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Mo1624 A Novel Marking Technique With Magnetic Clip on Laparoscopic Colon Tumor Operation : a Pilot Study
Abstracts
Mo1624 A Novel Marking Technique With Magnetic Clip on Laparoscopic Colon Tumor Operation : a Pilot Study Bora Keum*1, Minho Seo1, Sung Chul Park2, Hyuk Soon Choi1, Eun Sun Kim1, Yoon Tae Jeen1, Hong Sik Lee1, Hoon Jai Chun1, Soon Ho Um1, Chang Duck Kim1, Ho Sang Ryu1, Jin Kim3 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea, Seoul, Republic of Korea; 2Department of internal medicine, Kangwon National University School of Medicine, kangwon, Republic of Korea; 3 Division of Colorectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea Background: It is difficult to locate correctly and safely a colorectal tumor for laparoscopic surgery. Tattooing is generally used for localization of colorectal tumor during laparoscopic surgery. Tattooing is simple and inexpensive method. However there are limitations of this methods, such as incorrect tumor localization due to spread of ink and complication like perforation and peritonitis. To overcome these limitations, we devised a simple magnetic marking technique to locate a tumor. We conducted pilot study and report results of the study. Method: This study enrolled 15 patients undergoing laparoscopic surgery for early colorectal cancer. We devised 10mm sized ring type magnet (outdiameter:10mm, indiameter:4mm, thickness:3mm) which was coated with silicon, and we tied loop using 3-0 nylon. We inserted the marking magnet near lesion with biopsy forcep, and then we clipped magnet on target through loop of magnet. But it was difficult to reach above rectosigmoid level with ring type magnet. Therefore, We devised rod type magnet. Its outer diameter was 3mm and height was 10mm, therfore it could pass through endoscopy channel. A magnetic marking clip was applied on the distal side of lesion during preoperative colonoscopy. During surgery, another magnetic body hanged with long thread which was inserted through laparoscopic trocar, was used to find out the lesion that was marked by magnetic clipping. We analyzed detection rate, detection time, resection margin length from lesion and complication associated with method. Result: 7 of 15 patients’ tumor locations were on the rectum, 5 were on the sigmoid colon. 1 was hepatic flexure, 2 was on the transverse colon. We used ring type magnet for mostly rectosigmoid cancer, and used rod type magnet for transverse colon and hepatic flexure colon caner. Magnetic marking clips were successfully detected in all 15 patients. The time required for detection ranged from 8 to 44 sec. The resection margin from lesion ranged from 42 to 87mm. None of our patients experienced complication s from this marking technique. Conclusion: Magnetic marking technique was simple and convenient for surgeon, and showed good result for accuracy of tumor localization without complication associated with method. Therefore, the magnetic marking clip method may be useful for colorectal tumor detection during laparoscopic surgery. And we expect that correct and simple method results in minimzing extent of colon resection.
Mo1625 Surgical Outcomes of Self-Expandable Metal Stent As a Bridge to Surgery for Malignant Colorectal Obstruction Jung Ho Kim*, Jong Joon Lee, Minsu HA, Yoonjae Kim, Jun-Won Chung, Dongkyun Park, Yeonsuk Kim, Yang Suh Ku, Kwang an Kwon Department of Internal medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea Background/Aims: Colorectal stenting as a bridge to surgery is an alternative for emergency surgery in patients with acute malignant colorectal obstruction. The aim of our study was to evaluate the efficacy and safety of the self-expandable metal stent (SEMS) as a bridge to surgery in patients with malignant colorectal obstruction. Methods: The medical records of patients who received SEMS for acute colorectal obstruction between February 2004 and April 2012 were retrospectively reviewed. A total of 79 patients with primary colorectal cancer with acute colorectal obstruction were enrolled in this study. Results: The mean age of the patients was 63.6 years (range 30-85 years). Fifty-six patients (70.9%) were male and 23 (29.1%) were female. The most common obstructive site was in the rectosigmoid junction (25/79, 31.6%). The technical success rate and clinical success rate of SEMS were 76/79 (96.2%) and 71/79 (89.8%), respectively. Covered SEMS were used in 40/76 (50.6%) of patients with technical success. In patients with technical success (n⫽76), emergency surgery following SEMS insertion was performed in 5 patients (4 stomas) for treatment of clinical failure, and elective surgery after SEMS insertion was performed in 71 patients (6 stomas). The complication rates of SEMS was 10.1%, including perforation in 2.5%, stent migration in 2.5%, insufficient decompression in 3.8%, and reobstruction in 1.3%. In patients with elective surgery, one patient died six days after surgery, he had sepsis with pneumonia related to surgery. Conclusions: SEMS allows restoration of bowel patency and elective surgery with primary anastomosis in most patients. SEMS provides an effective bridge to surgery treatment with an acceptable complication in patients with malignant colorectal obstruction.
Mo1626 The Newly Nitinol Conformable Self-Expandable Metal Stents for Malignant Colonic Obstruction: a Pilot Experience As Bridge to Surgery Treatment in a Tertiary Referral Center Roberto Di Mitri*, Filippo Mocciaro, Anna Calì, Antonino Marino Gastroenterology and Endoscopy Unit, ARNAS Civico-Di CristinaBenfratelli Hospital, Palermo, Italy Introduction: Self-expandable metal stents (SEMS) are a non-surgical option for treatment of malignant colorectal obstruction also as a bridge to surgery approach. The advent of the new nitinol conformable SEMS has improved clinical outcomes in these kinds of patients. Aims and Methods: We report a pilot experience with nitinol conformable SEMS placement as bridge to surgery treatment in patients with malignant colorectal obstruction. Between April and August 2012 we collected data on colonic nitinol conformable SEMS placement (Niti-S enteral uncovered stent [D-Type], TaeWoong, Seoul, Korea) in a cohort of consecutive symptomatic patients. Technical success, clinical success, and adverse events were recorded. Results: Ten patients (7 male [70%]), with a mean age of 69.2⫾10.1 were evaluated. The mean length of the stenosis was 3.6⫾0.6 cm. Five patients (50%) were treated on an emergency basis. The median time from stent placement to surgery was 16 days (interquartile range, 7-21). After SEMS placement technical and clinical success was achieved in all patients with a significant early improvement of symptoms and QoL. No adverse events due to the SEMS placement were observed. No signs of decubitus or perforation were found on the surgical specimens. Conclusions: This pilot study, though it has certain limitations, confirmed the effective and safe “bridge-to-surgery” role of nitinol conformable SEMS placement in the treatment of symptomatic malignant colorectal obstruction. The Niti-S enteral uncovered stent (D-Type) is made of nitinol wire, which provides a flexible, fine mesh tubular prosthesis with 8 radiopaque markers for an accurate release. D-Type’s conformability also facilitates immediate and continuous wall apposition which decompresses the colon until resective surgery can be performed.
Mo1627 Is the Immediate Opening Diameter Related to the Effectiveness of the Evo-C Stent in the Resolution of Acute Neoplastic Colonic Obstruction? Bartolomé L. Viedma*1, JoaquíN RodríGuez-SáNchez2, María Alonso Lablanca1, Rufo Lorente1, Francisco Domper1, José Olmedo Camacho1 1 Hospital General Ciudad Real, Ciudad Real, Spain; 2Hospital Gutierrez Ortega, Valdepeñas, Spain Background: The use of self-expanding metal stents (SEMS) for the treatment of acute malignant colonic obstruction (AMCO) is a well-established practice. However, there are few studies linking clinical success and the degree of immediate postinsertion expansion. Objective: To evaluate whether the immediate postinsertion expansion diameter of the stent EVO-C (TM Evolution EVO-C, Cook Medical, USA) determines the immediate clinical success (⬍48 hours) and final follow-up success (defined by the absence of clinical obstruction and the lack of endoscopic treatment during follow-up) in the resolution of high grade AMCO (complete bowel obstruction caused by critical stenosis of colonic lumen impassable by an ultrathin endoscope). Materials and Methods: Retrospective observational study (Nov 2009-Apr 2012) on a cohort of patients with AMCO treated with EVO-C stent. Results: 26 patients (12 women, mean age 71.19 years). Treatment intention: bridge to surgery: n⫽9, palliation: n⫽ 17. Location: rectum: n⫽8, sigmoid: n⫽15, descending colon: n⫽ 3. Technical success: 25/26 (96.15%) (one case without guidewire progression). Immediate clinical success: 88.5%, final follow-up clinical success: 73.1%. Complications: immediate/delayed perforation 1 (7.7%), stent migration: 3 (11.5%), late reocclusion by intratumoral growth: 1 (3.8%). Mean diameter of maintenance opening: bridge to surgery/palliation: 25.11 mm/147 days. Mean diameter of minimal expansion point: immediate/ 48 hours: 7.73 mm (3.7 to 23 mm)/15.19 mm (7-23 mm) (100% increase). Immediate expansion diameter ⬍25%/⬎ 25% and delayed expansion diameter ⬎50%/⬍50% of total diameter were compared with immediate clinical success and overall clinical success without evidence of significant differences. Conclusions: The EVO-C stent shows high expansion capacity at 48 hours post insertion. Although the series is limited, in our experience, the effectiveness in resolving acute neoplastic colonic obstruction is independent of immediate opening diameter, achieving clinical success even if the stent expands less than 25% of total diameter.
AB450 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Mo1624 A Novel Marking Technique With Magnetic Clip on Laparoscopic Colon Tumor Operation : a Pilot Study Bora Keum*1, Minho Seo1, Sung Chul Park2, Hyuk Soon Choi1, Eun Sun Kim1, Yoon Tae Jeen1, Hong Sik Lee1, Hoon Jai Chun1, Soon Ho Um1, Chang Duck Kim1, Ho Sang Ryu1, Jin Kim3 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea, Seoul, Republic of Korea; 2Department of internal medicine, Kangwon National University School of Medicine, kangwon, Republic of Korea; 3 Division of Colorectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea Background: It is difficult to locate correctly and safely a colorectal tumor for laparoscopic surgery. Tattooing is generally used for localization of colorectal tumor during laparoscopic surgery. Tattooing is simple and inexpensive method. However there are limitations of this methods, such as incorrect tumor localization due to spread of ink and complication like perforation and peritonitis. To overcome these limitations, we devised a simple magnetic marking technique to locate a tumor. We conducted pilot study and report results of the study. Method: This study enrolled 15 patients undergoing laparoscopic surgery for early colorectal cancer. We devised 10mm sized ring type magnet (outdiameter:10mm, indiameter:4mm, thickness:3mm) which was coated with silicon, and we tied loop using 3-0 nylon. We inserted the marking magnet near lesion with biopsy forcep, and then we clipped magnet on target through loop of magnet. But it was difficult to reach above rectosigmoid level with ring type magnet. Therefore, We devised rod type magnet. Its outer diameter was 3mm and height was 10mm, therfore it could pass through endoscopy channel. A magnetic marking clip was applied on the distal side of lesion during preoperative colonoscopy. During surgery, another magnetic body hanged with long thread which was inserted through laparoscopic trocar, was used to find out the lesion that was marked by magnetic clipping. We analyzed detection rate, detection time, resection margin length from lesion and complication associated with method. Result: 7 of 15 patients’ tumor locations were on the rectum, 5 were on the sigmoid colon. 1 was hepatic flexure, 2 was on the transverse colon. We used ring type magnet for mostly rectosigmoid cancer, and used rod type magnet for transverse colon and hepatic flexure colon caner. Magnetic marking clips were successfully detected in all 15 patients. The time required for detection ranged from 8 to 44 sec. The resection margin from lesion ranged from 42 to 87mm. None of our patients experienced complication s from this marking technique. Conclusion: Magnetic marking technique was simple and convenient for surgeon, and showed good result for accuracy of tumor localization without complication associated with method. Therefore, the magnetic marking clip method may be useful for colorectal tumor detection during laparoscopic surgery. And we expect that correct and simple method results in minimzing extent of colon resection.
Mo1625 Surgical Outcomes of Self-Expandable Metal Stent As a Bridge to Surgery for Malignant Colorectal Obstruction Jung Ho Kim*, Jong Joon Lee, Minsu HA, Yoonjae Kim, Jun-Won Chung, Dongkyun Park, Yeonsuk Kim, Yang Suh Ku, Kwang an Kwon Department of Internal medicine, Gachon University Gil Medical Center, Incheon, Republic of Korea Background/Aims: Colorectal stenting as a bridge to surgery is an alternative for emergency surgery in patients with acute malignant colorectal obstruction. The aim of our study was to evaluate the efficacy and safety of the self-expandable metal stent (SEMS) as a bridge to surgery in patients with malignant colorectal obstruction. Methods: The medical records of patients who received SEMS for acute colorectal obstruction between February 2004 and April 2012 were retrospectively reviewed. A total of 79 patients with primary colorectal cancer with acute colorectal obstruction were enrolled in this study. Results: The mean age of the patients was 63.6 years (range 30-85 years). Fifty-six patients (70.9%) were male and 23 (29.1%) were female. The most common obstructive site was in the rectosigmoid junction (25/79, 31.6%). The technical success rate and clinical success rate of SEMS were 76/79 (96.2%) and 71/79 (89.8%), respectively. Covered SEMS were used in 40/76 (50.6%) of patients with technical success. In patients with technical success (n⫽76), emergency surgery following SEMS insertion was performed in 5 patients (4 stomas) for treatment of clinical failure, and elective surgery after SEMS insertion was performed in 71 patients (6 stomas). The complication rates of SEMS was 10.1%, including perforation in 2.5%, stent migration in 2.5%, insufficient decompression in 3.8%, and reobstruction in 1.3%. In patients with elective surgery, one patient died six days after surgery, he had sepsis with pneumonia related to surgery. Conclusions: SEMS allows restoration of bowel patency and elective surgery with primary anastomosis in most patients. SEMS provides an effective bridge to surgery treatment with an acceptable complication in patients with malignant colorectal obstruction.
Mo1626 The Newly Nitinol Conformable Self-Expandable Metal Stents for Malignant Colonic Obstruction: a Pilot Experience As Bridge to Surgery Treatment in a Tertiary Referral Center Roberto Di Mitri*, Filippo Mocciaro, Anna Calì, Antonino Marino Gastroenterology and Endoscopy Unit, ARNAS Civico-Di CristinaBenfratelli Hospital, Palermo, Italy Introduction: Self-expandable metal stents (SEMS) are a non-surgical option for treatment of malignant colorectal obstruction also as a bridge to surgery approach. The advent of the new nitinol conformable SEMS has improved clinical outcomes in these kinds of patients. Aims and Methods: We report a pilot experience with nitinol conformable SEMS placement as bridge to surgery treatment in patients with malignant colorectal obstruction. Between April and August 2012 we collected data on colonic nitinol conformable SEMS placement (Niti-S enteral uncovered stent [D-Type], TaeWoong, Seoul, Korea) in a cohort of consecutive symptomatic patients. Technical success, clinical success, and adverse events were recorded. Results: Ten patients (7 male [70%]), with a mean age of 69.2⫾10.1 were evaluated. The mean length of the stenosis was 3.6⫾0.6 cm. Five patients (50%) were treated on an emergency basis. The median time from stent placement to surgery was 16 days (interquartile range, 7-21). After SEMS placement technical and clinical success was achieved in all patients with a significant early improvement of symptoms and QoL. No adverse events due to the SEMS placement were observed. No signs of decubitus or perforation were found on the surgical specimens. Conclusions: This pilot study, though it has certain limitations, confirmed the effective and safe “bridge-to-surgery” role of nitinol conformable SEMS placement in the treatment of symptomatic malignant colorectal obstruction. The Niti-S enteral uncovered stent (D-Type) is made of nitinol wire, which provides a flexible, fine mesh tubular prosthesis with 8 radiopaque markers for an accurate release. D-Type’s conformability also facilitates immediate and continuous wall apposition which decompresses the colon until resective surgery can be performed.
Mo1627 Is the Immediate Opening Diameter Related to the Effectiveness of the Evo-C Stent in the Resolution of Acute Neoplastic Colonic Obstruction? Bartolomé L. Viedma*1, JoaquíN RodríGuez-SáNchez2, María Alonso Lablanca1, Rufo Lorente1, Francisco Domper1, José Olmedo Camacho1 1 Hospital General Ciudad Real, Ciudad Real, Spain; 2Hospital Gutierrez Ortega, Valdepeñas, Spain Background: The use of self-expanding metal stents (SEMS) for the treatment of acute malignant colonic obstruction (AMCO) is a well-established practice. However, there are few studies linking clinical success and the degree of immediate postinsertion expansion. Objective: To evaluate whether the immediate postinsertion expansion diameter of the stent EVO-C (TM Evolution EVO-C, Cook Medical, USA) determines the immediate clinical success (⬍48 hours) and final follow-up success (defined by the absence of clinical obstruction and the lack of endoscopic treatment during follow-up) in the resolution of high grade AMCO (complete bowel obstruction caused by critical stenosis of colonic lumen impassable by an ultrathin endoscope). Materials and Methods: Retrospective observational study (Nov 2009-Apr 2012) on a cohort of patients with AMCO treated with EVO-C stent. Results: 26 patients (12 women, mean age 71.19 years). Treatment intention: bridge to surgery: n⫽9, palliation: n⫽ 17. Location: rectum: n⫽8, sigmoid: n⫽15, descending colon: n⫽ 3. Technical success: 25/26 (96.15%) (one case without guidewire progression). Immediate clinical success: 88.5%, final follow-up clinical success: 73.1%. Complications: immediate/delayed perforation 1 (7.7%), stent migration: 3 (11.5%), late reocclusion by intratumoral growth: 1 (3.8%). Mean diameter of maintenance opening: bridge to surgery/palliation: 25.11 mm/147 days. Mean diameter of minimal expansion point: immediate/ 48 hours: 7.73 mm (3.7 to 23 mm)/15.19 mm (7-23 mm) (100% increase). Immediate expansion diameter ⬍25%/⬎ 25% and delayed expansion diameter ⬎50%/⬍50% of total diameter were compared with immediate clinical success and overall clinical success without evidence of significant differences. Conclusions: The EVO-C stent shows high expansion capacity at 48 hours post insertion. Although the series is limited, in our experience, the effectiveness in resolving acute neoplastic colonic obstruction is independent of immediate opening diameter, achieving clinical success even if the stent expands less than 25% of total diameter.
AB450 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org