A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction.

BACKGROUND: The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies. METHODS: Subjects admitted to the authors' department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon. RESULTS: Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan-Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %. CONCLUSIONS: In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.

[Duodenal perforation post-ERCP: diagnostically and therapeutic management]. / Strategia diagnostico-terapeutica nelle complicanze perforative post-colangiopancreatografia retrograda endoscopica (ERCP).

OBJECTIVE: Author's experience with periduodenal perforation after ERCP and there systematic approach is presented. METHODS: A retrospective study of 6 instances of duodenal perforation related to endoscopic retrograde cholangiopancreatography. The study follows these parameters: type of perforations, clinical presentation, diagnostic methods, time to diagnosis, methods of management, surgical procedures, length of stay, mortality and morbidity. RESULTS: Traditionally duodenal perforation after ERCP has been managed surgically; however in last decade management has been shifted to a more selective approach, but some authors promotes non surgical routine management: the reported death rate of medical treatment is high as 50%. In our experience an aggressive diagnostically and therapeutically management may reduce mortality. The decision to manage patients without surgery is a dynamic one and should undergo frequent reevaluation whenever the clinical circumstances demonstrate even the slightest untoward development. CONCLUSION: A selective management scheme and an aggressive but selective surgical approach may influence overall mortality.

Percutaneous transhepatic biliary drainage and occlusion balloon in the management of duodenal stump fistula.

BACKGROUND: Duodenal stump fistula (DSF) after gastrectomy is a complication with a high mortality rate. We report a series of patients with postoperative DSF treated with percutaneous transhepatic biliary drainage and occlusion balloon (PTBD-OB). The aim of this study is to explore the feasibility and efficacy of PTBD-OB in the treatment of DSF. PATIENTS AND METHODS: Six patients developing DSF underwent PTBD-OB because of high DSF output and because medical and surgical management was unsuccessful. In these patients, an occlusion balloon was percutaneously inserted into the common bile duct and a biliary drain was positioned above the balloon to obtain external drainage of bile. RESULTS: In all cases, percutaneous access to the biliary tree was achieved. Patients maintained the PTBD-OB for a median of 43 days. In all patients, DSF output decreased after PTBD-OB placement from a median of 500 to 100 ml/day (p = 0.02). The DSF resolved in three patients and three patients died of sepsis, but in two of them, death was related to other digestive fistulas that developed before PTBD-OB placement. CONCLUSIONS: This paper presents the first published series on DSF management with PTBD-OB and shows that it is a feasible and safe procedure which reduces DSF output.