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Colorectal tumors with complete obstruction – Endoscopic recovery of passage replacing emergency surgery? A report of two cases
© Ramadori et al; licensee BioMed Central Ltd. 2007
Received: 20 July 2006
Accepted: 28 March 2007
Published: 28 March 2007
Incomplete or complete obstructive ileus due to colorectal cancer is generally treated by emergency surgery that has higher morbidity and mortality than elective surgery.
Here we describe an endoscopic technique by which a safe bowel decompression was performed instead of emergency surgery in two patients with complete tumorous obstruction of the colon. By means of a polypectomy snare, a soft wire, an ERCP catheter, a set of endoscopes with different diameters (baby endoscope, gastroscope) and of argon plasma coagulation the tumor mass was reduced and the tumor stenosis was passed. The patients recovered from symptoms of colon obstruction, no procedure-associated complications were observed. One patient had surgery of the sigmoid tumor one week later (UICC-stage III), the other patient (UICC-stage IV) received systemic chemotherapy starting one week after endoscopic decompression.
Complete tumorous obstruction of the colon may be managed by endoscopic tumor debulking avoiding high risk emergency surgery and allowing immediate medical treatment of the primary tumor and of metastases.
Colorectal cancer (CRC) ranks among the most common malignancies in the Western World . Although effective screening and risk management is available up to 30% of patients present with locally advanced disease and/or synchronous metastases . The primary tumor may cause symptoms like bowel obstruction and/or colorectal bleeding recognized both by patients and by physicians as emergency situation. In fact, in up to 38% of patients presenting with large bowel obstruction CRC is diagnosed . Management of tumorous obstruction of the colon by CRC generally consists in surgical colostomy or ileostomy. Resection of the tumor as part of a two-stage procedure after the patient has recovered from acute obstruction still is frequently performed even in stage IV CRC in surgical clinics although a benefit in survival has to be questioned. We recently described a small series of patients with stage IV CRC in whom the non-obstructive primary was treated endoscopically. Highly effective systemic chemotherapy had been applied immediately after endoscopic management of the primary and this policy may have avoided subsequent colon obstruction by the primary . Now we describe two patients who presented with symptoms of complete large bowel obstruction who underwent a successful endoscopic recanalization.
In the Western World acute obstruction of the large bowel is most frequently caused by colorectal cancer . Main symptoms are abdominal pain, acute meteorism, spasms, vomiting. The symptoms may proceed to those of peritonitis and of hypovolemic/toxic shock, if diagnosis is delayed. It is generally managed as an acute emergency and patients receive extensive diagnostic procedures including abdominal ultrasound, abdominal X-ray, computertomography including intravenous contrast medium administration and even angiographic procedures. In case of a tumorous obstruction which in most patients is located in the left colon  surgical procedures may be one-staged (tumor resection and primary anastomosis) or two-staged (colostomy and secondary resection of the tumor). However, there is still no consensus which procedure should be preferred because of high morbidity and mortality associated with each procedure . In fact, a large cohort study has shown that the majority of patients presenting in stage IV CRC receive resection of the primary, but only a minority of them receive chemotherapy within 4 months after surgery . Thirty-days mortality was as high as 10% and it may be concluded that morbidity which is likely to be the main reason precluding chemotherapy was in the range reported earlier . Non-operative management of patients has shown that complication rates due to the primary are lower than expected not justifying preventive resections [9, 10].
Taken together, complete tumorous obstruction of the colon may be managed by endoscopic tumor debulking as described here. We believe that our technical procedure is safe and it can avoid emergency surgery. Further experience must be collected and the impact on survival of these patients should be investigated.
The authors would like to acknowledge the patients written consent that his medical history is published.
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