Stenting as bridge to surgery versus upfront emergency resection for non-metastatic left sided obstructing colorectal cancer: risk of peritoneal recurrence and long-term outcomes.

BACKGROUND: Oncological outcomes of stenting as a bridge to surgery (SBTS) remain a major concern, despite perioperative benefits it offers. This study aims to evaluate the differences in recurrence patterns and survival in patients with non-metastatic, obstructing left sided colon cancers treated by SBTS versus upfront emergency surgery (ES). METHODS: This is a retrospective, single-centre cohort study of 227 consecutive patients with non-metastatic, obstructing left sided colon cancer between 2007 and 2016. Primary outcomes were pattern of recurrence, and survival. Univariate, bivariate and multivariate logistic regression were done to determine relationships between factors and recurrence. Kaplan Meier curves and log rank tests were used to analyse survival outcomes. RESULTS: Of the 227 patients included, 62 underwent SBTS and 165 underwent upfront ES. There was a higher rate of peritoneal recurrence in SBTS group (27.4 vs 15.2% p = 0.034), with no difference observed in overall, liver or lung recurrences. No significant difference in overall survival (p = 0.11), cancer specific survival (p = 0.35), or recurrence free survival (p = 0.107) was observed. Univariate analysis showed that SBTS (OR 2.12, p = 0.036), diabetes mellitus (DM) (OR 2.58, p = 0.013), T4 (OR 2.81, p = 0.001), N + (OR 4.02, p = 0.001), lymphovascular invasion (OR 2.43, p = 0.011) contributed to a higher rate of peritoneal recurrence. Bivariate analysis showed synergistic relationship between T4 tumors and SBTS: in T4 tumors that underwent SBTS, the odds of having peritoneal recurrence was 6.8 times higher when compared to ES (p = 0.004); whilst in T2/3 tumors there was no significant difference observed (OR 1.33, p = 0.55). Multivariable analysis showed SBTS (OR 2.60, p = 0.04), DM (OR 2.88, p = 0.012), N + (OR 2.97, p = 0.026) were significant predictors for peritoneal recurrence. CONCLUSIONS: There are concerns over oncological safety of SBTS even with low rates of stent-related perforation. Higher rates of peritoneal recurrence are seen especially with T4 colon cancers treated with SBTS. SBTS, DM and nodal stage were significant predictors for peritoneal recurrence.

[Complicated gastric cancer and modern treatment approaches]. / Oslozhnennye formy raka zheludka ­ sovremennye podkhody k lecheniyu.

Among all patients with gastric cancer, 40% admit to the hospitals due to cancer-related complications. The most common complications of gastric cancer are bleeding (22-80%), malignant gastric outlet obstruction (26-60%), and perforation (less than 5%). The main treatment methods for gastric cancer complicated by bleeding are various forms of endoscopic hemostasis, transarterial embolization and external beam radiotherapy. Surgical treatment is possible in case of ineffective management. However, surgical algorithm is not standardized. Malignant gastric outlet stenosis requires decompression: endoscopic stenting, palliative gastroenterostomy. Surgical treatment is also possible (gastrectomy, proximal or distal resection of the stomach). The main problem for patients with complicated gastric cancer is the lack of standardized algorithms and abundance of potential surgical techniques. The aim of our review is to systematize available data on the treatment of complicated gastric cancer and to standardize existing methods.

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.

BACKGROUND: Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO. METHODS: MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed. RESULTS: After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001). CONCLUSION: ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

A modular simulation curriculum to teach endoscopic stenting to practicing surgeons: an "Into the fire" approach.

BACKGROUND: Flexible endoscopy is a valuable tool for the gastrointestinal (GI) surgeon, creating a need for effective and efficient training curricula in therapeutic endoscopic techniques for trainees and practicing providers. Here, we present a simulation-based modular curriculum using an "into the fire" approach with hands-on pre- and post-testing to teach endoscopic stenting to practicing surgeons. METHODS: Three advanced flexible endoscopy courses were taught by expert surgical endoscopists from 2018 to 2019. The stenting module involved using self-expandable metal stents to manage simulated esophageal and gastroduodenal strictures on a non-tissue GI model. Based on the educational theories of inquiry-based learning, the simulation curriculum was designed with a series of pre-tests, didactics, mentored hands-on instructions, and post-tests. Assessments included a confidence survey, knowledge-based written test, and evaluation form specific to the hands-on performance of endoscopic stenting. RESULTS: Twenty-eight practicing surgeons with varying endoscopic experiences participated in the course. Most of the participants (67.9%) had completed over 100 upper endoscopic procedures and 57.1% were certified in Fundamentals of Endoscopic Surgery. After completing the modular curriculum, participant confidence survey scores improved from 11.4 ± 4.2 to 20.7 ± 4.0 (p < 0.001). Knowledge-based written test scores also improved from 7.1 ± 1.2 to 8.4 ± 0.9 (p < 0.001). In terms of technical performance, overall hands-on performance scores improved from 21.3 ± 2.7 to 28.9 ± 1.2 (p < 0.001) with significant improvement in each individual component of the assessment (all p values < 0.01) and the greatest improvement seen in equipment handling (88%) and flow of procedure (54%). CONCLUSION: Our modular simulation curriculum using an "into the fire" approach to teach endoscopic stenting is effective in improving learner knowledge, confidence, and hands-on performance of endoscopic stenting. This approach to simulation is effective, efficient, and adaptable to teaching practicing surgeons with varying levels of experience.

Management of intra-thoracic anastomotic leakages after esophagectomy: updated systematic review and meta-analysis of endoscopic vacuum therapy versus stenting.

Despite a significant decrease of surgery-related mortality and morbidity, anastomotic leakage still occurs in a significant number of patients after esophagectomy. The two main endoscopic treatments in case of anastomotic leakage are self-expanding metal stents (SEMS) and the endoscopic vacuum therapy (EVT). It is still under debate, if one method is superior to the other. Therefore, we performed a systematic review and meta-analysis of the existing literature to compare the effectiveness and the related morbidity of SEMS and EVT in the treatment of esophageal leakage. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leak after esophageal surgery. Predefined endpoints including outcome, treatment success, endoscopy, treatment duration, re-operation rate, intensive care and hospitalization time, stricture rate, morbidity and mortality were assessed and included in the meta-analysis. Seven retrospective studies including 338 patients matched the inclusion criteria. Compared to stenting, EVT was significantly associated with higher healing (OR 2.47, 95% CI [1.30 to 4.73]), higher number of endoscopic changes (pooled median difference of 3.57 (95% CI [2.24 to 4.90]), shorter duration of treatment (pooled median difference - 11.57 days; 95% CI [- 17.45 to - 5.69]), and stricture rate (OR 0.22, 95% CI [0.08 to 0.62]). Hospitalization and intensive care unit duration, in-hospital mortality rate, rate of major and treatment related complications, of surgical revisions and of esophago-tracheal fistula failed to show significant differences between the two groups. Our analysis indicates a high potential for EVT, but because of the retrospective design of the included studies with potential biases, these results must be interpreted with caution. More robust prospective randomized trials should further investigate the potential of the two procedures.

[Endoscopic intraluminal treatment of pancreatic fluid collections after pancreas transplantation]. / Endoskopicheskoe vnutriprosvetnoe lechenie pankreaticheskikh zatekov posle transplantatsii podzheludochnoi zhelezy.

OBJECTIVE: To improve the outcomes after pancreas transplantation complicated by pancreatitis using percutaneous drainage and endoscopic stenting of the main pancreatic duct. MATERIAL AND METHODS: There were 64 transplantations of the pancreatoduodenal complex between January 1, 2012 and December 31, 2021 at the Sklifosovsky Research Institute for Emergency Care. In 11 (17.2%) cases, early postoperative period was complicated by acute pancreatitis and parapancreatic fluid accumulations. Of these, 7 patients underwent ultrasound-guided percutaneous drainage of focal destructions. This procedure was effective and did not require additional treatment. In 4 patients, debridement and drainage were ineffective and required additional endoscopic stenting of the main pancreatic duct. RESULTS: All patients underwent percutaneous drainage of peripancreatic fluid collections and subsequent fistulography. All patients had inhomogeneous cavities with irregular shape and volume of 19.6±1.8 cm3. In 3 (75%) out of 4 patients, there was a passage of contrast agent into the main pancreatic duct of the graft and donor duodenal stump. We did not find contrast enhancement of ductal system in 1 (25%) patient since filling of the cavity with a contrast agent was not tight. Sensitivity of this method for detecting pancreatic ductal defects was 75%. Indications for stenting of the main pancreatic duct were established in 22.5±9.6 days after transplantation. Drainage and debridement were ineffective in 2 (50%) patients. In other 2 (50%) patients, peripancreatic fluid collections enlarged. All patients underwent endoscopic stenting of the main pancreatic duct. CONCLUSION: Endoscopic stenting of the main pancreatic duct of the donor pancreas combined with percutaneous drainage of peripancreatic fluid accumulations is a highly effective and minimally invasive approach for fluid collections after transplantation of the pancreatoduodenal complex. This method also minimizes the incidence of postoperative complications. Thanks to this method, we avoided redo open surgeries in all cases.

Preoperative Endoscopic Biliary Stenting Before Pancreaticoduodenectomy: Does Timing Matter?

Background. The role of preoperative biliary stenting (PBS) before pancreaticoduodenectomy (PD) in patients with obstructive jaundice is debatable. The objective of the current study was to assess PD outcomes after upfront surgery or PBS and determine the impact of stent to surgery duration on PD outcomes. Methods. We reviewed patients who underwent PD between 2011 and 2019. Patients were grouped based on whether they underwent upfront surgery (n = 67) or PBS (n = 66). We further assessed outcomes based on stent to surgery duration. Results. There was no significant difference in 30-day mortality (3% vs. 2.9%, P = 1), 90-day mortality (7.5% vs. 4.4%, P = .4), and Grade B-C pancreatic fistula rates (7.5% vs. 4.4%, P = .4) in the PBS and upfront surgery groups, respectively. A significant increase in wound infections (22.7% vs. 7.4%, P = .01) and readmissions (10.6% vs. 0, P = .006) was seen in the PBS group. The highest rate of wound infection was seen when stent to surgery duration was 4-6 weeks (41.6%). The wound infection rates in the upfront surgery group, high-risk PBS group (4-6 weeks), and low-risk PBS group were 5/67(7.4%), 5/12(41.6%), and 7/36(19.4%), respectively (P = .008). Conclusions. PBS increases postoperative wound infections when compared with upfront surgery. Patients operated between 4 and 6 weeks after stenting have the highest rate of wound infection.

[Technical features of esophageal stent deployment]. / Tekhnicheskie osobennosti ustanovki pishchevodnykh stentov v zavisimosti ot tipa dostavochnogo ustroistva.

OBJECTIVE: To work out the optimal technique of endoscopic stenting of the esophagus (ESE) using various delivery devices (DD); to analyze immediate and long-term results of stenting depending on the type of DD. MATERIAL AND METHODS: ESE results were studied in 83 patients. Group 1 included 41 patients with implantation of metal stents delivered on a knitted tubular casing (21 stents with proximal opening and 20 stents with distal opening). Group 2 consisted of 42 patients who underwent ESE using a DD in the form of a contracting outer shell. RESULTS: In the 1st group, DD «stumbling¼ in 6 cases (14.6%) required additional tubular hollow rigid conductor. In the 2nd group, there was no need for additional conductor (p=0.011). Intraoperative stent repositioning after its initial installation was required in 7 cases (17.1%) of the 1st group and 16 cases (38.1%) of the 2nd group (p=0.033). Higher likelihood of stent repositioning was observed in distal stent opening. Technical success rate was 100% in both groups. Clinical success rate was 100% in the 1st group and 97.6% in the 2nd group (p>0.05). Incidence of early and long-term postoperative complications was similar (p>0.05). CONCLUSION: ESE with various DDs is safe and effective in patients with malignant unresectable esophageal tumors and symptoms of dysphagia. However, certain features of stent installation should be considered. In our opinion, DD with proximal disclosure is more convenient due to better visual positioning of stent.

Endoscopic management of post-surgical GI wall defects with the overstitch endosuturing system: a single-center experience.

BACKGROUND AND AIMS: Post-GI surgical wall defects are frequent and life-threatening complications, with limited literature regarding current treatment. This case series aims to assess the safety, feasibility, and outcomes of endoluminal therapy with the overstitch endoscopic suturing system (Apollo Endosurgery Inc, Austin). MATERIALS AND METHODS: All patients who underwent endoscopic suturing for post-surgical wall defect management at IRCCS-ISMETT Palermo from October 2017 until January 2019 were retrospectively enrolled. Stratification therapy was applied according to the clinical scenario, time from surgery to endoscopic intervention, and structural condition of the wall defect layers (tissue status and suture feasibility). The therapeutic endoscopic strategy was divided into three groups (A: pure endoscopic direct suture; B: combined therapy with endoscopic direct suture + FC-SEMS placement + anchoring; C: FC-SEMS placement + anchoring). Success was considered the resolution of symptoms and the presence of a regular intestinal transit after a period of 4-6 weeks. RESULTS: Twenty (20) patients (male/female 7/13; mean age 54 ± 13.43 years) were included in the study (group A: 9 patients, group B: 7 patients, group C: 4 patients). The types of operative procedures were bariatric (9/20), post-tracheostomy (3/20), post-operative GI surgery (8/20). The post-surgical defects were predominantly intermediate and chronic (24-72 h: 1/20; 3-30 days: 13/20; > 30 days: 6/20). The overall clinical success was 80% (17/20 patients), with a success of 94% (16/17 patients) when excluding the three cases of tracheo-esophageal fistula. No evidence of migration was detected. The only complication was short stenosis of the distal esophagus, present in 4 patients (19%) and successfully treated with a novel lumen-apposing metal stent. CONCLUSIONS: In our experience, considering the absence of clear guidelines, the endoluminal approach with the overstich endoscopic suturing system is a valid alternative to conventional therapy, offering mini-invasiveness, and presenting promising opportunities in terms of technical feasibility and clinical efficacy.

Efficiency and risks of laparoscopic conversion of omega anastomosis gastric bypass to Roux-en-Y gastric bypass.

BACKGROUND: There is a paucity on literature data related to conversion of Omega anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB). METHODS: This is a retrospective study. Records of all patients who underwent this conversion were analyzed. Additionally, patients were contacted to answer a questionnaire on their current clinical condition. RESULTS: Twenty-eight patients underwent laparoscopic conversion between September 2007 and June 2016. Indications were peritonitis in 7 patients (leaks after OAGB in 5, perforated marginal ulcer (MU) and blow-out remnant with concomitant leak in one patient each), anastomotic bleeding in one, bile reflux in 6, recalcitrant MU in 4, afferent loop syndrome in 6, postprandial vomiting in 2 (related to anastomotic stenosis and perianastomotic diverticulum, one each), and malnutrition and hypoglycemia both in 1. Thirty-day mortality was zero, complication rate (Clavien-Dindo grade III or more) 5% ((N = 1/20), abscess) when conversion was elective and 50.0% ((N = 4/8), all persisting leaks) when conversion was urgent. All 4 leaks persisting after conversion were successfully treated by endoscopic stenting, despite stent migration in 2 patients. Follow-up was available in 92.9%, for a mean time of 64.5 ± 30.1 months. Successful symptom relief (Likert score 4 or more) was noted for bile reflux and postprandial vomiting. Additionally, malnutrition was corrected. CONCLUSIONS: When indicated, conversion of OAGB to RYGB is a safe treatment strategy. In case conversion is performed for leak after OAGB, persisting subclinical leaks are frequent but can be efficiently addressed by endoscopic stenting.

Palliative surgical bypass is superior to palliative endoscopic stenting in patients with malignant gastric outlet obstruction: systematic review and meta-analysis.

BACKGROUND: Gastrojejunostomy (GJ) and self-expanding metal stents (SEMS) are the two most common palliative treatment options for patients with malignant gastric outlet obstruction (GOO). Randomised trials and retrospective studies have shown discrepant results, so that there is still a controversy regarding the optimal treatment of GOO. METHODS: Medline, Web of Science and Cochrane Library were systematically searched for studies comparing GJ to SEMS in patients with malignant GOO. Primary outcomes were survival and postoperative mortality. Secondary outcomes were frequency of re-interventions, major complications, time to oral intake and length of hospital stay. RESULTS: Twenty-seven studies, with a total of 2.354 patients, 1.306 (55.5%) patients in the SEMS and 1.048 (44.5%) patients in the GJ group, were considered suitable for inclusion. GJ was associated with significantly longer survival than SEMS (mean difference 43 days, CI 12.00, 73.70, p = 0.006). Postoperative mortality (OR 0.55, CI 0.27, 1.16, p = 0.12) and major complications (OR 0.73, CI 0.5, 1.06, p = 0.10) were similar in both groups. The frequency of re-interventions, however, was almost three times higher in the SEMS group (OR 2.95, CI: 1.70, 5.14, p < 0.001), whereas the mean time to oral intake and length of hospital stay were shorter in the SEMS group (mean differences - 5 days, CI - 6.75, - 3.05 days, p < 0.001 and - 10 days, CI - 11.6, - 7.9 days, p < 0.001, respectively). CONCLUSIONS: Patients with malignant GOO and acceptable performance status should be primarily considered for a palliative GJ rather than SEMS.

Long-term outcomes following endoscopic stenting in the management of leaks after foregut and bariatric surgery.

INTRODUCTION: Endoscopic stenting has been shown to be effective in treating leaks after bariatric surgery. However, concerns remain regarding its long-term efficacy. The purpose of this study was to assess the evolution of endoscopic stenting and its efficacy over time, as well as the impact of stent fixation on migration rates and long-term outcomes. In addition, the effect of stenting on long-term weight loss and chronic reflux was also evaluated. METHODS: A retrospective review was conducted including 37 patients from 2005 to 2017 who had undergone placement of stents after various bariatric procedures. Stents were placed endoscopically and, after 2012, secured with a figure-of-eight overstitch. Demographics, weight loss data, stent migration rates, incidence of revision surgery, chronic PPI use, and chronic symptoms of reflux data were obtained and analyzed. RESULTS: Thirty-seven patients from 2005 to 2017 required endoscopic stenting for leaks. 43.24% patients underwent sleeve gastrectomy, 40.54% gastric bypass, 5.40% patients underwent duodenal switch, and 10.81% underwent miscellaneous foregut procedures. The overall success rate was 94.59% (35 of 37 patients). The incidence of stent migration before 2012 was 41.18% versus 15% after 2012 (p = 0.136271). There were 2 treatment failures, one treated successfully with re-stenting and another other requiring revision surgery. Overall, the percent of excess body weight lost was 57.21% over an average of 21 months. 58.82% of patients used PPI chronically; however 41.17% noted actual symptoms of reflux. 16.22% (6 of 37) patients ultimately underwent revision surgery. CONCLUSION: Endoscopic stenting is a safe and effective treatment for leaks after bariatric surgery. While complications can include stent migration, newer stent technology and endoscopic overstitching techniques show promise in reducing the incidence of stent migration. Despite undergoing treatment with stenting, these patients had successful weight loss with relatively low rates of chronic PPI use and reflux symptoms.

Self-Expanding Metal Stents for the Treatment of Post-Surgical Esophageal Leaks: A Tertiary Referral Center Experience.

BACKGROUND/AIMS: The study aimed to evaluate the effectiveness and safety of self-expanding metal stents (SEMS) in the management of post-surgical esophageal leaks. METHODS: Retrospective data of consecutive patients with a post-surgical esophageal leak treated by means of a metal stent between January 2008 and December 2014 at the Humanitas Research Hospital (Milan, Italy) were extracted from a prospectively maintained register of SEMS used for benign indications, such as post-surgical benign esophageal strictures and/or leaks. The primary outcome of the study was to assess the rate of successful leak closure and to identify the variables associated with its achievement. As a secondary outcome, we evaluated the overall safety of SEMS placement and the efficacy and safety for different types of SEMS in this specific setting of patients. Leak resolution was documented with endoscopic and/or imaging studies. In the case of leak persistence, further attempts of esophageal stenting were carried out at the discretion of both endoscopists and surgeons. RESULTS: A total of 49 patients were included in the study (men 41 of 49, 83.7%, mean age 62.4 ± 11.9). One patient was excluded from analysis, because of death 1 day after stent insertion due to worsening of pre-existing mediastinitis. A total number of 82 stents were placed (mean number of stents per patient: 1.7) in 49 patients: 35 patients (71.4%) received a partially covered SEMS (PCSEMS) as the first stent positioned, while the remaining 14 (28.6%) received a fully covered SEMS (FCSEMS); but 1 patient (2%) died following stent insertion; therefore, data regarding therapeutic success were available for 48 patients. Stents were left in place for a mean period of 21.9 ± 15.2 days. Leak closure after the first stent placement was achieved in 22 of 48 (45.8%) patients. Of the 26 patients with failure of index stent placement, 18 patients underwent further stenting attempts (69.2%), and secondary closure of leak was achieved in 7 (38.9%) of these 18 patients. Thus, the overall success rate was 60.5% (29 of 48). On the basis of stent type, the success rate was 57.1% (8 of 14) for FCSEMS and 64.7% (22 of 34) for PCSEMS. Logistic regression analysis did not find any significant association between successful leak closure and analyzed variables. Overall mortality was 13.0%. Complication rate was 38.8% (19 of 49 patients). CONCLUSION: The use of SEMS is an effective and safe option for post-surgical esophageal leaks, with no evidence of any significant influence of stent type on outcome.

[Pancreatic duct stenting in the treatment of acute pancreatitis]. / Vliyanie stentirovaniya glavnogo pankreaticheskogo protoka na rezul'taty lecheniya bol'nykh s ostrym pankreatitom.

OBJECTIVE: To study the effect of pancreatic duct stenting on the results of treatment of acute pancreatitis. MATERIAL AND METHODS: Analysis included 99 patients with acute pancreatitis. Endoscopic stentingwas appliedin the study group, conventional approach - in the control group. RESULTS: Pancreatic duct stenting at theearly stages ofacute pancreatitis results decreased level of enzyme toxemia and manifestations of systemic inflammatory response. CONCLUSION: Stenting interrupts course of pathological process and minimizes the possibility of transition of aseptic to infected pancreatic necrosis. Therefore, reduced early mortalityis observed.

[Effectiveness of various approaches for acute malignant colonic obstruction]. / Sravnitel'naia otsenka éffektivnosti razlichnykh sposobov lecheniia bol'nykh ostroi tolstokishechnoi neprokhodimost'iu opukholevogo geneza.

AIM: To determine optimal treatment strategy for acute malignant colonic obstruction. MATERIAL AND METHODS: 349 patients with acute malignant colonic obstruction were retrospectively analyzed for the period 2005-2017. All patients were divided into two groups depending on surgical approach. Surgical group comprised 259 patients, endoscopic group - 90 patients. Both groups were comparable by gender, age, level of intestinal obstruction and duration of the disease. However, morbidity and mortality rate were significantly different. RESULTS: In surgical group incidence of complications was 63.3%, mortality - 19.7%. In group of endoscopic stenting the same values were 8.9% and 6.7%, respectively. Significant differences of morbidity and mortality were observed between groups (p<0.05). CONCLUSION: Endoscopic stenting should be preferred over surgery to eliminate colonic obstruction in patients with acute malignant ileus.

Predictors of outcome for endoscopic colorectal stenting: a decade experience.

PURPOSE: Endoscopic stenting is used with increasing frequency to treat colorectal conditions. Little is known about what influences outcome. This study aimed to determine the impact of various factors on the short- and long-term results of colorectal stenting. METHODS: A retrospective review was conducted of all endoscopic stenting procedures performed by a colorectal surgeon at a tertiary referral institution between 2003 and 2013. Main outcome measures included technical success, clinical success, complications, and predictors of outcome. RESULTS: Of the stent procedures, 183 were performed in 165 patients. The majority of patients (90 %) presented with a malignant obstruction (intrinsic colonic vs. extrinsic non-colonic). Carcinomatosis was present in 22 % of patients with malignancy, and it was associated with lower technical success compared to non-carcinomatosis (adjusted odds ratio [AOR] 0.2 [95 % confidence interval (CI) 0.1-0.8]; p = 0.021). Colonic malignancy was associated with higher clinical success compared to non-colonic malignancy (AOR 3.8 [95 % CI 1.4-10.3]; p = 0.009). Carcinomatosis increased the risk of complications compared to non-carcinomatosis (AOR 3.2 [95 % CI 1.0-10.0]; p = 0.049). The risk of complication was higher when a stent was deployed in the rectum compared to the colon (AOR 4.1 [95 % CI 1.5-11.7]; p = 0.008). The use of a covered stent was associated with higher complication rate compared to a non-covered stent (AOR 13.6 [95 % CI 2.6-71.2]; p = 0.002). Balloon dilation was associated with an increased risk of complications (AOR 4.6 [95 % CI 1.3-16.2]; p = 0.017). CONCLUSIONS: Carcinomatosis was associated with lower technical success rate. Clinical success was higher in patients with a primary colonic malignancy. The use of a covered stent, balloon dilation of stricture, lesions in the rectum, and carcinomatosis were associated with higher risk for complications.

Percutaneous biliary approach as a successful rescue procedure after failed endoscopic therapy for drainage in advanced hilar tumors.

BACKGROUND AND AIM: Palliative endoscopic or percutaneous biliary drainage is used for unresectable advanced hilar cancer (HC). The best option for drainage in Bismuth type III or IV HC has not been established. The aims of this study are to identify factors predictive of endoscopic stenting failure and evaluate the effectiveness of rescue percutaneous stenting in patients with advanced HC. METHODS: Data from 110 patients with inoperable advanced HC were retrospectively reviewed. All received bilateral self-expandable metallic stents. Patients were divided into three groups: I, successful initial endoscopic stenting; II, unsuccessful initial endoscopic stenting, followed by percutaneous stenting; and III, initial percutaneous stenting. We analyzed clinical results and radiologic tumor characteristics. RESULTS: Baseline characteristics and clinical outcomes of all groups were similar, except the hospital stay was longer in group III than group I. Technical success rate was higher in groups II and III (100%) than in group I (72.4%). The functional success rate, stent patency time, patient survival time, and complication rate were similar between groups. Endoscopic stenting failed because of guide-wire passage failure (n = 12) or stent passage failure (n = 7). The only factor significantly associated with endoscopic failure was a smaller left intrahepatic duct-common bile duct angle. CONCLUSIONS: As clinical outcomes were generally similar between approaches, percutaneous stenting is recommended for patients with Bismuth type III or IV advanced HC. Acute left intrahepatic duct-common bile duct angulation predicts endoscopic stenting failure. If endoscopic stenting fails, immediate conversion to the percutaneous approach is a necessary and effective rescue method.

Colonic stenting as a bridge to surgery versus emergency surgery for malignant colonic obstruction: results of a multicentre randomised controlled trial (ESCO trial).

BACKGROUND: The aim of colonic stenting with self-expandable metallic stents in neoplastic colon obstruction is to avoid emergency surgery and thus potentially reduce morbidity, mortality, and need for a stoma. Concern has been raised, however, about the effect of colonic stenting on short-term complications and long-term survival. We compared morbidity rates after colonic stenting as a bridge to surgery (SBTS) versus emergency surgery (ES) in the management of left-sided malignant large-bowel obstruction. METHODS: This multicentre randomised controlled trial was designed with the endorsement of the European Association for Endoscopic Surgery. The study population was consecutive patients with acute, symptomatic malignant left-sided large-bowel obstruction localised between the splenic flexure and 15 cm from the anal margin. The primary outcome was overall morbidity within 60 days after surgery. RESULTS: Between March 2008 and November 2015, 144 patients were randomly assigned to undergo either SBTS or ES; 29/144 (13.9%) were excluded post-randomisation mainly because of wrong diagnosis at computed tomography examination. The remaining 115 patients (SBTS n = 56, ES n = 59) were deemed eligible for analysis. The complications rate within 60 days was 51.8% in the SBTS group and 57.6% in the ES group (p = 0.529). Although long-term follow-up is still ongoing, no statistically significant difference in 3-year overall survival (p = 0.998) and progression-free survival rates between the groups has been observed (p = 0.893). Eleven patients in the SBTS group and 23 in the ES group received a stoma (p = 0.031), with a reversal rate of 30% so far. CONCLUSIONS: Our findings indicate that the two treatment strategies are equivalent. No difference in oncologic outcome was found at a median follow-up of 36 months. The significantly lower stoma rate noted in the SBTS group argues in favour of the SBTS procedure when performed in expert hands.

Treatment of rectovaginal fistula after colorectal resection with endoscopic stenting: long-term results.

AIM: To treat patients with rectovaginal fistula after anterior resection for cancer using self-expanding metal stents. METHOD: Ten patients of mean age of 56.3 years with rectovaginal fistula after colorectal resection for cancer were treated with endoscopic placement of a self-expanding metal stent. In three patients a diverting proximal stoma had been performed elsewhere. The rectal opening of the fistula was located from 3 to 10 cm from the anal verge (mean 6 cm). All patients had preoperative radiotherapy. In seven patients the stent was placed as the initial treatment while three referred patients had had multiple failed operations. RESULTS: There were no complications after the procedure. At a mean follow-up of 24 months the rectovaginal fistula has healed without major faecal incontinence in eight patients. In the remaining two the fistula has reduced significantly in size to allow a successful flap transposition. CONCLUSION: Endoscopic placement of a self-expanding metal stent is a valid adjunct to treat patients with rectovaginal fistula after colorectal resection for cancer.