Endoscopic palliative therapy of an obstructing rectal cancer

Fifteen per cent of rectal cancers are unresectable because of local extension or metastasis. Endoscopic palliative treatments have been described to avoid surgical palliative procedures (ileostomy, colostomy), which inevitably affect the patient's quality of life. Endoscopic electrocoagulation, laser therapy and cryotherapy have been used for this purpose, but they need multiple therapeutic sessions: these have a high cost and cause patient discomfort. Permanent stenting with Self Expanding Metal Stents (SEMS) has been increasingly used for the palliative treatment of obstructing gastrointestinal tumors. This is the case of a 74-year-old man with an adenocarcinoma of the rectum, T4 N+ M+, that was admitted to our surgical department with sub-occlusion and rectal bleeding. Under endoscopic-fluoroscopic control, a SEMS was delivered with no complications and the patient was discharged the day after. He was scheduled for a palliative chemotherapy. Endoscopic stent introduction is a safe palliative procedure performed to improve the quality of life of patients with inoperable tumors of the rectum.

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Endoscopic palliative therapy of an obstructing rectal cancer

Authors

Gf Donatelli, P Ruiz Rodriguez, D Coumaros

Abstract

Fifteen per cent of rectal cancers are unresectable because of local extension or metastasis.
Endoscopic palliative treatments have been described to avoid surgical palliative procedures (ileostomy, colostomy), which inevitably affect the patient's quality of life.
Endoscopic electrocoagulation, laser therapy and cryotherapy have been used for this purpose, but they need multiple therapeutic sessions: these have a high cost and cause patient discomfort.
Permanent stenting with Self Expanding Metal Stents (SEMS) has been increasingly used for the palliative treatment of obstructing gastrointestinal tumors.
This is the case of a 74-year-old man with an adenocarcinoma of the rectum, T4 N+ M+, that was admitted to our surgical department with sub-occlusion and rectal bleeding.
Under endoscopic-fluoroscopic control, a SEMS was delivered with no complications and the patient was discharged the day after. He was scheduled for a palliative chemotherapy.
Endoscopic stent introduction is a safe palliative procedure performed to improve the quality of life of patients with inoperable tumors of the rectum.

Classification

clinical cases

Keywords

Endoscopic palliative therapy, obstructing rectal cancer

Media type

Surgical video

Duration

07'00''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2661.htm

Endoscopic palliative therapy of an obstructing rectal cancer

1. Introduction 00'08''

An otherwise healthy 74-year-old man underwent a colonoscopy for sub-occlusion and rectal bleeding, revealing a stenotic tumoral lesion 10cm from the anal verge. The biopsies corroborated the diagnosis of an adenocarcinoma. The pelvic MRI confirmed a rectal cancer situated 10cm from the anal verge and obstructing the intestinal lumen over a 5cm length. It also showed coeliac metastatic lymph nodes. A CT-scan demonstrated lung and cerebral metastasis. A water-soluble contrast enema confirmed a 5cm long tumoral stenosis situated 10cm from the anal verge. The patient was then admitted to our department for palliative treatment.

2. Identification of the lesion 00'52''

With the patient in a supine position and without sedation, a flexible endoscopy was performed and a necrotic, friable, oozing neoplasm occluding the rectal lumen was identified at the level of the upper rectum.

3. Fluoroscopy 01'03''

Under fluoroscopy, the contrast injection revealed a 5cm stenosis and a cannula with a guidewire was then passed through.

4. Guidewire insertion 01'20''

The cannula was withdrawn and the guidewire was then left in place.

5. Stent positioning 01'30''

The stent was inserted over the guidewire. Then, under fluoroscopic control and endoscopic vision, a Wallflex® colonic Self Expanding Metal Stent with a diameter of 22mm and a length of 9cm was delivered. During the stent delivery, continuous scope traction and continuous fluoroscopy were necessary to avoid the sliding of the stent above the lesion.

6. Control of the stent’s position 01'54''

The good position of the prosthesis was confirmed both under endoscopic vision and under fluoroscopy. A small bleeding occurred but was negligible. Contrast medium was injected to confirm that there was a good passage through the stent, but also to check for a possible perforation that could have occurred during the manipulation of the cannula, guidewire or stent. The patient was discharged the day after the procedure in a good condition: he had no aches, and a palliative chemotherapy was started. In conclusion, this is a safe way to avoid palliative surgery in a patient with unresectable rectal cancer.