Self-expanding metal stents in malignant colonic obstruction: experiences from Sweden

<p/> <p>Background</p> <p>Acute surgery in the management of malignant colonic obstruction is associated with high morbidity and mortality. The use of self-expanding metal stents (SEMS) is an alternative method of decompressing colonic obstruction. SEMS may allow time to optimize the patient and to perform preoperative staging, converting acute surgery into elective. SEMS is also proposed as palliative treatment in patients with contraindications to open surgery. Aim: To review our experience of SEMS focusing on clinical outcome and complications. The method used was a review of 75 consecutive trials at SEMS on 71 patients based on stent-protocols and patient charts.</p> <p>Findings</p> <p>SEMS was used for palliation in 64 (85%) cases and as a bridge to surgery in 11 (15%) cases. The majority of obstructions, 53 (71%) cases, were located in the recto-sigmoid. Technical success was achieved in 65 (87%) cases and clinical decompression was achieved in 60 (80%) cases. Reasons for technical failure were inability to cannulate the stricture in 5 (7%) cases and suboptimal SEMS placement in 3 (4%) cases. Complications included 4 (5%) procedure-related bowel perforations of which 2 (3%) patients died in junction to post operative complications. Three cases of bleeding after SEMS occurred, none of which needed invasive treatment. Five of the SEMS occluded. Two cases of stent erosion were diagnosed at the time of surgery. Average survival after palliative SEMS treatment was 6 months.</p> <p>Conclusion</p> <p>Our results correspond well to previously published data and we conclude that SEMS is a relatively safe and effective method of treating malignant colonic obstruction although the risk of SEMS-related perforations has to be taken into account.</p

Mucinous colorectal adenocarcinoma with signet-ring cells: Immunohistochemical and ultrastructural study

A primary mucinous colorectal adenocarcinoma tissue with signet-ring cells, as revealed after histological evaluation, was examined ultrastructurally. The authors also analyzed the immunohistochemical data of the tissue for serotonin, vasoactive intestinal polypeptide (VIP), bombesin, somatostatin, and glucagon, using the peroxidase anti-peroxidase (PAP) method and the immunogold labeling method for light and electron microscope, respectively. Electron microscopically mucinous adenocarcinoma was characterized by the formation of small lumen. Adenocarcinoma cells were full of mucous granules of varying electron density, providing a good environment for the tumor cells to grow. They also exhibited a significant loss of microvilli and intracytoplasmic junctions, which could allow the cells to disseminate. Signet-ring cells were located in the basal site of the ducts or in the lamina propria and appeared neoplastic, with mucin accumulation intracellularly and an eccentric crescent-shaped nucleus. The cytoplasmic organelles were decreased and at the periphery of the cell. The PAP method demonstrated that these cells were strongly positive for bombesin and also positive for vasointestinal polypeptide (VIP). The immunogold method detected bombesin immunoreactivity in the vacuoles as well as in other cytoplasmic membranes, whereas VIP was localized mainly in the plasma membrane. The location of signet-ring cells combined with the immunoreactivity for bombesin and VIP indicated that signet-ring cells were of neuroendocrine origin and probably dedifferentiated enterochromaffin-like endocrine cells. These findings have implications for understanding the biological behavior of these composite malignant tumors and could help in the knowledge of the origin of signet-ring cells. © 2010 Informa Healthcare USA, Inc

Pancreatic duct guidewire placement for biliary cannulation in a single-session therapeutic ERCP

AIM: To investigate the technical success and clinical complication rate of a cannulated pancreatic duct with guidewire for biliary access. METHODS: During a five-year study period, a total of 2843 patients were included in this retrospective analysis. Initial biliary cannulation method consisted of single-guidewire technique (SGT) for up to 5 attempts, followed by double-guidewire technique (DGT) when repeated unintentional pancreatic duct cannulation had taken place. Pre-cut papillotomy technique was reserved for when DGT had failed or no pancreatic duct cannulation had been previously achieved. Main outcome measurements were defned as biliary cannu-lation success and post-endoscopic retrograde cholan-giopancreatography (ERCP) complication rate. RESULTS: SGT (92.3% success rate) was characterized by statistically significant enhanced patient outcome compared to either the DGT (43.8%, P &lt; 0.001), pre-cut failed DGT (73%, P &lt; 0.001) or pre-cut as first step method (80.6%, P = 0.002). Pre-cut as first step method offered a statistically significantly more favorable outcome compared to the DGT (P &lt; 0.001). The incidence of post-ERCP pancreatitis did not differ in a statistically significant manner between either method (SGT: 5.3%, DGT: 6.1%, Pre-cut failed DGT: 7.9%, Pre-cut as first step: 7.5%) or with patients&apos; gender. CONCLUSION: Although DGT success rate proved not to be superior to SGT or pre-cut papillotomy, it is considered highly satisfactory in terms of safety in order to avoid the risk of a pre-cut when biliary therapy is necessary in difficult-to-cannulate cases. © 2011 Baishideng. All rights reserved

Comparative study of balloon and metal olive dilators for endoscopic management of benign anastomotic rectal strictures: Clinical and cost-effectiveness outcomes

Background: Postoperative anastomotic strictures frequently complicate colorectal resection. Currently, various endoscopic techniques are being employed in their management, but the establishment of an optimal therapeutic strategy is still pending. The purpose of our study is to compare through-the-scope (TTS) balloon dilators versus Eder-Puestow metal olive dilators in the treatment of postoperative benign rectal strictures, considering the clinical outcome and cost-effectiveness of each method. Methods: A total of 39 patients with benign anastomotic rectal stenosis were retrospectively studied. In group A, 15 patients underwent dilation with Eder-Puestow metal olives, while in group B 19 patients were treated by means of TTS balloon dilators. The technical and clinical success of dilation, complications, number of repeated sessions required, disease-free time intervals, and the overall cost of each procedure were evaluated. Results: Dilations were technically successful in all patients. No major complications occurred in either group. The number of dilations needed, rate of stricture recurrence, and duration of stenosis-free time intervals were not statistically significantly different between the two groups. Both methods proved more effective in older patients, given the greater number of dilations required in younger patients of both groups and higher frequency of stricture relapse in younger balloon-dilated patients (median 64.00 years) compared with older ones (median 75.00 years) (p = 0.001). An indisputable advantage of the Eder-Puestow technique, compared with TTS balloon dilators, is the low cost of equipment (median 22.30 € compared with 680 €, respectively; p &lt; 0.001). Conclusion: Endoscopic dilation of postoperative benign rectal strictures is equally effective and safe, especially in older patients, when performed by Eder-Puestow bougies or TTS balloon dilators. However, metal olivary tips seem to surpass balloon dilators when considering the obvious economical benefits of the first method. © 2010 Springer Science+Business Media, LLC

Alcohol consumption and colorectal cancer in a mediterranean population: A case-control study

BACKGROUND: Alcohol is considered to be a cocarcinogen or a tumor promoter, and various studies have shown a linear dose-dependent association between alcohol consumption and colorectal cancer. However, a few studies suggest that moderate alcohol consumption may have a protective effect, similar to that in cardiovascular disease. OBJECTIVE: The aim of this study was to evaluate the relationship of colorectal cancer to quantity and type of alcohol consumed. DESIGN: This was case-control study. SETTINGS: The study was conducted in the area of Attica, Greece. PARTICIPANTS: A total of 250 consecutive patients with a first diagnosis of colorectal cancer were matched for age group and sex with 250 controls recruited from the community. The mean age was 63 (SD, 12) years for the patient group (147 men, 59%; 103 women, 41%) and 55 (SD, 13) years for the control group (112 men; 44.8%; 138 women, 55.2%). MAIN OUTCOME MEASURES: Questionnaires were administered by trained interviewers to assess sociodemographic, clinical, and lifestyle characteristics, in addition to dietary habits and quantity and type of alcoholic beverages usually consumed during the preceding year. Adherence to the Mediterranean diet was evaluated with the MedDietScore (theoretical range, 0-55). RESULTS: With intake of less than 12 g of alcohol per day as the reference, moderate alcohol intake (12-35 g/day) was associated with a significantly decreased likelihood of colorectal cancer in men (OR, 0.35; 95% CI, 0.16-0.74) and in women (OR, 0.40; 95% CI, 0.18-0.91). High alcohol intake (more than 48 g/day) was associated with an increased likelihood, which was significant in men (OR, 3.45; 95% CI, 1.35-8.83) but not in women (OR, 3.40; 95% CI, 0.50-22.92). Drinking red wine was associated with reduced odds of colorectal cancer, significant in men (OR, 0.47; 95% CI, 0.23-0.96) but not in women (OR, 0.54; 95% CI, 0.23-1.30). None of the associations between other beverage types and colorectal cancer were significant. Adherence to the Mediterranean diet was independently associated with lower odds of colorectal cancer overall (p &lt; 0.001), in men (OR, 0.90; 95% CI, 0.83-0.97), and in women (OR, 0.87; 95% CI, 0.80-0.94). LIMITATIONS: The major limitations of this study included the inability of a case-control design to determine causation and the potential for recall bias. CONCLUSIONS: The association between quantity of alcohol consumed and the presence of colorectal cancer followed a J-shaped curve. While demonstrating the detrimental effect of consuming large amounts of alcohol, the results of this study suggest that moderate alcohol consumption exerts a protective effect on colorectal cancer in both men and women, possibly related to the effects of red wine. © The ASCRS 2012

Metabolic syndrome and colorectal cancer: The protective role of mediterranean diet-a case-control study

The effect of Mediterranean diet on colorectal cancer, in the presence of the metabolic syndrome, was evaluated in 250 patients with first developed cancer (63 ± 12 years, 59% males) and 250 age-gender-matched controls. Adherence to the Mediterranean diet was evaluated with the modified-MedDietScore (theoretical range 0-75), while assessment of the metabolic syndrome (MetS) was based on the third Adult Treatment Panel ([ATP III] National Cholesterol Education Program) criteria. Presence of MetS (1.66, 95% confidence interval [CI] 1.02, 2.69), age (4.25, 95% CI 2.33, 7.77), smoking (1.85, 95% CI 1.27, 2.70), and family history of colorectal cancer (3.37, 95% CI 1.69, 6.75) had a detrimental effect, whereas adherence to the Mediterranean diet (0.88, 95% CI 0.84, 0.92) and body mass index (0.93, 95%CI 0.89, 0.98) had a protective role regarding colorectal cancer. Mediterranean diet had the same effect in relation to colorectal cancer, in both participants with (0.84, 95% CI 0.76, 0.93) and without MetS (0.89, 95% CI 0.85, 0.94). © 2012 The Author(s)