Andrea Cavallaro1, Giorgio Maria Paolo Graziano2, Marco Cavallaro3 and Antonino Graziano4*
1Surgical and Breast Unit Azienda Policlinico Ct, Italy
2University of Catania, Medical School, Italy
3Radiology unit ASP Ragusa, Italy
4Aggregate Professor, University of Catania Azienda Policlinico Dpt Sciences Surgery and advanced technologies “ G Ingrassia” , via S Sofia 86, Catania. Cap 95125, Italy
Received: 18 September, 2015; Accepted: 13 October, 2015; Published: 15 October, 2015
Prof. Antonino Graziano, via s Sofia n 87 Catania cap95125 Sicilia Italy, University of Catania, Tel: 0953782880; E-mail:
Cavallaro A, Paolo Graziano GM, Cavallaro M, Graziano A (2015) The Stent Evolution in Colo-Rectal Emergencies. J Surg Surgical Res 1(3): 045-048. 10.17352/2455-2968.000012
© 2015 Cavallaro A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Stent; Intestinal occlusion
Introduction: The appearance of a framework for occlusive colorectal tumor raises complex issues and difficult. We need to ensure a resumption of normal bowel function in patients often in extreme conditions. Emergency surgery flounders in a derivation and a resection with restoration of intestinal transit. The progress of digestive endoscopy can now make available a medical procedure can solve the framework occlusive both as palliation both as a bridge to safer surgery. The purpose of this study is to evaluate the indications and limitations of the method of colon prosthesis with self-expandable stents.
Materials and methods: From 1996 to 2004 at the surgical clinic III - University Policlinic of Catania - were performed 162 interventions for colorectal pathology of which 82 for benign disease and the remaining 80 for malignant disease. In four of these cases of neoplastic occlusions (one in which the precarious clinical condition and high anesthetic risk high - ASA 5 - in a metastatic patient made problematic the surgical indication and 3 in which the significant intestinal distension induced to believe priority prosthetic re-canalization) recovery of bowel function was made possible with an attachment of metal self-expandable prosthesis. These 4 patients were compared with the same number of patients in overlapping conditions in which the re-channeling has been obtained by surgical methods in emergency. This has highlighted, despite its low numbers, at least a trend of lower risk in favor of the prosthesis, while recognizing that the endoscopic procedure involves a considerable wealth of complications. It emphasizes collaboration, critical, of course, with the endoscopist, even with the radiologist who, in addition to laying the groundwork for the definition of indications, is directly implicated in the satisfactory development of the procedure during and after his implementation.
Conclusions: In patients with blocking colorectal tumor is feasible to implement an attempt endoscopic decompression useful to the recovery of the intestinal canalization.
The appearance of a framework for occlusive colorectal tumor raises the issue of how the therapy should be accurate and timely, and its goal is to rebalance the overall clinical condition of the patient, and to restore the re-canalization of bowel function with a therapeutic approach in relation to the specific clinical situation. The occluded patient is usually admitted to a department of emergency surgery and underwent surgical treatment in relation to the anatomical and clinical situation occurring. This intervention may be a derivation and/or a resection and whether or not followed by the restoration of intestinal continuity. The choice is obviously complex and difficult in emergency. For this reason, initially, the positioning of self-expandable metal prostheses has emerged as a possible palliative treatment in emergency-urgency [1-3], utilized for the solution of the framework of extreme acute occlusion, in patients in severe general conditions with extensive neoplasm disease. Initially, therefore, the prosthesis was placed in alternative to emergency surgery that is burdened with rates of mortality and morbidity, significantly higher than those in elective colorectal surgery. In fact, palliation with prosthesis provides results comparable to those of emergency surgery but at lower risk (halved) compared to decompressed colostomy, the ileo-colic derivation or Hartman procedure [9,11]. In patients not amenable to curative resection [7,8] or deemed too risky for causes of local and general disorders, the indications in the palliative treatment of malignant strictures of the colon and rectum, are determined primarily by the occlusion of a tumor locally advanced or with distant metastases, or from a patient with clinical conditions so complex that make the operative risk unacceptable. But beyond these cases, it soon became apparent that, even in patients not extreme, the affixing of a prosthesis can be used to ensure normal bowel function before surgery, and therefore to obtain an optimal rehydration of the patient, a reduction gas expansion of the bowel, with improved intestinal trophism loops upstream and lower risk for the anastomosis. That affixing can make the indicated treatment in one time of the occlusive status. In these cases, therefore, the prosthesisation of acute occlusion can be a procedure able to move the patient to a virtually elective surgical procedure, This represent a bridge to surgery, without a doubt the best procedure in every sense (bridge to surgery) , The purpose of this study is to evaluate the indications and limitations of this method on the basis of a comparison of the endoscopic procedure and emergency surgery. This, despite numbers too small, certainly not useful for statistical evaluation, however, can indicate an operative trend and gives an idea of the possibilities of the endoscopictechnique.
Materials and Methods
From 1996 to 2004 at the surgical clinic III - University Policlinic of Catania were treated 162 interventions for colorectal pathology moving from the emergency room. Of these cases, 82 were benign diseases (diverticulitis, volvulus, and intussusception), the remaining 80 were cancer diseases. Given their provenance of urgency, in 75 cases the patients presenting with a severe bowel obstruction for which it was necessary to adopt an emergency procedure. In 3 cases was present sigmoid volvulus with septic shock, n 2 necrosis and bowel perforation for femoral strangled hernia and peritonitis. These cases, suffering with the intestinal wall, were all surgically treated in emergency. In 4 of the 75 cases occluded by cancer occurred to our observation, we have tried alternative routes to emergency surgery in the period 2002/04. In the first case we have adopted the procedure of palliative endoscopic placement of a self-expandable stent for cancer of the rectum-sigma locally advanced in a very elderly patient in poor general condition with pulmonary repetitions. The patient lived a couple of months, but fully ducted. The success of the procedure, has led us to extend the indications of the use of stents to patients not in poor general condition, in that mode which has since been called “bridge to surgery”. Three other patients had indeed placed the stent and, after an average of 16 days, underwent definitive surgical treatment in channeling state, with a chance to make preoperative bowel cleaning. The clinical postoperative evolution of these patients was a subclinical dehiscence in case 3 and a burrowing led by drainage in case 1, both healed without major problems. Uneventful the case 2. These patients were all treated in the early 2000. After we have not got to continue the procedure for both the endoscopist transfer to another hospital and hints for both negative the Dutch experience that was maturing. We now, years later, given the renewed interest in the procedure, compare our 4 patients with prostheses with as many cases of our series emergency surgery, stratified by age, sex, site of occlusion and comorbidity similar the previous, but not undergoing “re-canalization” stents, and treated in emergency with surgical resection / anastomosis and ileostomy. While, as mentioned, in re-canalized endoscopic bridge were only a postoperative subclinical dehiscence and a fistula, both healed without special measures, in historians patients instead there were two important clinical dehiscence that required the first a) repackaging of the anastomosis and the positioning of multiple drainages, the other b) an intervention of Hartman, after disassembly of the anastomosis, and then a double stoma and both a third intervention to restore intestinal continuity. In 4 cases underwent stent only in the first case (palliation) the clinical condition at admission were precarious and high anesthetic risk (ASA 5) while the occlusion was caused by metastatic tumor. The other three were in better clinical conditions, such as to consider feasible the adoption of the stent as a bridge to surgery. In all cases the re-canalization, both palliative both preoperative, of bowel function was made possible by affixing of a self-expandable metallic prosthesis (Figure 1). The devices used for localized stenosis in the left colon, for anatomical reasons, were of the Evolution type. Today the covered stents are also available, perhaps more suitable for palliative action, while for the short period of the bridge to surgery, open stents that pass in the working channel of the endoscope (TTS), are still eligible.