Outcome of self-expandable metal stents placement for obstructive colorectal cancer: 7 years' experience from a Swedish tertiary center.

BACKGROUND AND STUDY AIMS: Self expandable metal stents (SEMS) is an alternative to emergency surgery to treat malignant large bowel obstruction. It can be used either for palliation or as a bridge to curative surgery. Our study aims to review the outcomes of SEMS treatment in a tertiary center and to find predictors for the clinical outcome. PATIENT AND METHODS: We retrospectively analyzed data from SEMS insertion at Sahlgrenska University Hospital, a referral center in Western Sweden (1.7 million inhabitants), between 2014 and 2020. Data collected were age, the intent of intervention, tumor localization, complication rate, technical and clinical success, 30- and 90-days mortality as well as long-term survival for the indication bridge to surgery. RESULTS: We identified 265 SEMS insertions (mean age 72, female 49.4%). Most SEMS were used for palliation (90.2%). The malign obstruction was most often located in the left colon (71.7%). Technical success was achieved in 259 (97.7%) cases and clinical success in 244 (92.1%) cases. Post-operative complications occurred in 11 cases (4.2%). The 30-days mortality rate was 11.7% and the 90-day was 31.7%. In our analysis the tumor site was not associated with adverse outcomes and bridge to surgery indication was a positive prognostic factor for the 90-day mortality. CONCLUSIONS: We found that SEMS is an effective and safe treatment for patients with acute obstructive colorectal cancer.

The diagnostic value of a change in bowel habit for colorectal cancer within different age groups.

BACKGROUND: Change in bowel habit as a sole alarm symptom for colorectal cancer is disputed. OBJECTIVE: We investigated the diagnostic value of change in bowel habit for colorectal cancer, particularly as a single symptom and within different age groups. METHODS: This retrospective cohort study examined colorectal cancer fast track referrals and outcomes across four Swedish hospitals (April 2016-May 2017). Entry criteria constituted one or more of three alarm features: anaemia, visible rectal bleeding, or change in bowel habit for more than 4 weeks in patients over 40 years of age. Patients were grouped as having only change in bowel habit, change in bowel habit plus anaemia/bleeding or anaemia/bleeding only. RESULTS: Of 628 patients, 22% were diagnosed with colorectal cancer. There were no cases of colorectal cancer in the only change in bowel habit group under 55 years, while this was 6% for 55-64 years, 8% for 65-74 years and 14% for 75 years and older. Among subjects under 55 years, 2% with anaemia/bleeding had colorectal cancer, this increased to 34% for 55 years and older (P < 0.0001). Change in bowel habit plus anaemia/bleeding gave a colorectal cancer prevalence of 16% in under 55 years and increased to 30% for 55 years and older (P = 0.07). CONCLUSION: Change in bowel habit as the only alarm feature has a low diagnostic yield for colorectal cancer in patients under 55 years.

Implementation of mentor-assisted colorectal endoscopic submucosal dissection in Sweden; learning curve and clinical outcomes.

OBJECTIVE: It's still challenging to introduce colorectal (CR) ESD in Western countries. We assessed the feasibility of introducing and implementing CR-ESD in Sweden with hiring Japanese expert as a supervisor. METHODS: We analyzed 71 consecutive CR-ESD cases performed by two endoscopists who had no (endoscopist A (E-A)) or 20 cases (endoscopist B (E-B)) of experience in ESD. E-A performed rectal lesions while E-B performed lesions in any locations. Factors associated with failure in en bloc resection and in self-accomplishment were analyzed. RESULTS: Overall en bloc and R0 resection rates were 80.3% and 70.4%. Adverse event occurred in 7.0% including two perforations, two post-operative hemorrhage and one delayed perforation. Only case with delayed perforation underwent surgical treatment. Total self-accomplishment rate was 50% (10/20) for E-A, and 37.3% (19/51) for E-B. Dividing each performer's cases into three learning phases, self-accomplishment rates increased from 42.9% to 83.3% for E-A, and from 29.4% to 70.6% for E-B, as well as en bloc resection rates from 71.4% to 100% for E-A, and from 52.9% to 94.1% for E-B. Multivariate analysis revealed that location upper than rectum, lesions with formerly taken biopsy and lesions larger than 30mm were significantly associated with en bloc resection failure. CONCLUSIONS: Implementation of CR-ESD with hiring Japanese supervisor for certain period was safe for patients and effective for good learning curve.

Technological review on endoscopic submucosal dissection: available equipment, recent developments and emerging techniques.

Endoscopic submucosal dissection (ESD) is widely practiced in Japan and the Eastern World and is rapidly expanding in western countries for the management of early malignancies of the upper and lower gastrointestinal tube. In addition, novel therapeutic applications deriving from ESD have emerged including the treatment of achalasia, of submucosal tumors, of diverticula, of strictures and of reflux disease. An ESD procedure necessitates not only skills and specific training, but also familiarization with a vast spectrum of devices (endoscopes, high-frequency generators and their settings, endoknives, hoods, irrigation devices) and techniques (such as countertraction, artificial ulcer closure), that render the procedure faster, more efficient and safer. This technological article gives an overview on current and novel equipment for an ESD and associated techniques.