Malignant Disease

Malignant colon strictures can also be dilatated with the above-mentioned technologies but results are transient and usually done in conjunction with other treatment modalities. Historically, unresectable or poor surgical risk patients presenting with bleeding or obstruction were invariably treated with Nd:YAG laser ablative therapy (Figure 85-5). More recently, however, SEMS insertion has evolved both to treat unresectable malignancies in patients who would have historically undergone palliative decompressive colostomy and as a preoperative procedure in obstructed, resectable patients conventionally treated with two-stage operations (Kozarek, 2001; Martinez-Santos et al, 2002; Khot et al, 2002; Dauphine et al, 2002; Kozarek, 2000; Kozarek, 2002). A recent meta-analysis of the latter approach suggests a 20 to 60% morbidity and a 5 to 20% mortality in patients with obstructing colorectal cancer treated surgically (Keymling, 2003).

Colorectal Prostheses

A number of prostheses have been used worldwide for obstructing colorectal neoplasms (Table 85-6). Technically, strictures are usually delineated using a small caliber endoscope or a combination of endoscopy and contrast injected fluoroscopically. Prostheses should be 4 to 5 cm longer than the stricture to be stented, and technically stents can be inserted through the scope (eg, Enteral Wallstent), alongside it over a previously placed guide wire using a combination of endoscopy and fluoroscopy, or using fluoroscopy alone (Figure 85-7).

Nd:YAG laser fiber (A, B).

In a recent analysis of multiple series using prostheses for obstructing colorectal neoplasms, there was a 93% technical success rate in 234 patients in whom stenting was attempted (Khot et al, 2002). There was a 90% success rate clinically and a 9% total complication rate (bleeding, perforation, malplacement, migration). Fifty-eight percent of patients were stented under fluoroscopic control alone, 11% under endoscopic control, and 31% underwent insertion using both modalities.

Despite the encouraging data noted above, it should be stressed that there have been no controlled trials randomiz ing stent insertion versus surgery in patients with unresectable, malignant colon obstructions (intrinsic or extrinsic). Nor have controlled trials been done randomizing stent insertion preoperatively in resectable but obstructed individuals versus two-stage surgery. Nevertheless, as the technology continues to improve and techniques become standardized, SEMS insertion for malignant colorectal obstruction is only likely to increase. There is a separate chapter on palliation for colorectal cancer (see Chapter 99, "Palliative Therapy for Rectal Cancer").

FIGURE 85-6. Colonic Z (A) and Memotherm (B) SEMS. The latter is released using a "pistol-type" delivery system. SEMS = self-expandable metal stent.

FIGURE 85-7. Malignant sigmoid stricture is delineated using a small caliber upper endoscope, the tumor margins marked with contrast injection (A), followed by fluoroscopic release of Ultraflex stent placed over an endoscopically placed guidewire (B, C, and D). Arrows outline expanded stent. Continued on next page.

FIGURE 85-7. Malignant sigmoid stricture is delineated using a small caliber upper endoscope, the tumor margins marked with contrast injection (A), followed by fluoroscopic release of Ultraflex stent placed over an endoscopically placed guidewire (B, C, and D). Arrows outline expanded stent. Continued on next page.

FIGURE 85-7 Continued. Fluoroscopic release of Ultraflex stent placed over an endoscopically placed guidewire (C, and D). Arrows outline expanded stent.
Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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