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© Borgis - New Medicine 3/2011, s. 79-83
*Tomasz Miłek1, Piotr Ciostek1, Witold Wożniak1, Andrzej Lewczuk1, Robert Petryka2, Jakub Słowik2, Mirosław Jarosz2
Preliminary results of the use of self-expanding nitinol stents in inoperable gastrointestinal cancers
1First Chair and Department of General and Vascular Surgery of the Warsaw Medical University Department
Head: Prof. Piotr Ciostek, MD, PhD
2Gastrology Department of the Food and Nutrition Institute in Warsaw Department
Head: Prof. Mirosław Jarosz, MD, PhD
Summary
Aim. The aim of the study was to present preliminary results of the palliative treatment of strictures and obstruction of the gastrointestinal tract in stage IV cancers with the use of self-expanding stents.
Material and methods. Within a one-year period, from October 2008 to September 2009, stent implantation in the gastrointestinal tract was performed in 32 patients. Eligibility for palliative treatment was determined on the basis of a clinical examination and diagnostic tests to assess cancer stage. Local advancement of cancer with infiltration of other tissues, such as metastases to the liver, distant lymph nodes or other organs, determined the choice of palliative treatment. The procedures were performed using a c-arm X-ray system and endoscope.
Results. A total of 33 stents were implanted in 32 patients. Problems with stent placement occurred in one patient. During implantation into a stricture secondary to sigmoid colon cancer, the stent slipped down and incompletely filled the tumor lumen. In this case, a short supplementary stent was added, which yielded a satisfactory result of the procedure. In another case, the stent migrated and adhered to the gastric wall, which further impaired passage through the patient′s gastrointestinal tract.
Conclusions. 1) Stent implantation in the gastrointestinal tract lumen in the setting of inoperable carcinomas under endoscopic and X-ray control is effective and safe. 2) In the case of gastrointestinal tract obstruction in patients with left colon cancers and in poor general condition, this procedure should be considered prior to pursuing surgical operations.
Introduction
Along with an increase in incidence of gastrointestinal cancers, there is a growing need for optimisation of surgical management, at best with the use of minimally invasive treatment methods. Unfortunately, advanced and/or obstruction-complicated forms predominate among newly diagnosed gastrointestinal cancer cases. These patients are of particular concern due to the poor results of treatment in this group obtained so far. The recently introduced self-expanding stents implanted into the gastrointestinal tract lumen seem to offer new possibilities in palliative management. Their applications so far were limited to strictures in inoperable eosophageal, gastric and duodenal malignancies. There also have been recent attempts to use them in colonorectal cancer. Stent implantation is a minimally invasive technique. Owing to its use, operation can be avoided, which means the elimination of the risk of systemic and local complications, relatively common after typical operative treatment, or operation can be delayed by several weeks, using the time gained for preliminary anticancer treatment and improvement of the body functioning of the candidate for the procedure. Patients′ life comfort improves, which includes maintaining the possibility of feeding via the physiological oral route or stoma creation avoidance.
The following clinical situations are generally accepted indications for stent implantation:
1. The patient is non-eligible for classical surgical treatment in view of local and general advancement of cancer – stent placement resolves the problem of imminent obstruction and gives the chance for immediate initiation of systemic treatment.
2. The tumour is initially inoperable, as a result of which the patient is found eligible for neoadjuvant chemotherapy – stent use gives time to perform chemotherapy and a chance for a later curative operation.
3. The patient is found non-eligible for classical surgical treatment due to advanced coexisting disorders – the stent solves the problem of imminent obstruction and gives the chance for curing the patient and improving his/her performance, owing to which the patient′s general clinical condition may improve and operation eligibility may favourably change.
In view of the increasing experience of medical teams implanting stents, the indications for their use are more and more confidently extended. The direction which is highly likely to be extensively accepted by clinicians is the use of gastrointestinal stents in conditions of acute malignant obstruction. After endoscopic clearing of the obstruction, to fixate the distension and prevent re-obstruction of the intestinal lumen, a stent is placed at the cleared site. Another interesting indication for the use of stents, this time the so-called coated stents, is sealing of gastrointestinal fistulae, especially when reoperation seems to be technically difficult or unfeasible due to the patient′s poor general clinical condition resulting from undernourishment and electrolyte and protein loss through the fistula. In these cases, stent placement causes immediate sealing of the fistula and enables rapid elimination of the deficiencies via the physiological route (fig. 1, 2). Finally, a particular problem associated with stent use is relapsing cancerous strictures at the place of anastomosis after previous operations, caused by a local relapse. In these cases, when local relapse is associated with generalisation of the cancer process, it is indicated to use the endoscopic technique of widening the stricture and its fixation with the use of a stent. Minimally invasive restoration of gastrointestinal passage and a short hospitalisation enables immediate initiation of systemic treatment.
Fig. 1. Stent placement in sigmoid colon.
Fig. 2. Stent placement in lower esophagus.
aim of the Study
The aim of the study is to present the preliminary results of the palliative treatment of strictures and obstruction of the gastrointestinal tract in stage IV cancers, with the use of self-expanding stents.
Material and methodS

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Piśmiennictwo
1. Brehant O, Fuks D, Bartoli E et al.: Elective (planned) colectomy in patients with colorectal obstruction after placement of a self-expanding metallic stent as a bridge to surgery: the results of a prospective study. Colorectal Dis 2008 May 9 (Epub ahead of print). 2. McLoughlin MT, Byrne MF: Endoscopic stenting: where are we now and where we go? World J Gastroenterol 2008; 14(24): 3738-803. 3. Trompetas V: Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl 2008; 90(3): 181-6. 4. Liberman H, Adams DR, Blatchford GJ et al.: Clinical use of the self-expanding metallic stent in the management of colorectal cancer. 2000; 180, 6: 407-412. 5. Kim TH, Song HY, Park IK et al.: Usefulness of multifunctional gastrointestinal coil catheter for colorectal stent placement. Eur Radiol 2008 (Epub ahead of print). 6. Baerlocher MO, Asch MR, Vellahottam A et al.: Safety and efficacy of gastrointestinal stents in cancer patients at a community hospital. Can J Surg 2008; 51(2): 130-4. 7. van Hoft JE, Focken P, Marinelli AW et al.: Dutch Colorectal Stent Group: Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-aided colorectal cancer. Endoscopy 2008; 40(3): 184-91. 8. Vape P, Huhinen H, Rantala A et al.: Adoption of self-expanding metallic stents in the palliative treatment of obstructive colorectal cancer-look out for perforations. Surg Laparosc Endosc Percutan Tech 2008; 18(4): 353-6. 9. Gupta K, Freeman ML: Enteral and colonic self-expanding metallic stents. Rev Gastroenterol Disord 2008; 8(2): 83-97. 10. Dormann AJ, Deppe H, Wigginghaus B: Self-expanding metallic stents for continuous dilatation of benign stenoses in gastrointestinal tract – first results of long-term follow-up in interim stent application in pyloric and colonic obstructions. Gastroenterol 2001; 39: 957-960; DO1:10.1055/s-2001-18531. 11. Harris GJC, Senagore AJ, Lavery JC, Fazio VW: The management of neoplastic colorectal obstruction with colonic endolumental stenting devices. Am J Surg 2001; 181, 6: 499-506. 12. Kim H, Kim SH, CHoi SY et al.: Fluoroscopically Guided Placement of Self-Expandable Metallic Stents and Stent-Grafts in the Treatment of Acute Malignant Colorectal Obstruction. J Vasc Interv Radiol 2008; 7 (epub ahead of print). 13. Stenhouse GJ, Page B, McKelvi A et al.: Self expanding wall stents in malignant colorectal cancer; is complete obstruction a contraindication to stent placement? Colorectal Dis 2008; (epub ahead of print). 14. Lopes CV, Pesenti C, Bories E et al.: Self-expandable metallic stents for palliative treatment of digestive cancer. J Clin Gastroenterol 2008; 42(9): 991-6. 15. Gomez Herrero H, Paul Diaz L, Pinto Pabon I, Lobato Fernandez R: Cardiovasc Intervent Radiol 2001; 24(1): 67-9. 16. Ernst S, Stippel D, Lackner K: Placement of palmaz stent in malignant duodenal stenosis through a cutaneous fistula. Eur Radiol 1999; 9(6): 1142-4. 17. Keymling M, Wagner HJ, Vakil N, Knyrim K: Relief of malignant duodenal obstruction by percutaneous insertion of a metal stent. Castrointestinal Endoscopy 1993; 39: 439-441.
otrzymano: 2011-08-22
zaakceptowano do druku: 2011-09-01

Adres do korespondencji:
*Tomasz Miłek
Mazowiecki Szpital Wojewódzki w Warszawie
Bródnowskie Centrum Specjalistyczne
ul. Kondratowicza 8, 03-242 Warszawa
tel.: (22) 326-58-00
e-mail: tomasz_milek@wp.pl

New Medicine 3/2011
Strona internetowa czasopisma New Medicine