Javier Jiménez-Pérez

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. ESGE guidelines represent a consensus of best practice based on the available evidence at the time of preparation. They may not apply in all situations and should be interpreted in the light of specific clinical situations and resource availability. Further controlled clinical studies may be needed to clarify aspects of these statements, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. ESGE guidelines are intended to be an educational device to provide information that may assist endoscopists in providing care to patients. They are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment

Self-expandable metal stents for relieving malignant colorectal obstruction: short-term safety and efficacy within 30 days of stent procedure in 447 patients

BACKGROUND The self-expandable metal stent (SEMS) can alleviate malignant colonic obstruction and avoid emergency decompressive surgery. OBJECTIVE To document performance, safety, and effectiveness of colorectal stents used per local standards of practice in patients with malignant large-bowel obstruction to avoid palliative stoma surgery in incurable patients (PAL) and facilitate bowel decompression as a bridge to surgery for curable patients (BTS). DESIGN Prospective clinical cohort study. SETTING Two global registries with 39 academic and community centers. PATIENTS This study involved 447 patients with malignant colonic obstruction who received stents (255 PAL, 182 BTS, 10 no indication specified). INTERVENTION Colorectal through-the-scope SEMS placement. MAIN OUTCOME MEASUREMENTS The primary endpoint was clinical success at 30 days, defined as the patients ability to maintain bowel function without adverse events related to the procedure or stent. Secondary endpoints were procedural success, defined as successful stent placement in the correct position, symptoms of persistent or recurrent colonic obstruction, and complications. RESULTS The procedural success rate was 94.8% (439/463), and the clinical success rates were 90.5% (313/346) as assessed on a per protocol basis and 71.6% (313/437) as assessed on an intent-to-treat basis. Complications included 15 (3.9%) perforations, 3 resulting in death, 7 (1.8%) migrations, 7 (1.8%) cases of pain, and 2 (0.5%) cases of bleeding. LIMITATIONS No control group. No primary endpoint analysis data for 25% of patients. CONCLUSION This largest multicenter, prospective study of colonic SEMS placement demonstrates that colonic SEMSs are safe and highly effective for the short-term treatment of malignant colorectal obstruction, allowing most curable patients to have 1-step resection without stoma and providing most incurable patients minimally invasive palliation instead of surgery. The risk of complications, including perforation, was low.

3351 Iatrogenic perforation in diagnostic colonoscopy related to the type of sedation.

INTRODUCTION: Diagnostic colonoscopy is a safe procedure, although a iatrogenic perforation rate ranging from 0.04% to 0.9% has been reported by different authors. The influence of deep sedation in the occurrence of this complication remains controversial as it eliminates pain due to excessive insuflation and endoscope loop formation, both potential causes of colonic perforation. The aim of this study is to evaluate the incidence of colonic perforation during diagnostic colonoscopy and the role of the type of sedation. MATERIAL AND METHOD: 7.286 consecutive diagnostic colonoscopies performed during a 3 year period were included in the study. Patients were randomized to undergo deep sedation with propofol I.V. (Group A; n=4.005) or conscious sedation with diazepan I.V. (Group B; n=3.281). Therapeutic colonoscopies were excluded from the protocol. Incidence of iatrogenic perforation was analyzed in both groups, evaluating patients characteristics and both endoscopist (senior/trainee) and endoscopy assistant experience. Fisher test was used for statistical analysis. RESULTS: 7 perforations took place in group A (0.17%) and 2 in group B (0.06%) (p=0.03). Among those perforations in group A, 6 of them (0.32%) occured during the first 18 months of the study, whereas only one (0.04%) occured during the following 18 months (p = 0.06). No significant differences were found concerning patient characteristics or experience of the endoscopy team. CONCLUSIONS: 1. Diagnostic colonoscopy performance under deep sedation has a higher rate of iatrogenic perforation although without statistical significance. 2. As this increment concentrates within the initial period of using deep sedation, extreme caution must be taken until experience is acquired in order to avoid this complication.

Sa1908 Onodera Index Independently Predicts Survival in Surgically Treated Colorectal Carcinoma

INTRODUCTION: Onodera index (OI) combines circulating lymphocytes and albumin levels. It has been used as a nutritional and immunological marker and it has been recently proposed in Eastern literature its possible value as a predictive variable of prognosis in colorectal cancer (CRC). AIMS: To analyse the prognostic value of OI, assessed at initial diagnosis, on survival of patients with resected CRC. PATIENTS AND METHODS: We present a retrospective observational study including 207 consecutive patients with CRC and surgically treated on elective basis. Clinical follow-up was performed, documenting all cases of tumor-related deaths. OI was calculated according to the equation: [10 x serum albumin (g/dl) + 0.005 x circulating lymphocytes/mm2]. OI values 6 mcg/l, OI < 40 and OI ≥ 40. Univariant and multivariant analysis were performed [Cox model, stepwise, determining hazard ratio (HR) and 95% confidence interval (CI 95%)]. Finally, Fisher and square chi tests were used to compare 5-year mortality rates between groups with OI < 40 and OI ≥ 40, calculating odds ratio (OR) and CI. RESULTS: 26 patients (12.6%) presented a low OI. Median follow up was 81 months, with an interquartile range of 60-96. Overall tumor-related mortality was 23.7% and 19.8% 5 years after surgery. Variables with independent prognostic value in multivariant analysis are summarised in the following table below. 5-year mortality rate was significantly higher in patients with low OI: 42.3% vs 16.7% [OR = 3.69; CI = (1.42-9.58); p=0.002]. CONCLUSIONS: 1. A low Onodera index, assessed at initial CRC diagnosis, is associated with a worse survival curve after tumor resection. 2. This negative prognostic significance of an Onodera index < 40 has proved to have an independent predictive value. 3. Post-surgery 5-year mortality is higher in patients with a low Onodera index. Variables with independent prognostic value in multivariant analysis

T1091 Synchronous Neoplastic Lesions in Colorectal Cancer. Analysis of Possible Risk Factors Favouring Presentation

Aim: few data have been published regardingthe causes of synchronous lesionsinpatientswith colorectal cancer.The aim of our study was to identifypotentialfactors that mightbe implicated in the development of multicentric lesions, since this knowledge could be useful for tailored follow-up once initial synchronousle sions havebeenremoved. Methods: we retrospectively reviewed 382 colorectal cancer cases diagnosedby total colonoscopy and histological study of surgical specimens. We divided our population into 2 groups, based on whether they had synchronous lesions or otherwise. Several data related to personal and family history, habits, symp toms, and tumor characteristics were assessed. Univariateand multivariate statistical analyses were performed. Results: 208 (54.5%) patients had synchronous adenomas and 28 (7.3%) had synchronouscancer. A multivariate analysis showed that the followingparameters were consistently related to the presence of multicentriclesions –male gender:OR = 1.97; CI = 1.13-3.45; p = 0.017; age ≥ 59 years: OR = 2.57; CI = 1.54-4.29; p < 0.001; personal history of colonic adeno mas: OR = 3.04; CI = 1.04-8.85; p = 0.042; and obstructivetu mors: OR = 0.48; CI = 0.27-0.85; p = 0.012. Conclusion: our results show that severalparameters that are easy to measure could be considered risk factors for the develop ment of multicentric lesions. These factors need to be confirmed with follow-up studies analyzingtheir role in patients with and without metachronic lesions once all synchronous lesions have beenremoved.

4659 Is dilation really necessary before stenting in malignant biliary strictures

INTRODUCTION: Malignant biliary strictures have been classically considered an indication for biliary dilatation in order to facilitate subsequent placement of a biliary stent. Some endoscopists routinely dilate before stenting while others use axial or pneumatic balloon dilators only in high grade strictures (7-20% of cases). The aim of this study is to evaluate real dilation requirements before stent insertion in patients harbouring malignant biliary strictures.MATERIAL AND METHODS: During a 5 year period, 177 consecutive patients with malignant biliary strictures were endoscopically treated with a single 10F polyethylene posthesis. Stents were of variable lengths ranging from 5 to 15 cms (median 9 cms). Oasis stent introduction system (Wilson Cook Inc.) was used to place the stents in all cases. RESULTS: Attempts to cross the stricture with the guiding catheter of the device failed in 4 patients (2.25%) and pneumatic balloon dilation was performed prior to placing the stent. Dilation was not needed in the remaining patients. CONCLUSIONS: 1. Dilation is seldom needed before stenting in malignant biliary strictures. 2. This one action stent introduction system reduces dilation requirements with conventional dilators before biliary stenting. 3. We believe that the guiding catheter of the system may act as an axial dilating catheter facilitating stent insertion. 4. This system shortens stenting procedure time and might be advantageous in economical terms