Letter to the editor on "Stents and surgical interventions in the palliation of gastric outlet obstruction. A systematic review"

We read with interest the paper, “Stents and surgical interventions in the palliation of gastric outlet obstruction: a systematic review” by Minata MK et al, which appeared in Endoscopy International Open (2016; 4: E1158 – 1170) [1]. The Authors should be congratulated for an extensive and careful review. In recent studies, we prospectively analyzed the clinical outcomes of 72 patients [2, 3] and we came to similar conclusions. We have abandoned the use of covered stents. Distal migration of a covered stent can lead to serious consequences and a stent rarely can be retrieved endoscopically [4]. Endoscopic stenting offers many advantages in comparison to surgery: shorter hospital stay, faster return to oral intake, a less invasive procedure. However, life expectance may be longer than 1 year in some patients with malignant gastric outlet obstruction, particularly those with distal gastric cancer or gastric obstruction from metastatic disease. In this selected group of patients, food obstruction is common. The reason for it in rare cases derives from tumor ingrowth within the stent; in the majority of patients, food obstruction is secondary to dismotility of the pyloric region. The dismotility depends on many factors, including nerve infiltration by the tumor. Food obstruction is not easily diagnosed. The stomach can enlarge significantly before vomiting occurs. Stomach dilation can lead to nausea, discomfort, and dyspnea, symptoms that easily can be attributed to the cancer itself. For all these reasons, patients who have endoscopic stenting in this clinical setting should have a very careful follow-up with repeated endoscopies and computed tomography scan. This careful follow-up may not be well tolerated by a patient whose general condition is slowly deteriorating or for his or her family. Laparoscopic surgery can be performed with minimal discomfort for patients and it should be seriously considered in patients whose conditions are generally acceptable. Before such a procedure, the patient and family should be consulted and all positive and negative aspects of the surgery should be thoroughly explained, leaving them to choose the preferred treatment

Endoscopic stenting for left-sided obstructing colorectal cancer

Si sottolinea l'importanza dello stenting endoscopico in pazienti con occlusione da tumore del colon rett

Positive aspects of self-expandable metallic stent endoscopic placement for malignant colorectal obstruction during the COVID-19 pandemic

Lo studio sottolinea l'importanza e l'utilità di stents posizionati per via endoscopica in caso di occlusione acuta-subacuta per tumore del colon retto, nel periodo della pandemia da COVID 1

Self-expandable metal stents for left sided colon obstruction from diverticulitis. A single center retrospective series

Background and Objectives: The incidence of diverticulitis is increasing in western countries. Complicated diverticulitis is defined as diverticulitis associated with localized or generalized perforation, localized or distant abscess, fistula, stricture or obstruction. Colonic symptomatic strictures are often treated with segmental colectomy. The aim of our study is to report our experience with Self Expandable Metal Stents (SEMS) placement to relieve sigmoid obstruction secondary to diverticulitis, either as a permanent solution or as a bridge to elective colectomy. Material and Methods: From January 2016 to December 2018, 21 patients underwent SEMS placement for sigmoid obstruction secondary to diverticulitis at our institution. In four patients with poor general conditions, SEMS was considered the definitive form of treatment. In 17 patients, the stent was placed as bridge to elective colectomy. Data were prospectively collected and retrospectively analyzed. Primary outcomes were postoperative mortality and morbidity after SEMS and subsequent elective colectomy. Results: There was no mortality or major morbidity after SEMS placement or subsequent elective colectomy. No stoma was performed. Conclusions: Placement of Colorectal Self Expandable Stent represents a useful tool to relieve obstruction in patients with left-sided colonic diverticulitis. SEMS placement makes it possible to transform an emergency clinical condition into an elective condition, giving time to resolve the inflammation and the infection inevitably associated with complicated diverticulitis

The Role of Insulin Resistance in Fueling NAFLD Pathogenesis: From Molecular Mechanisms to Clinical Implications

Non-alcoholic fatty liver disease (NAFLD) represents a predominant hepatopathy that is rapidly becoming the most common cause of hepatocellular carcinoma worldwide. The close association with metabolic syndrome's extrahepatic components has suggested the nature of the systemic metabolic-related disorder based on the interplay between genetic, nutritional, and environmental factors, creating a complex network of yet-unclarified pathogenetic mechanisms in which the role of insulin resistance (IR) could be crucial. This review detailed the clinical and pathogenetic evidence involved in the NAFLD-IR relationship, presenting both the classic and more innovative models. In particular, we focused on the reciprocal effects of IR, oxidative stress, and systemic inflammation on insulin-sensitivity disruption in critical regions such as the hepatic and the adipose tissue, while considering the impact of genetics/epigenetics on the regulation of IR mechanisms as well as nutrients on specific insulin-related gene expression (nutrigenetics and nutrigenomics). In addition, we discussed the emerging capability of the gut microbiota to interfere with physiological signaling of the hormonal pathways responsible for maintaining metabolic homeostasis and by inducing an abnormal activation of the immune system. The translation of these novel findings into clinical practice could promote the expansion of accurate diagnostic/prognostic stratification tools and tailored pharmacological approaches

Colon or rectal stent positioning for advanced cancer influences quality of life: a critical point of view

Background/Aim: Endoluminal self-expanding metallic stents (SEMS) may overcome the risk of mortality and morbidity of acute intestinal obstruction because of stage IV colon (CC) or rectal (RC) cancer. We evaluated the QoL in these groups of patients. Patients and Methods: Forty-eight patients were enrolled in a prospective longitudinal cohort single-center trial to undergo SEMS positioning. Twenty-five patients had a CC and 23 RC. Karnofsky performance scale, Visual Analogue Scale and the EQ-5D- 5LTM questionnaire were administered before treatment and at 1, 3 and 6 months. Results: Harmonized to the Italian population, the index values showed a statistically significant deterioration of the QoL in patients with RC when compared to those with CC at 1-, 3- and 6-months (1 month: p=0.001; 3- month: p=0.001; 6-month: p=0.045). Similarly, Visual Analogue Scale showed variations at 1- (p=0.008), 3- (p=0.001) and 6-months (p=0.020). Rectal stent deployment was the only independent predictor for a worse QoL in all domains (p<0.017; OR=0.196; 95%CI=0.51-0.749). Conclusion: Patients affected with stage IV CC had a better QoL after SEMS placement when compared to those affected with RC. The persistency of the primary tumor at the rectal level, even if irradiated, might negatively affect QoL

Ruolo degli stent metallici auto-espansibili nell'ostruzione da cancro colo-rettale o extracolico

Gli autori riportano la loro esperienza sul ruolo degli stent metallici auto-espansibili nell'ostruzione da cancro colo-rettale o extracolic