Diverticular Stricture Research Articles

Outcomes of Colonic Stenting Using a Specifically Designed Expandable Metal Colonic Stent (Ultraflex™ Precision)

Outcomes of Colonic Stenting Using a Specifically Designed Expandable Metal Colonic Stent (Ultraflex Precision) Jose G. de la Mora, Todd Baron, Christopher Gostout, Nicole Pochron Background: Colonic stenting is now accepted for obstructing lesions, either as a temporary or definitive treatment. Until now, studies have used stents not designed specifically for use in the colon. The Ultraflex Precision stent is designed specifically for the colon, with a larger diameter (25 vs 20 mm), proximal flare (30 mm) and atraumatic ends. The aim of this study is to describe the results using this stent at our institution. Material & Methods: A retrospective review of patients that underwent placement of this stent (S), were included. Variables were: diagnosis, site, need for dilation, use of fluoroscopy, S length, placement success, complications, follow-up and final outcome. Results: 38 S were placed in 30 patients. In 6 cases 2 S were used and 3 S in one patient. Diagnosis was: cancer in 23, post-radiation in 2 and 1 each for: diverticular stricture, crohn’s, extrinsic tumor, anastomotic stricture and pancreatitis with colonic involvement. 13 lesions were located in descending colon, 15 in rectosigmoid and 2 in transverse. S lengths used were 5.7 cm (10), 8.7 cm (20) and 11.7 cm (8). Fluoroscopy was used in 28 patients with endoscopic control in 23. No dilatation was performed in 26; in 3 cases dilatation was performed after deployment . Placement success was 27/30 (90%) with two misplaced & repositioned S, and 1 that failed to expand. Severe pain occurred in 6 cases, evident perforation in 2 and suspected perforation (with late abscess formation) in 2 patients. One pt. experienced bacteremia with fever. Both evident perforations occurred in cancer pts. , The two cases with abscess formation occurred in benign disease (pancreatitis and post-radiation). Colostomy was performed in 2 and conservative treatment in two, one of which died from disease progression. Follow-up was available in 24, for a mean of 2 months (1-180 days). No stent malfunction was seen in 21 (2 abscess excluded) up to proctocolectomy (in 5) or death from disease progression (in 4). One stent required trimming. One intraoperative perforation occurred at the stent site. Conclusions: Placement success is similar to previous series using other types of stents not specifically designed for the colon. No migrations occurred, and other complications presented also at a similar rate. The later cases could be due to the fact that they were not neoplastic, although the increased diameter of the new stents cannot be excluded as an additional factor. Abstracts

Outcomes after placement of colorectal stents

Colonic stents are increasingly used to palliate or alleviate large bowel obstruction in patients with colon cancer and other obstructing lesions in whom a definitive surgical procedure is inappropriate. We report on the outcomes of a large group of patients who underwent deployment of a colon stent in a single institution by a single operator. This was a retrospective observational cohort study of all patients undergoing colonic stenting between September 1995 and May 2002. Data collected included nature of pathology, type of stent used, procedure morbidity, patient survival and details of any definitive procedures performed after stenting. One hundred and seven patients were evaluated (58 male) with a median age of 75 years (range 36-99 years). A total of 112 stents were successfully deployed (46 as an emergency). Twelve patients had double stents inserted coaxially and overlapping. In 7 patients the stent could not be safely deployed. Eighty-seven patients had colorectal cancer, 13 patients had an extra-luminal malignancy, 5 had diverticular strictures and in 2 patients the pathology was unknown. At last review (May 2002) 18 patients were alive, 82 patients had died and 7 patients had been lost to follow-up. Of those patients who died, the median survival after stenting alone was 6 weeks (range 4 days-36 weeks). Ten patients underwent subsequent definitive surgery. Stent complications included, 2 colonic perforations, 3 stent occlusions and 4 stent migrations. Colonic stenting can be used effectively, with acceptable morbidity, to manage patients presenting with large bowel obstruction. In a smaller number of patients colon stents may safely temporize symptoms while definitive surgery is planned.

Metallic stents in large bowel obstruction: experience in a District General Hospital

Metallic stents are used increasingly in the palliation of malignant large bowel obstruction. Stenting has also been used in the setting of acute obstruction, allowing appropriate patient preparation for an elective colectomy. Uncovered metallic stents were inserted using a combined endoscopic/radiological technique in patients presenting with large bowel obstruction. Seventeen patients (10 female, mean age 75.2 years) presented with large bowel obstruction, 14 due to malignancy and 3 secondary to diverticular stricture. Technical success was achieved in 13/17 with clinical success in 12 of these 13. There were no perforations or procedure related deaths. One stented patient had elective surgery. The five patients with clinical/technical failure required emergency surgery. The result of our preliminary experience in the use of metallic stents is encouraging. Metallic stents should be available in all hospitals as part of a multimodality approach in treating large bowel obstruction.

Immediate CT Pneumocolon for Failed Colonoscopy; Comparison With Routine Pneumocolon

AIM: To assess the role and reliability of 2D CT pneumocolon in the diagnosis of colonic malignancy, and compare feasibility of referral sources.MATERIALS AND METHODS: A prospective study of 50 patients with suspected large bowel malignancy. Patients underwent bowel cleansing, rectal air insufflation and contrast enhanced CT with 5 mm collimation, 3 mm reconstruction and a pitch of 1.4. Subsequent correlation was with pathology (16), colonoscopy (13), barium enema (5), ERCP (1) and clinical follow-up alone (8).RESULTS: Diagnostic images were obtained in 43/50 patients (86% feasibility). Follow-up was obtained in 35/43 patients (one patient died of an unrelated cause, and seven patients were deemed unfit for further investigation). Seventeen colonic carcinomas were diagnosed (three false-positives: one ischaemic colitis, one diverticular stricture and one faecal mass), one diverticular stricture, one fistula, one pancreatic carcinoma and one ovarian malignancy. The remaining 14 were negative. Overall sensitivity was 100% (for lesions >1.5 cm) with a specificity of 94% for structural abnormalities, but only 82% for the correct identification of malignancy.CONCLUSION: Computed tomography (CT) pneumocolon is a reliable alternative to barium enema where colonoscopy is incomplete, with the advantage of extraluminal screening, and examination of the proximal bowel. In the frail elderly or young unfit patient, it is a valuable additional diagnostic tool.Britton, I. (2000). Clinical Radiology56, 89–93.

Is minimal preparation computed tomography comparable with barium enema in elderly patients with colonic symptoms?

The barium enema (BE) examination in the elderly is often an unsatisfactory investigation. Recent papers have proposed computed tomography (CT) as an alternative method of investigation. They have used a variety of preparation techniques prior to the CT study such as bowel preparation, rectal air insufflation, tap water enemas and intravenous contrast medium. We wished to devise a minimal preparation, minimal supervision technique that could realistically replace the standard BE. One hundred and eighteen elderly patients admitted with symptoms referable to the large bowel had an unenhanced CT following oral contrast medium commenced the previous evening, followed at an interval by a BE performed to a standard technique. Both techniques congruently gave negative reports in 66 (68.8%) individuals. Ten tumours were confidently diagnosed on CT. One annular tumour of the sigmoid colon and one case of colitis were diagnosed on BE only and the severity of a diverticular stricture was underestimated on CT. CT raised the possibility of lesions in 3 (3.1%) patients where the BE was negative. Ten (8.5%) patients had significant abnormalities identified outside the colon using CT. Seven (5.9%) barium enemas were abandoned or severely limited. Minimal preparation, minimal supervision CT is a practical alternative to BE in the frail elderly patient. Radiologists and referring clinicians should be aware that occasionally lesions will not be identified on CT but CT has the advantage that other significant pathology unrelated to the colon may be detected.

Helical CT pneumocolon to assess colonic tumors: radiologic-pathologic correlation.

The objective of this study was to determine the accuracy of helical CT pneumocolon in the staging of colonic carcinomas. Fifty-two patients (27 men, 25 women; age range, 40-88 years old; mean age, 67 years old) with known or strongly suspected colonic disorders underwent CT pneumocolon. After bowel cleansing, administration of smooth muscle relaxant, and rectal air insufflation, CT pneumocolon was performed with 5-mm collimation, 2.5-mm reconstruction interval, and a pitch of 1.5. Two contrast administration protocols were used. Twelve patients received 100 ml of i.v. contrast material that was injected at 3 ml/sec; scan delay was 45 sec. The other 40 patients received 150 ml of contrast material at 5 ml/sec; scan delay was 25 sec. Images were prospectively evaluated. All patients had pathologic confirmation: 46 patients had resections and six patients had endoscopic biopsies. Diagnostic images were obtained in 47 of 52 patients. In the 47 patients, there were 38 colonic carcinomas (one synchronous), nine diverticular strictures, eight polyps, one ischemic stricture, and one normal study. Thirty of 38 carcinomas were correctly staged by CT. Sensitivity and specificity for serosal infiltration were 100% (35/35 carcinomas) and 33% (one of three carcinomas), respectively; sensitivity and specificity for lymph node involvement were 56% (nine of 16 carcinomas) and 95% (21/22 carcinomas), respectively. Four polyps that were smaller than 5 mm in diameter were not revealed by CT. Twelve of 14 benign lesions were correctly diagnosed and two were believed to be malignant. No malignant lesion was misdiagnosed. CT pneumocolon gave an overall staging accuracy of 79% in 38 carcinomas.

Is Minimal Preparation Computed Tomography Comparable with Barium Enema in Elderly Patients with Colonic Symptoms?

The barium enema (BE) examination in the elderly is often an unsatisfactory investigation. Recent papers have proposed computed tomography (CT) as an alternative method of investigation. They have used a variety of preparation techniques prior to the CT study such as bowel preparation, rectal air insufflation, tap water enemas and intravenous contrast medium. We wished to devise a minimal preparation, minimal supervision technique that could realistically replace the standard BE. One hundred and eighteen elderly patients admitted with symptoms referable to the large bowel had an unenhanced CT following oral contrast medium commenced the previous evening, followed at an interval by a BE performed to a standard technique. Both techniques congruently gave negative reports in 66 (68.8 %) individuals. Ten tumours were confidently diagnosed on CT. One annular tumour of the sigmoid colon and one case of colitis were diagnosed on BE only and the severity of a diverticular stricture was underestimated on CT. CT raised the possibility of lesions in 3(3.1%) patients where the BE was negative. Ten (8.5%) patients had significant abnormalities identified outside the colon using CT. Seven (5.9%) barium enemas were abandoned or severely limited. Minimal preparation, minimal supervision CT is a practical alternative to BE in the frail elderly patient. Radiologists and referring clinicians should be aware that occasionally lesions will not be identified on CT but CT has the advantage that other significant pathology unrelated to the colon may be detected. Domjan, J., Blaquiere, R. & Odurny, A. (1998). Clinical Radiology 53, 894-898. Is Minimal Preparation Computed Tomography Comparable With Barium Enema in Elderly Patients With Colonic Symptoms?

Obstructive enterocolitis: a clinico‐pathological discussion

Obstructive colitis is a condition that is not widely appreciated by pathologists. It is defined as an ulcero-inflammatory lesion(s) proximal to a colonic obstruction from which it is separated by a variable length of normal mucosa. Five cases are described which illustrate the clinico-pathological spectrum of the condition. All presented surgically as acute intestinal obstruction, secondary to adenocarcinoma in four cases and a diverticular stricture in one case. Pathologically, the severity of colitis ranged from a single discrete ulcer to an extensive area of fulminant colitis indistinguishable from colitis indeterminate. Furthermore, two cases represented 'obstructive enteritis', a variant of obstructive disease not previously reported. Microscopically, all cases were characterized by distinctive areas of localized ulceration and active inflammation, the features of which were quite unlike those of Crohn's disease or ischaemia, separated by islands of normal mucosa. The role of mural hypoperfusion and secondary localized ischaemia in the pathogenesis of this disorder is discussed. It is suggested that colitis indeterminate represents the final common pathological pathway of the intestine to a wide range of initial insults, be they obstructive or inflammatory.