Colonic Stent Usage in Modern Day Management for Colonic Obstruction

Abstracts

of red blood on early colonoscopy and absence of ulcerative mucosal lesions on colonoscopy -J. Guardiola, DDW 2007-) to predict recurrence of bleeding, and to determine the risk and predictive factors of readmission, need for surgery and mortality. Results: A total of 126 consecutive patients admitted with diverticular hemorrhage were identified with 144 bleeding events. The 12% (15/126) were definitive source of bleeding (active bleeding, visible vessel and/or adherent clot). During the first episode, 20% of patients presented recurrence of bleeding. Some kind of therapy was given to 11 patients (9%): 7 endoscopic therapies, 3 urgent surgeries and 1 arterial embolization by angiography. Independent predictive factors for recurrence of bleeding were: rectal bleeding during de first 4 hours after admission (RR 6.06; 95% CI, 1.80-20.03; pZ0.003) and presence of red blood on diagnostic colonoscopy (RR 3.76; 95% CI, 1.02-13.92; pZ0.04). If diagnostic colonoscopy was performed within the first of 24 hours (55 patients), the combination of both factors can to predict the recurrence of bleeding (0 factors: 3.4%, 1 factor 10% and 2 factors 66%) The area under de ROC curve was 0.82. Fifteen patients (12%) were readmitted with a new episode of diverticular bleeding. With a median of 421 days of follow-up, the accumulative risk of readmission was 7%, 9% and 12% for 6, 12 and 24 months respectively. One patient required surgery and 3 patients were readmitted a second time. All of them were discharged. Predictive factors of readmission were not identified. Conclusion: The clinicalendoscopic risk score can identify the diverticular bleeding episodes with a high risk for recurrence bleeding. Given the low probability of readmission, and the absence of mortality in our cohort, we don’t recommend elective surgery in the second episode of diverticular hemorrage.

T1425 Preoperative Placement of Self-Expandable Metallic Stent for Obstructive Colorectal Cancers: Factors Influencing Clinical Success Bo-in Lee, Kang-Moon Lee, Jung Hwan Oh, Dae Yeong Cheung, Hyeon Seong Kim, Jeong-Seon Ji, Byung Wook Kim, Hwang Choi, Chang Nyol Paik, Woo Chul Chung, Jeongjo Jeong, Kyu-Yong Choi Background: Self-expandable metallic stent (SEMS) placement followed by elective surgery is a feasible treatment option for obstructive colorectal cancer (CRC). This study was performed to investigate factors influencing clinical success rate of preoperative SEMS placement for obstructive CRC. Method: Preoperative SEMS placement for seventy patients with obstructive CRC from four academic hospitals was analyzed retrospectively. Technical success was defined as coverage of the entire stricture length, and clinical success as relieving obstructive symptoms and bridging to elective surgery. Results: Technical success rate was 94%, elective surgery was performed in 63 patients at 27  43 (3-233) days after SEMS placement, thus clinical success rate was 90%. Perforation occurred in 5 patients (7%). Migration occurred in three patients with the covered stent (1-226 days after SEMS placement), more common for the covered stent than the uncovered (12% vs. 0%, respectively, PZ0.050), and two of them required reinsertion of SEMS. There was no significant difference for clinical success rate between the distal CRC and the proximal (89% vs. 94%), the covered stent and the uncovered (92% vs. 89%), and the complete obstruction and the incomplete (93% vs. 81%), while through-thescope (TTS) placement showed higher tendency for clinical success than over-thewire (OTW) technique (93% vs. 70%, retrospectively, PZ0.055). Multivariate analysis showed significant difference for clinical success rate between TTS placement and OTW technique only (PZ0.030). Conclusions: SEMS placement for obstructive CRC is effective for bridging to elective surgery. Migration is related to the covered stent and TTS placement is preferred for higher clinical success rate.

undergone to LS. Of the 75 admitted pts, 11 were excluded from BTS for already known advanced disease and 10 for too poor clinical conditions to undergo to a safe endoscopic procedure. 54 cases have been suitable for an emergency endoscopic procedure, and in 46 cases a rectal/colonic obstructive cancer has been detected. In all these cases we attempt a stent insertion, using an endoscopic approach with fluoroscopic guidance if necessary. 44 pts received a stent: we suffer 2 stent insertion failures (1 perforation followed by death within 1 month) and they were treated with OS and CS. In 2 cases the stents were ineffective on intestine deflation (in one case a small covered perforation has been detected during the surgical act). In other 2 cases a perforation was ruled out at the end of endoscopic maneuvers and an OS with CS was immediately necessary. Among the 40 successful deflated pts 35 (87.5%) have been treated starting a laparoscopic one stage resection. In 9 a protective CS has been anyway necessary. Conversion rate to OS has been of 20% (7 cases all receiving a CS). Five (12.5%) have required a Hartmann operation for local advanced disease. In conclusion, related to the BTS, our experience has recorded an overall success rate of 86.9%, with a complication rate of 8.6% and a mortality rate of 2.1%. A successful LS resection has been possible on 28 cases (60.8%). The overall CS rate was only of 39.1%. These favorable data encourage the use of BTS both for prepare the pts to an effective LS, than to reduce the number of colostomies anyway necessary

T1427 Trans Rectal Ultrasound (TRUS) Helps Select Patients for Transanal Surgery for T1 Rectal Cancers and Large Polyps Sarba Kundu, Jason Conway, Gregory Waters, Girish Mishra Background: Transanal excision (TAE) is an appropriate and attractive approach to managing patients with T1 rectal cancers and large polyps not amenable to endoscopic resection. Invasive vs. localized surgery is contingent upon accurate staging. Aims: To determine the accuracy of TRUS in determining resectability by TAE for T1 rectal cancers and polyps too large to be resected endoscopically. Methods: All patients with rectal lesions undergoing TRUS from January 2001 through April 2008 who underwent surgery without any neoadjuvant treatment were identified from our database. Demographics, lesion characteristics, performance characteristics for TRUS, and pathologic follow-up are reported. Results: 83 patients were identified (55% female, 92% Caucasian; mean ageZ 63 years). The average rectal lesion was 28 mm in size and the average distance from the anal verge was 7.4 cm. 46 patients underwent TAE. TRUS was highly sensitive in delineating the depth of invasion in large polyps and T1 rectal lesions with diminished sensitivity in more invasive lesions and lymph nodes (Table 1). TRUS was 90% accurate in determining if the lesion was confined to the mucosa. Conclusions: TRUS is highly accurate in delineating the depth of invasion for mucosal lesions and large polyps not amenable for endoscopic resection and the antecedent appropriateness for TAE. As TRUS is highly sensitive in correctly identifying T1 rectal cancers, it’s value in determining appropriate TAE cannot be underscored. Nodal staging remains problematic and treatment strategies based on TRUS N-staging should be used with caution. TRUS performance based on T & N stage (Table 1) T Stage

Sensitivity

Specificity

PPV

NPV

Kappa

T Polyp T1 T2 N0 N1

80% 86% 52% 97% 11%

98% 72% 90% 11% 97%

97% 53% 67% 78% 50%

87% 94% 83% 50% 78%

0.8 0.49 0.45 0.11 0.11

T PolypZLimited to mucosa only. Stage T3, T4 not included due to prior chemoradiation exposure

T1426 The Bridge to Surgery with Metal Stents in Acute Occlusive Colonic Cancer Allows Laparoscopic Elective Surgery and Reduce the Number of Colostomies Diego Fregonese, Attilio Pirillo, Pieralberta Ravagnan, Giovanna Andrian, Manuela Dinca, Emilio Morpurgo, Barbara Termini, Sara Maria Tosato, Annibale D’Annibale Acute occlusion due to colorectal cancer requires immediate deflation. Usually these occluded patients (pts) undergo to a traditional Open Surgery (OS) that requires in the majority of the cases a colostomy (CS). Recently many Reports suggest the use of a metal stent to deflate the distended colon, to avoid temporary colostomies. Moreover the modern trend is to purpose laparoscopic Surgery (LS) as gold standard for colon cancer resection. To understand if a stent insertion, followed by colon deflation, made LS feasible and really reduce the number of colostomies required, we have prospectively enrolled in our Study all the pts with severe intestinal occlusion consecutively admitted in our Department between 2001 and 2008. Our Study consider for bridge to surgery (BTS) only pts suffering by an acute occlusion due to a primitive cancer; once admitted, they have undergone to a colonoscopy within 12 hours, and immediately treated with a stent if necessary. Once inserted the prosthesis, if the stool passage has been effective, the pts have

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T1428 Colonic Stent Usage in Modern Day Management for Colonic Obstruction Mazin R. Aljabiri, Christopher C. Thorn, Kim Jaggs, Salman T. Uppal, C. Kelly, Neerav M. Joshi, P. Mathur, Niall Van Someren, Kalpesh Besherdas Background: Colorectal cancer is the second leading cause of cancer-related death in the Western world. When presenting with colonic obstruction is usually at an advanced and incurable stage of disease. Colonic stents potentially offer effective palliation for patients with colonic cancer presenting with bowel obstruction and as a "bridge to surgery". Data from several publications has shown that emergency surgery for malignant colonic obstruction has a relatively high mortality and morbidity rate in comparison to elective surgery and necessitates a two-step resection requiring a stoma. Insertion of colorectal self expandable metal stent (SEMS) may decompress the obstructed colon, allowing for surgery to be performed electively thus reduces morbidity and mortality. There remains limited available evidence on the utility of SEMS in clinical practice. Aim: To retrospectively

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Abstracts

assess the success of colonic stents in our District General Hospitals with subsequent bridge to surgery or as an effective palliation for patients with bowel obstruction attributable to incurable malignancy. Methods: A retrospective analysis of patients undergoing colonic stent insertion with our two associate teaching hospitals (one Hospital Trust) until September 2008. Data was obtained from the Unisoft endoscopy software and from patient’s clinical records. The indications and outcome of stents performed was assessed. Results104 colonic stents were performed under fluoroscopic and direct endoscopic visualisation in the period of the study. 66 Male (w63%) & 38 females (w37%), age range from 56-99 years. 103 colonic stents were inserted for colonic cancer, 1 for benign stricture. Boston Ultraflex and metal TTS stents were used, length of stent ranged 5.7-10cm with a diameter from 22-30mm. Successful deployment in 98 patient (94%) was achieved. In 2 patient perforations occurred at site of stricture requiring emergency surgery. Stent migration occurred in 12 patients (w13%), of these 5 were late migrations. 61 patients (w57%) subsequently underwent palliative chemotherapy, 16 (w15%) went to successful resection. 26 patients (25%) were not suitable for chemotherapy or surgery. There were no SEMS related deaths. Conclusions: Modern day management for obstruction from colorectal cancer with colonic stenting is a safe and effective intervention with a complication rate of less than 2%. It can be safely considered for both preoperative (as a ‘‘bridge to surgery’’) and palliative decompression of colonic obstruction with high technical success rate.

T1429 Imiquimod As a First Line Treatment for Intra-Anal Condylomata Acuminata Panagiota Mavrogianni, Georgios Alexandrakis, Periklis Apostolopoulos, Georgios Alexandrakis, C. Stefanaki, Chrissostomos Kalantzis, Panagiotis Tsibouris, Georgios Rouvas, Evagelos Kalafatis, Andreas Katsambas, Nikolaos Kalantzis Background: Imiquimod, a topical immune response modifier, has been approved for the treatment of external anogenital warts and more specifically as a supplementary treatment option after ablative procedure. Despite that, few studies in the literature exist concerning imiquimod as a first line treatment for intra-anal warts. Aim: Prospective study to reveal the role of imiquimod as a first line monotherapy for intra-anal condylomata. Patients and Methods: 43 consecutive patients (8 females/35 males) with intra-anal warts underwent treatment with cream imiquimod 5%. Application was performed either by finger or by anal tampons 3 times per week (minimum Tx duration: 2 months and maximum: 4 months). Each month, during the ongoing treatment, the patients underwent anoscopy and blood examination. No improvement after two months therapy period, led to imiquimod cessation. Patients with partial response after maximum therapy period underwent supplementary treatment with APC. After condylomata eradication, all the treated patients underwent a surveillance programme for one year period. The study protocol was approved by the hospital protocol committee and written informed consent was obtained from each patient. Results: Intra-anal warts were eradicated completely in 26/43 (60.5%) patients with imiquimod monotherapy. Partial response reported in 10/43 (23.2%) of the patients after 4 months of treatment and required supplementary management with APC. The number and the duration of APC applications was remarkable less in these patients (1-2 applications, duration 4 to 6 min) comparatively with APC sessions in intra-anal condylomata naı¨ve patients (3-6 applications, duration 15 to 20 min). In 7/43 (16.3%) patients imiquimod monotherapy was ineffective and these patients underwent treatment with APC. Imiquimod application method, either by anal tampons or by finger, seems to have no difference concerning the therapeutic success, even though the patients report better compliance and less discomfort with the finger application treatment. No side effects were observed during the treatment, except of a mild irridation of the perianal skin. None of the patients discontinue the treatment due to any reason. Conclusions: A. The use of imiquimod as first line monotherapy, seems to be a reliable, alternative method in the management of intra-anal warts, and the only self - applicable treatment for these kind of warts and B. Even when partial response is observed, facilitation of the following supplementary ablative treatment was reported. Further investigation is required to establish this study encouraging results and to delineate drug ineffectiveness in selected patients.

T1430 Real-Time Tissue Elastography Determines Optimal Treatment and Predicts the Prognosis of Ulcerative Colitis Osamu Watanabe, Takafumi Ando, Kazuhiro Ishiguro, Nobuyuki Miyake, Motofusa Hasegawa, Shinya Kondo, Tsuyoshi Kato, Ryoji Miyahara, Naoki Ohmiya, Yoshiki Hirooka, Yasumasa Niwa, Hidemi Goto Background/Aims: Ulcerative colitis (UC) is a chronic inflammatory disease with frequent remissions and relapses. Although colonoscopic examination is important in determining treatment for patients with UC, it is an invasive procedure and can lead to complications. Non-invasive methods to facilitate evaluation of the large bowel have therefore been sought. Real-time tissue elastography is a new technique that visualizes the differences in tissue strain produced by freehand compression during routine ultrasonography. The aim of this study was to evaluate the

AB294 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009

usefulness of real-time tissue elastography in patients with UC. Methods: Real-time tissue elastography was performed before colonoscopy in 41 patients with UC. Findings were classified into four types (normal, homogeneous, random, hard) on the basis of color arrangement. Endoscopy findings were classified into four types as follows A: normal mucosa, B: mucosal edema and erosion, C: punched-out ulcer, D: extensive ulcer. We then compared the relationship between real-time tissue elastography and colonoscopy findings, and also investigated whether elastography could reflect clinical stage, therapeutic response, and prognosis of UC patients. Results: On elastography, 13 cases were classified as normal, 15 as homogeneous, 6 as random, and 7 as hard; while on endoscopy, 13 were classified as type A, 18 as type B, 8 as type C, and 2 as type D. We found significant associations between normal type and type A, homogeneous type and type C, random type and type C, and hard type and type D (p!0.001). Twelve patients (75%) with the normal type and six (66%) with the homogeneous type were in remission, while six (100%) with the random type and five (72%) with the hard type were in the active phase. All patients with the normal and homogeneous types responded to treatment with prednisolone and leukocytapheresis and were induced into remission. In contrast, no patients with the random or hard type responded to this treatment. Following the addition of tacrolimus, cyclosporine A and/or ganciclovir, five (38%) with the random type were induced into remission, whereas remission was achieved in only one (20%) with the hard type and three (50%) required colectomy. Of the 21 patients induced into remission and followed for more than a year, remission was maintained in 13 (76%) of 17 with the normal and homogeneous types and 1 (25%) of 4 with the random and hard types. Conclusion: Findings of real-time tissue elastography reflected colonoscopic findings. We consider that real-time tissue elastography may be a useful tool in determining the optimal treatment for and predicting the prognosis of UC patients.

T1431 Role of Cytology in the Evaluation of End-Point Treatment Effect of Anorectal Condylomata Acuminata Georgios Alexandrakis, Panagiota Mavrogianni, A. Mela, Georgios Alexandrakis, Periklis Apostolopoulos, E. Nikolaidou, M. Hadzivassiliou, Panagiotis Tsibouris, Vasiliki Kakavetsi, Chrissostomos Kalantzis, Evaggelos Tsiambas, Nikolaos Kalantzis Background: Treatment of condylomata acuminata is related with high recurrence rate, due to the fact that the responsible Human Papilloma Virus (HPV) remains inside the human cells despite warts eradication. Warts radical elimination is crucial in order to prevent its early recurrence. Aim: The aim of this prospective study was to reveal the importance of cytology in the evaluation of end-point treatment effect of anorectal warts. Materials and Methods: Seventy three consecutive patients with anorectal warts, documented by anoscopy, underwent appropriate treatment and were included in a surveillance program. After the end of treatment, the patients were evaluated with both anoscopy and acetowhite staining, as well as with cytology of anal smears. The latter were collected blindly by brushing according to the Palefsky technique. Cytology slides were manually stained at the time of collection in alcohol fixative fluid and coverslipped using the standard Papanikolaou staining technique according to the instructions given for cervical specimens. Follow-up of the treated patients was performed in the months 1, 3, 6 and 9. Chi-square test was used for the statistical analysis. Results: Ten patients were excluded due to surveillance program interruption. 17/63 patients underwent treatment with Argon Plasma Coagulation (APC), 22/63 patients received initial treatment with imiquimod and 20/63 patients received combination treatment with APC ablation and imiquimod, one patient underwent radiotherapy, 2 patients laser therapy and 4 patients surgical excision. After treatment ending, despite negative findings in anoscopy with flexible conventional endoscope, acetowhite staining revealed remaining disease (positive results) in 4/63 (6.3%) patients, whereas cytology revealed remaining disease in 6 more patients [10/63 (15.8%) patients] (chi-square testZ10.86, pZ0.0010). Eventually, after a new therapeutic cycle, all the patients were negative with the combination of the aforementioned examination (anoscopy, acetic acid and cytology). During the 9 months follow up period, only 2/63 (3.1%) patients revealed recurrence. Conclusions: Cytology is a significant more sensitive examination in the evaluation of end-point treatment effect of anorectal warts compared to anoscopy. Anoscopy alone seems to be insufficient for the assessment of anorectal condylomata acuminata therapy. Negative cytology as an end-point treatment could lead to a significant decrease of the well-known high recurrence rate of condylomata acuminata.

T1432 Clinical Significance of Polyps Smaller Than 1cm in Brazil, South America Adriana F. Costa, Wagner Takahashi, Frederico F. Almeida, Janaı´na ´jo L. Brabo, Te´rcio Genzini, Sergio Arau Background: According to the U.S. National Cancer Institute, it is estimated there are 150,000 new cases of colorectal cancer (CA) per year. There is a high correlation of cancer with colonic polyps (CP). In Brazil, the estimated number of new CA cases in 2007 was 30,000, though this is markedly underestimate becasue of the low

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