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Similar to Λαπαροσκοπική Κολεκτομή σε Εντερική Απόφραξη - Stents
Similar to Λαπαροσκοπική Κολεκτομή σε Εντερική Απόφραξη - Stents (20)
Λαπαροσκοπική Κολεκτομή σε Εντερική Απόφραξη - Stents
- 1. Λαπαροσκοπική Κολεκτομή σε Εντερική Απόφραξη: Η Hartmann απειλείται; Κωνσταντίνος Σ. Μαυραντώνης
- 2. Λαπαροσκοπική Κολεκτομή σε Εντερική Απόφραξη: Η Hartmann απειλείται; ΝΑΙ
- 3. Εντερική Απόφραξη Παραδοσιακή Αντιμετώπιση • Καρκίνος: συχνότερη αιτία • Χειρουργική αποσυμφόρηση • Εως 29% όγκων • 90% αριστερά Πρόγνωση: Κακή
- 4. Stents • 1991 (οισοφάγου) • Τοποθέτηση – Ακτινοσκοπικά – Ενδοσκοπικά – Συνδυασμός και των δύο • Παρόν: Aποδεκτός χειρισμός • Μέλλον: Kλασσική αντιμετώπιση
- 5. Ενδείξεις 1. Παρηγορικά 2. «Γέφυρα» με προγραμματισμένη επέμβαση 3. Στενώσεις • Crohn • Ισχαιμικές • Μετεγχειρητικές • Εκκολπωματίτιδας 4. Συρίγγια
- 6. Ενδείξεις Παρηγορικά – Γενικευμένη νόσος – Υψηλό ASA score – Ως 50% νοσηρότητα – Ως 25% θνητότητα
- 7. Αποτελέσματα • Παρηγορική αντιμετώπιση – 2 μεταναλύσεις • 29 σειρές με 598 ασθενείς (BJS 2002) • 54 σειρές με 1198 ασθενείς (Am J Gastrenterology) • Εφικτή = 93% • Απότελεσματική = 89% (< εξωτερική πίεση)
- 8. Ενδείξεις 2. «Γέφυρα» με προγραμματισμένη επέμβαση • Αποσυμφόρηση • Προετοιμασία ασθενούς και εντέρου • Ελεγχος όλου του εντέρου • Δυνατότητα λαπαροσκοπικής κολεκτομής • Αποφυγή στομίας • Βράχυνση νοσηλείας • Μία επέμβαση
- 9. Αποτυχία - Επιπλοκές (Κεντρικοί όγκοι) – 0,6% θνητότητα – 3,7% διάτρηση – 12% Μετακίνηση – 7% Επαναπόφραξη
- 10. 2. Γέφυρα με προγραμματισμένο χειρουργείο – Δύο τυχαιοποιημένες προοπτικές μελέτες – Surg Endoscopy 2004, Anticancer Research 2004 – Προετοιμασία 8,6 ημέρες – ΜΤΧ νοσηλεία 10 ημέρες – Κολεκτομή έως 100% – Ογκολογικά ασφαλής
- 12. Αντενδείξεις Απόλυτες Σχετικές – Διάτρηση – Μεγάλο μήκος στένωσης – Ισχαιμία – Πολύ χαμηλές στενώσεις – Πολλαπλές στενώσεις – Πολύ κεντρικές – Στενώσεις σε καμπή – Ισχαιμικές
- 13. Συμπεράσματα 1. Παρηγορική αντιμετώπιση 1. Διαθέσιμη τεχνική; 3. Eπείγουσα κολεκτομής σε 3. Οι επιλογές παραμένουν: προγραμματισμένη – Εκτομή + αναστόμωση – Hartmann 5. Αποφυγή κολοστομίας – Απλή κολοστομία ΧΕΙΡΟΥΡΓΕΙΟ ΣΕ ΕΤΟΙΜΟΤΗΤΑ
Editor's Notes
- The role of stents in obstructing tumors is an evolving area.
- Colorectal carcinoma is currently the most common cause of acute obstruction . Acute obstruction occurs in 8-29% of patients with colorectal carcinoma and most of the obstructing cancers are located in the descending and sigmoid colon . Acute bowel obstruction is a medical and surgical emergency and patients have a poor prognosis because in general, they are elderly, debilitated, dehydrated and present with electrolyte imbalance. The traditional management strategy for acute colonic obstruction has been emergent surgical decompression .
- Colonic stent placement is a very attractive non-surgical option for the management of patients with acute colonic obstruction. A self-expanding metallic stent is placed across the stenotic lesion and successful, non-operative colonic decompression may be achieved. There is a variety of stent-delivery techniques (fluoroscopy alone, combined endoscopy and fluoroscopy, and occasionally endoscopy alone). The technique is now considered an accepted strategy in the management of patients with acute colonic obstruction and it may even become the standard approach for this condition.
- The placement of colonic stent in these cases may be permanent as a palliative option, or temporary, as a “bridge” to surgery, or in the treatment of acute obstruction secondary to benign conditions such as Crohn’s disease, ischemic & post surgical strictures, diverticulitis and fistulae .
- Patients with widespread peritoneal carcinomatosis may not be amenable to any form of palliative surgery due to the extensive nature of their disease and undergo an ‘open-and-close’ laparotomy. Such major surgery in a group of patients with widespread malignancy, who may also be nutritionally deplete and elderly, is associated with significant morbidity (5–50%) and mortality (5–25%). These may be even greater in the setting of ascites or jaundice that may accompany large-volume liver metastases. Whether or not resection of the primary tumor improves survival is not entirely clear from the literature, though intuitively one would suspect that the systemic disease is the limiting factor in survival rather than the resection itself.
- In palliative patients, clinical success was defined as colonic decompression within 48 h without the need for additional intervention. The technical success rate was similar in both palliative patients (93%) and bridge-to-surgery patients (92%). Success rates were higher if the obstruction was due to a colonic primary lesion (93.5%) rather than external lesions compressing the colon lumen
- The most common complications include including mild rectal bleeding, anorectal pain, tenesmus, stent malposition, tumor ingrowth and stent obstruction. Colonic perforation is a potentially severe complication that may require surgery, however, it may be asymptomatic and require no specific treatment. It may be related to catheter and wire manipulation during the procedure or may be related to erosion of the colonic wall by the sharp ends of the stent, which may cause colon microperforations . Another cause of colonic perforation is balloon dilation of a recently deployed stent. For this reason, stent dilation in the colon is not recommended. In the palliative unresectable lesions group 93% of stents remain patent until patient’s demise. The reported survival rate after palliative colonic stent placement is 25% at 9 months.
- For bridge-to-surgery patients, stent placement was considered clinically successful when it was possible to perform a one-stage surgery without the creation of a stoma. The mean colonic preparation time for an elective surgery is 8.6 days and the mean postoperative hospital stay is 10.3 days. Elective, uneventful single stage surgery is possible in 75-100% of patients who undergo a successful colonic stent placement. Concerns have been raised regarding the possibility that stents could spread malignancy in curable cancers. A study from Tokyo reviewed the long-term prognosis of patients with resectable colorectal cancers treated surgically, with or without stents as a bridge to surgery. They found no significant difference in survival between those treated with emergency operations compared to those given stents as bridges to surgery. These results suggest that implanted stents do not lead to spread of malignancy.
- Stent placement makes the laparoscopic procedure more difficult since stents make the colonic segment more bulky and more technically difficult to remove laparoscopically. This approach is however feasible in the hands of well trained laparoscopic surgeons. Although no formal randomized clinical data are available comparing open with laparoscopic resection after colonic stenting, the initial case series data appear favorable
- Contraindications to colorectal stent placement are similar to those for gastroduodenal stenting, and include known or suspected colonic ischemia or perforation, multiple sites of obstruction, and standard endoscopy contraindications. Failure rates were higher the more proximal the colonic obstruction and for externally compressing lesions .
- Colorectal self-expanding metal stents have revolutionized the palliative treatment of patients with advanced malignancies and those patients who present with acute colon obstruction and who were previously treated with emergent surgical decompression via formation of colostomy. The use of stents is associated with significant reduction in hospital duration, mortality and medical complications compared to surgery. The surgical team should be on stand by, in case of failure of the endoscopic stenting, due to the increased risk of bowel perforation caused by distension of the bowel above the stricture associated with endoscopic gas inflation.