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P.1.249: MANAGEMENT OF ACUTE MALIGNANT COLORECTAL OBSTRUCTION WITH SELF-EXPANDING METAL STENT IN GENERAL ENDOSCOPIC PRACTICE: A RETROSPECTIVE SINGLE CENTRE STUDY
Abstracts of the XVII National Congress of Digestive Diseases / Digestive and Liver Disease 43S (2011) S115–S264 P.1.249 MANAGEMENT OF ACUTE MALIGNANT COLORECTAL OBSTRUCTION WITH SELF-EXPANDING METAL STENT IN GENERAL ENDOSCOPIC PRACTICE: A RETROSPECTIVE SINGLE CENTRE STUDY L. De Luca ∗ ,1 , V. Sisti 2 , P. Cioccolini 1 , M.T. Fabi 1 , M. Rogheto 1 , M.L. Bianchi 1 , M.G. Mortilla 1 , M.B. Rocchi 3 , C. Zingaretti 2 , D. Baroncini 1 1 Gastroenterology and Digestive Endoscopy Unit, “san Salvatore” Hospital, Pesaro, Italy; 2 General Oncological and Vascular Surgery, “san Salvatore” Hospital, Pesaro, Italy; 3 2department of S.U.A.N., University of Urbino, Urbino, Italy
Background and aim: Self-expanding metal stents (SEMS) can alleviate malignant colorectal obstruction (MCRO) and avoid emergency decompressive surgery, usually reducing morbidity and mortality compared with elective situations such as a higher rates of primary anastomosis and lower rates of colostomy. This study reviewed the use of SEMS as initial interventional approach in the management of acute MCRO, evaluating the effectiveness both as a bridge to surgery and definitive palliative treatment. Material and methods: 92 patients (57 m, 35 f, age range 48-89 years) underwent the insertion of a nitinol SEMS presenting with acute MCRO were retrospectively evaluated during the period of time from Jan 2002 through Mar 2010. The SEMS was inserted into the obstructive site by using trough-thescope method. Technical success was defined as accurate SEMS deployment across the stricture on the first attempt; clinical success was defined as decompression and relief of obstructive colonic symptoms maintained without intervention or serious device-related complications. Results: Technical success was achieved in 92.3% (85/92) of patients with a 95% CI of 87% to 98% and initial clinical success in 97.6% (83/85) with a 95% CI of 94% to 100%. The stent was placed in the rectum (18/92 – 19.5%), sigmoid (46/92 – 50%), left colon (23/92 – 25%), transverse colon (4/92 – 4.3%), right colon (1/92 – 1%). In 29 patients (31.5%) the SEMS were attempted as primary palliative definitive treatment, whereas in 63 (68.5%) were placed as a bridge to surgery. All patients with operable tumours were successfully bridge to elective surgery within a median of 14 days from SEMS placement. SEMS-related perforation occurred in 4.3% of patients (4/92), obstruction in 7.6% (7/92) and migration was reported in 6.5% (6/92) of cases. Conclusions: SEMS insertion is an effective and safe treatment for patients with acute MCRO, providing time for a complete preoperative evaluation and avoiding emergency surgery. This procedure provides an effective outcome in patients with advanced cancer as a palliative therapy to surgery with satisfactory results. Moreover after palliative stent insertion the more rapid and less complicated recovery may facilitate the early administration of chemotherapy.
P.1.250 TREATMENT OF HCV COMPENSATED CIRRHOTIC PATIENTS IS EQUALLY EFFECTIVE BEFORE AND AFTER LIVER TRANSPLANTATION F.R. Ponziani ∗ , B.E. Annicchiarico, M. Siciliano, M. Pompili, A. Gasbarrini Policlinico A. Gemelli, Rome, Italy Background and aim: Response to combined antiviral treatment has been reported to be lower in patients with hepatitis C virus (HCV)-related cirrhosis if compared with non-cirrhotics. However, treatment is recommended to avoid decompensation and complications, and to prevent graft reinfection after liver transplantation (LT). Similarly, patients developing HCV-related cirrhosis after LT should be treated to avoid graft loss, even if a lower rate of response and tolerability have been reported. We report the differences in tolerability and response to treatment in a retrospective series of compensated HCV-cirrhotic patients before and after LT. Material and methods: 43 HCV-cirrhotic patients (mean age 55.2±8.9, 65.1% male, 34.9% female, Child-Pugh class A, genotype 1: 58.1%, 2: 30.2%, 3: 4.7%, 4: 7%) and 17 LT patients with recurrent HCV-related cirrhosis (mean age 57.4±9.1, 88.2% male, 11.8% female, Child-Pugh A, genotype 1: 64.7%, 2: 17.6%, 3: 5.9%, 4: 11.8%) were included in the analysis. Among LT and non-LT cirrhotics, 37.2% and 47.1%, respectively, previously received
S231
an unsuccessful treatment. All patients received recombinant or pegylated interferon plus ribavirin at standard dose and duration. No stopping rule was adopted for LT patients. Results: An early virological response (EVR) was reported in 30/43 (69.8%) non-LT and in 8/17 (47.1%) LT HCV cirrhotic patients, a sustained virological response (SVR) in 18/43 (41.9%) and 8/17 (41.1%), respectively. No statistical difference in EVR and SVR rates between the two groups was observed. In the group of LT patients, only one without EVR subsequently achieved SVR. Among HCV non-LT cirrhotics, 6/43 (13.9%) patients prematurely discontinued the treatment 4/43 (9.3%) due to adverse events (fatigue, intolerance, HCC, polytrauma); 8/17 (47%) among LT cirrhotics withdrew the treatment, 4/17 (23.5%) due to adverse events (anemia, leucopenia, encephalopathy) the remnants for lack of response. No statistical difference in the rate of discontinuation of the two groups was observed. Side effects are shown in Table 1. Table 1. Treament side effects Intolerance (fatigue, flu-like symptoms, depression) Anemia – Grade 1 – Grade 2 – Grade 3 Neutropenia – Grade 1 – Grade 2
Non-LT cirrhotics (43)
LT cirrhotics (43)
3/43 (6.9%)
0
12/42 (27.9%) 2/43 (4.6%) 0
0 4/17 (23.5%) 2/17 (11.7%)
0 6/43 (13.9%)
2/17 (11.7%) 1/17 (5.%)
Conclusions: HCV antiviral treatment is equally effective and tolerated in compensated cirrhotics both before and after LT.
P.1.251 THE FIRST TWO YEARS OF COLORECTAL CANCER SCREENING IN THE FERRARA DISTRICT, ITALY V.G. Matarese ∗ , C. Feo, G. Lanza, N. Fusetti, L. Simone, A. Zelante, R. Stockbrugger, V. Cifalà, L. Trevisani, S. Gullini Azienda Ospedaliero-Universitaria S. Anna, Ferrara, Italy Background and aim: In March 2005, a public CRC screening campaign was started in Emilia-Romagna. The screening activities from April 2005 to March 2007 in Ferrara district are reported. Material and methods: The screening program had two levels of organisation: local screening centres that provide the analysis of all screening data and hospital centres that organize and perform the diagnostic and therapeutic measures. The local screening centres sent a letter of invitation to perform an immunological FOBT (i-FOBT) to all the residents aged 50 to 69 years. If the i-FOBT was negative, the screenee was invited by letter to repeat the test after two years. Following a positive i-FOBT, the screenee was invited within 30 days for an appointment with a gastroenterologist during which a colonoscopy with sedation was suggested. Results: A total of 38.344 subjects (28%) were invited to perform the i-FOBT; 50.8% of them accepted: 5.9% had a positive test. 88.2% accepted a gastroenterology consultation and 99.5% accepted the colonoscopy. Following 1.025 colonoscopies occurred one perforation. 239 screenees had high-risk adenomas: 229 were treated endoscopically, 10 surgically. Patients with cancer had the following Dukes classification: A 53, B 18, C 17, D 3. 87 patients had a follow-up colonoscopy: 14 after adenoma with cancer resection, 21 after surgical resection for cancer (all negative); 52 after resection of multiple high-risk adenomas (31 positive for one or two low risk adenomas). Conclusions: The participation rate, the proportion of screnees adhesion to gastroenterologist consultation and the amount of pathological findings by confirmatory colonoscopy were much in line with previous reports, and were mainly achieved by information propaganda. The high proportion of Dukes A and B CRC stages in this report (78%) contrast favourably to the 39.8% of the equivalent stages diagnosed in the same area between 2003 and 2004, with no screening program. Based on this experience, it can be concluded that CRC screening can easily be established coupling existing public screening
Background and aim: Self-expanding metal stents (SEMS) can alleviate malignant colorectal obstruction (MCRO) and avoid emergency decompressive surgery, usually reducing morbidity and mortality compared with elective situations such as a higher rates of primary anastomosis and lower rates of colostomy. This study reviewed the use of SEMS as initial interventional approach in the management of acute MCRO, evaluating the effectiveness both as a bridge to surgery and definitive palliative treatment. Material and methods: 92 patients (57 m, 35 f, age range 48-89 years) underwent the insertion of a nitinol SEMS presenting with acute MCRO were retrospectively evaluated during the period of time from Jan 2002 through Mar 2010. The SEMS was inserted into the obstructive site by using trough-thescope method. Technical success was defined as accurate SEMS deployment across the stricture on the first attempt; clinical success was defined as decompression and relief of obstructive colonic symptoms maintained without intervention or serious device-related complications. Results: Technical success was achieved in 92.3% (85/92) of patients with a 95% CI of 87% to 98% and initial clinical success in 97.6% (83/85) with a 95% CI of 94% to 100%. The stent was placed in the rectum (18/92 – 19.5%), sigmoid (46/92 – 50%), left colon (23/92 – 25%), transverse colon (4/92 – 4.3%), right colon (1/92 – 1%). In 29 patients (31.5%) the SEMS were attempted as primary palliative definitive treatment, whereas in 63 (68.5%) were placed as a bridge to surgery. All patients with operable tumours were successfully bridge to elective surgery within a median of 14 days from SEMS placement. SEMS-related perforation occurred in 4.3% of patients (4/92), obstruction in 7.6% (7/92) and migration was reported in 6.5% (6/92) of cases. Conclusions: SEMS insertion is an effective and safe treatment for patients with acute MCRO, providing time for a complete preoperative evaluation and avoiding emergency surgery. This procedure provides an effective outcome in patients with advanced cancer as a palliative therapy to surgery with satisfactory results. Moreover after palliative stent insertion the more rapid and less complicated recovery may facilitate the early administration of chemotherapy.
P.1.250 TREATMENT OF HCV COMPENSATED CIRRHOTIC PATIENTS IS EQUALLY EFFECTIVE BEFORE AND AFTER LIVER TRANSPLANTATION F.R. Ponziani ∗ , B.E. Annicchiarico, M. Siciliano, M. Pompili, A. Gasbarrini Policlinico A. Gemelli, Rome, Italy Background and aim: Response to combined antiviral treatment has been reported to be lower in patients with hepatitis C virus (HCV)-related cirrhosis if compared with non-cirrhotics. However, treatment is recommended to avoid decompensation and complications, and to prevent graft reinfection after liver transplantation (LT). Similarly, patients developing HCV-related cirrhosis after LT should be treated to avoid graft loss, even if a lower rate of response and tolerability have been reported. We report the differences in tolerability and response to treatment in a retrospective series of compensated HCV-cirrhotic patients before and after LT. Material and methods: 43 HCV-cirrhotic patients (mean age 55.2±8.9, 65.1% male, 34.9% female, Child-Pugh class A, genotype 1: 58.1%, 2: 30.2%, 3: 4.7%, 4: 7%) and 17 LT patients with recurrent HCV-related cirrhosis (mean age 57.4±9.1, 88.2% male, 11.8% female, Child-Pugh A, genotype 1: 64.7%, 2: 17.6%, 3: 5.9%, 4: 11.8%) were included in the analysis. Among LT and non-LT cirrhotics, 37.2% and 47.1%, respectively, previously received
S231
an unsuccessful treatment. All patients received recombinant or pegylated interferon plus ribavirin at standard dose and duration. No stopping rule was adopted for LT patients. Results: An early virological response (EVR) was reported in 30/43 (69.8%) non-LT and in 8/17 (47.1%) LT HCV cirrhotic patients, a sustained virological response (SVR) in 18/43 (41.9%) and 8/17 (41.1%), respectively. No statistical difference in EVR and SVR rates between the two groups was observed. In the group of LT patients, only one without EVR subsequently achieved SVR. Among HCV non-LT cirrhotics, 6/43 (13.9%) patients prematurely discontinued the treatment 4/43 (9.3%) due to adverse events (fatigue, intolerance, HCC, polytrauma); 8/17 (47%) among LT cirrhotics withdrew the treatment, 4/17 (23.5%) due to adverse events (anemia, leucopenia, encephalopathy) the remnants for lack of response. No statistical difference in the rate of discontinuation of the two groups was observed. Side effects are shown in Table 1. Table 1. Treament side effects Intolerance (fatigue, flu-like symptoms, depression) Anemia – Grade 1 – Grade 2 – Grade 3 Neutropenia – Grade 1 – Grade 2
Non-LT cirrhotics (43)
LT cirrhotics (43)
3/43 (6.9%)
0
12/42 (27.9%) 2/43 (4.6%) 0
0 4/17 (23.5%) 2/17 (11.7%)
0 6/43 (13.9%)
2/17 (11.7%) 1/17 (5.%)
Conclusions: HCV antiviral treatment is equally effective and tolerated in compensated cirrhotics both before and after LT.
P.1.251 THE FIRST TWO YEARS OF COLORECTAL CANCER SCREENING IN THE FERRARA DISTRICT, ITALY V.G. Matarese ∗ , C. Feo, G. Lanza, N. Fusetti, L. Simone, A. Zelante, R. Stockbrugger, V. Cifalà, L. Trevisani, S. Gullini Azienda Ospedaliero-Universitaria S. Anna, Ferrara, Italy Background and aim: In March 2005, a public CRC screening campaign was started in Emilia-Romagna. The screening activities from April 2005 to March 2007 in Ferrara district are reported. Material and methods: The screening program had two levels of organisation: local screening centres that provide the analysis of all screening data and hospital centres that organize and perform the diagnostic and therapeutic measures. The local screening centres sent a letter of invitation to perform an immunological FOBT (i-FOBT) to all the residents aged 50 to 69 years. If the i-FOBT was negative, the screenee was invited by letter to repeat the test after two years. Following a positive i-FOBT, the screenee was invited within 30 days for an appointment with a gastroenterologist during which a colonoscopy with sedation was suggested. Results: A total of 38.344 subjects (28%) were invited to perform the i-FOBT; 50.8% of them accepted: 5.9% had a positive test. 88.2% accepted a gastroenterology consultation and 99.5% accepted the colonoscopy. Following 1.025 colonoscopies occurred one perforation. 239 screenees had high-risk adenomas: 229 were treated endoscopically, 10 surgically. Patients with cancer had the following Dukes classification: A 53, B 18, C 17, D 3. 87 patients had a follow-up colonoscopy: 14 after adenoma with cancer resection, 21 after surgical resection for cancer (all negative); 52 after resection of multiple high-risk adenomas (31 positive for one or two low risk adenomas). Conclusions: The participation rate, the proportion of screnees adhesion to gastroenterologist consultation and the amount of pathological findings by confirmatory colonoscopy were much in line with previous reports, and were mainly achieved by information propaganda. The high proportion of Dukes A and B CRC stages in this report (78%) contrast favourably to the 39.8% of the equivalent stages diagnosed in the same area between 2003 and 2004, with no screening program. Based on this experience, it can be concluded that CRC screening can easily be established coupling existing public screening