure with tramadol, buprenorphine, fentanyl, oxycodone and oral morphine. The patient was initially treated with palliative radio. therapy plus opioid rotation to parenteral morphine with adequate analgesia. Nevertheless, and in spite of an adequate use and titration of laxatives and enemas, she complained of very difficult defecation every 7 days with complications such as external thrombosed hemorrhoids, and finally an apparently acute episode of bowel obstruction. This clinical scenario of refractory opioid-induced constipation responded successfully to supportive measures, methylnaltrexone every 48 hours, and opioid rotation to methadone (AU)

Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation.

PURPOSE: To determine the effectiveness and safety of metallic stents in the treatment of malignant colorectal obstruction before surgery and for palliation. MATERIALS AND METHODS: Eighty patients with acute malignant colorectal obstruction presumed to be malignant were treated by means of implanting self-expanding metallic stents. RESULTS: Stent placement was successful in 70 of the 80 patients and resolved bowel obstruction in 67 patients (96%). Two patients had colonic perforation and developed peritonitis 18 and 24 hours after stent placement; one patient died as a consequence. Thirty-three patients underwent elective surgery after 7 days +/- 3 (SD; range, 4-10 days), and adequate tumoral coverage and cleansing of the colon were observed in all patients. Stent placement was used as final palliative treatment in another 35 patients. Patient follow-up lasted a mean of 138 days +/- 93 (range, 36-334 days). The survival rate for the palliative group was 55% at 3 months, 44% at 6 months, and 25% at 9 months. The estimated primary stent patency rate was 91% at 3 and 6 months. CONCLUSION: Management of colorectal obstruction by using metallic stents was effective and safe, although colonic perforation is a potential complication. In cases of palliation, the method may obviate palliative colostomy.