Diego Fregonese

7080 Treatment of very high esophageal malignancies: a new technique using metal tracheal stents with proximal release.

Palliative intubation of upper esophageal strictures is often impossible: plastic stents require almost 3 cm of free space from upper sphincter to the cancer for a correct intubation. Metal stents have the same limit and they cannot be removed, once inserted. We have experienced, in a series of 15 cases, the intubation using a tracheal stent with proximal release and full endoscopic control. All the patients were suffering by a squamous cancer just below the upper sphincter.We use in all cases the UltraflexTM tracheobronchial stent with proximal release by Boston Scientific, which are a cylindric metal uncovered coat up to 80 mm in lenght, with a diameter up to 16 mm at full distension. After a routinely premedication with midazolam 5 mg i.v., the stents have been inserted over a metal wire, with direct endoscopic control: once released the proximal end of the prosthesis, the stent is gently pushed in the right side, just at the upper eophageal sphincter. In few minutes we were able to release the entire stent. The patient is then given a fluid diet for two days, waiting for the complete opening of the stents. In our series we were able to insert the stent in all the cases. 13 patients were able to eat a solid diet within 3 days after intubation. In two cases a PEG was finally necessary for insufficent ability to swallow even a fluid diet. During the survival period (a mean of 3.8 months/patient) we suffered three severe clogging due to cancer ingrowth, treated by lasering. In conclusion these stents seem to be really effective on very high esophageal cancers, even in radiotrated patients with a rigid stricture.

7079 A new modality treatment of acute intestinal obstruction due to rectosigmoid cancer by metal stents.

Acute intestinal obstruction is a not rare complication of rectosigmoid cancer and the majority of these cases are usually treated by colostomy in emergency surgery. Insertion of metal prosthesis has the theoretical advantage to allow stool passage, and wait for a surgical elective treatment. We have considered for this temporary palliative treatment 12 patients presented with acute intestinal occlusion due to distal colorectal cancer They were admitted in the emergency department of our hospital, and they have undergone to endoscopy without intestinal washing, after a routine premedication with midazolam (5 mg i.v.). In all cases we have used a gastroscope to rule out the cancer and pass the stricture. On a guide wire a metal stent has been inserted across the stricture and then released by introduction device with full endoscopic control of distal end of the prosthesis. In 9 cases we used an UltraflexTM (Boston Scientific) with diameter 23 to 28 mm, 100 mm long, and proximal release. In the other 3 cases we used a PlacehitTM (Schneider) with diameter of 22 mm and 100 mm in length. No failure was suffered, and in all cases the stent has been correctly inserted. No complications were noted, related to endoscopic maneuver. In 11/12 patients the stool passage has been immediately effective, and they have undergone to radical left colectomy within a week after stenting. One patient required a colostomy the day after stenting for persistent obstruction. In conclusion metal stents seem to be useful in temporary treatment of acute intestinal obstruction, and they allow an elective surgical treatment in safe condition and with a radical purpose.