Endoscopic Palliative Treatment Research Articles

Surgery of primary tracheal tumors

To determine the main forms of primary tracheal cancer (PTC), to specify the indications for various surgeries in these patients depending on extent and localization of lesion. There were 263 PTC patients. Benign tumors were diagnosed in 68 (25.9%) patients, malignancies - in 195 (74.1%) cases. Tracheal cancer includes 3 basic morphological variants - adenocystic cancer (49.7%), carcinoid (18.7%) and squamous cell carcinoma (19.0%). Other forms of malignancies were much less common. We applied endoscopic intraluminal and open surgeries. In malignant PTC, open surgeries were performed in 165 (84.6%) out of 195 patients. Baseline palliative endoscopic treatment was performed in 30 patients. They underwent airway recanalization (with subsequent tracheal stenting in 19 patients). Endoscopic resection was preferred for benign tumors. Twenty (12.1%) patients died after open surgery, and 1 (3.3%) patient died after endoscopic procedure. Most lethal outcomes occurred in early years of development of tracheal surgery. The causes of mortality were tracheal anastomotic failure in 12 patients, pneumonia in 6 patients, and arterial bleeding in 2 patients. Severe postoperative period was observed in all 3 patients after tracheal replacement with a silicone prosthesis. Long-term treatment outcomes depended on morphological structure of PTC. Favorable results were observed in patients with neuroendocrine tumor (carcinoid), worse outcomes in adenocystic cancer and unfavorable results in squamous cell carcinoma (p<0.0013). Five-year survival rates were 75%, 65.6%, and 13.3%; 10-year survival rates were 75%, 56.2%, and 13.3%, respectively. These outcomes after combined treatment of primary tracheal cancer were significantly better compared to lung cancer (p<0.05 when compared to global data). Treatment of primary tracheal cancer should be based on classical principles of modern oncology (combined therapy, tumor resection with lymphadenectomy). Open and endoscopic interventions are justified. PTC is characterized by more favorable outcomes compared to lung cancer. It is difficult to analyze long-term results in tracheal cancer depending on various features of tumor process due to small number of observations. Accurate conclusions require multiple-center studies, preferably with international participation, which can convincingly prove certain concept.

Management of obstructive jaundice in patients with neoplasms of the major duodenal papilla

To develop the indications and assess an effectiveness of treatment of patients with ampullary tumors followed by mechanical jaundice. There were 26 patients with major duodenal papilla neoplasms for the period 2015-2020 at the Sklifosovsky Research Institute for Emergency Care. Twenty patients underwent transpapillary interventions: papillosphincterotomy followed by lithoextraction and bilio-duodenal stenting in 4 (15.3%) patients, bilio-duodenal stenting in 12 (46.1%) patients, nasobiliary drainage in 2 (7.6%) patients, pancreaticoduodenal stenting in 2 (7.6%) patients. Percutaneous transhepatic microcholecystostomy was performed in 6 (23.4%) patients. In all cases, laboratory values decreased in 5-7 days after drainage. Eight (30.7%) patients refused further surgical treatment and were discharged in satisfactory condition. Another 8 (44.5%) patients underwent endoscopic submucosal papillectomy. There were no postoperative complications. Patients were discharged after 5-7 days. Four (22.2%) patients underwent tumor resection via laparotomy. One of these patients required redo laparotomy in postoperative period due to acute perforated duodenal ulcer. Six (33.3%) patients underwent palliative bilio-duodenal stenting. Invasion of muscle layer or distal parts of the common bile duct, as well as abnormal vascularization are indications for open surgery or palliative endoscopic treatment. Tumor location within mucous and muscle layers without invasion of distal third of the common bile duct and no abnormal vascularization of tumor justify endoscopic papillectomy. Endoscopic approach can be considered as a final minimally invasive method with minimal risk of postoperative complications in case of benign ampullary tumor.

Palliative Endoscopic Treatment of Metastatic Uveal Melanoma to the Upper and Lower Urinary Tract

We report a rare case of uveal melanoma demonstrating simultaneous metastatic foci to the upper and lower urinary tract. A 60-year-old woman, with metastatic uveal melanoma, was referred for incidental right hydronephrosis. Diagnostic cystoscopy and ureteroscopy confirmed the diagnosis of metastatic malignant melanoma to the bladder and kidney. Both tumor resection and coagulation were possible with the neodymium/holmium laser combination. The goals of treatment in metastatic patients should be cessation of hematuria and relief of obstruction with preservation of functional renal reserve while minimizing morbidity.

Endoscopy and endosonography in the diagnostics of pancreatic cancer

Ductal adenocarcinoma accounts for 90% of all pancreatic malignancies and is the fourth leading malignant cause of mortality in the Western world and the fifth in Russia. Comprehensive preoperative examination is aimed not only at making an accurate diagnosis, but also at determining treatment strategy. The diagnostic algorithm involves endoscopic ultrasound. The modern possibilities of endosonography combined with tissue contrast enhancement and fine-needle aspiration, as well as some aspects of palliative endoscopic treatment are analyzed in the article.

Squamous Cell Carcinoma of the Esophagus

Although its incidence in the Western world is decreasing, squamous cell carcinoma of the esophagus (ESCC) remains a significant cause of cancer mortality worldwide. Recent analyses have identified a number of unique characteristics that differentiate ESCC from esophageal adenocarcinoma at the etiologic, genomic, and epigenetic levels. A thorough diagnostic and staging work-up includes endoscopy, endoscopic ultrasonography, and axial imaging. Applicable therapeutic modalities include definitive endoscopic therapies, resection alone, trimodality therapy, definitive chemoradiation, systemic therapy, and palliative treatment options. Given the complexity of this disease and its management, careful consideration in a multidisciplinary setting is warranted to appropriately individualize therapeutic options. This review contains 5 figures, 6 tables, and 51 references. Key Words: squamous cell carcinoma, esophageal diseases, esophageal cancer, esophageal neoplasms, gastroesophageal junction, Tylosis, bimodality therapy, trimodality therapy, endoscopic therapy

Squamous Cell Carcinoma of the Esophagus

Although its incidence in the Western world is decreasing, squamous cell carcinoma of the esophagus (ESCC) remains a significant cause of cancer mortality worldwide. Recent analyses have identified a number of unique characteristics that differentiate ESCC from esophageal adenocarcinoma at the etiologic, genomic, and epigenetic levels. A thorough diagnostic and staging work-up includes endoscopy, endoscopic ultrasonography, and axial imaging. Applicable therapeutic modalities include definitive endoscopic therapies, resection alone, trimodality therapy, definitive chemoradiation, systemic therapy, and palliative treatment options. Given the complexity of this disease and its management, careful consideration in a multidisciplinary setting is warranted to appropriately individualize therapeutic options. This review contains 5 figures, 6 tables, and 51 references. Key Words: squamous cell carcinoma, esophageal diseases, esophageal cancer, esophageal neoplasms, gastroesophageal junction, Tylosis, bimodality therapy, trimodality therapy, endoscopic therapy

Achalasia Associated With Esophageal Intramural Pseudodiverticulosis: A Rarely Reported Condition

Intro: Esophageal intramural pseudodiverticulosis (EIP) is a benign, rare condition that most commonly presents in patients ages 50-70. It is often associated with diabetes mellitus, chronic alcoholism, malnutrition, or achalasia as depicted in the case below. It was first reported in 1960 with roughly 250 cases worldwide, and only 2 reports are associated with achalasia.Figure: Barium esophagram showing multiple classic button and flask shaped EIP in the upper esophagus.Figure: Barium esophagram depicting dilatation of the mid esophagus with tortuosity of the mid to distal portion.Case: An 87 year old male with a history diabetes and progressive dysphagia with regurgitation of solids and liquids over many years presented to the ER in septic shock secondary to aspiration pneumonia. He had endoscopy three years prior showing candidal esophagitis, epiphrenic diverticulum, and a schatzki ring. Follow-up endoscopy revealed tertiary contractions and he was prescribed a calcium channel blocker, which he did not take. Two months prior to this admission, a barium esophagram showed dilatation of the mid esophagus, several pseudodiverticula in the upper esophagus, tortuosity of the mid to distal portion, a 4.2x4.3cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, silent aspiration of contrast, incomplete emptying and regurgitation to the oropharynx. High resolution manometry was significant for esophageal aperistalsis and lower esophageal sphincter pressure indicating achalasia. He presented with aspiration before achieving outpatient management. Given the patient's age and multiple comorbidities, palliative endoscopic treatment was given with botox injection and symptomatic improvement.Figure: Barium esophagram depicting a large 4.2x4.3 cm epiphrenic esophageal diverticulum proximal to the gastroesophageal junction, and regurgitation of contrast into the upper esophageal pseudodiverticula.Discussion: EIP is a rare condition caused by reactive hypertrophy and increased intramural pressure creating dilation and outpouching of the esophageal submucosal gland excretory ducts caused by a distal obstruction from chemical, infectious, or mechanical processes, such as achalasia. Dysphagia, reflux, and odynophagia are common presenting symptoms with stricture formation in up to 90% of cases. Barium esophagram shows flask or button-shaped outpouchings and may reveal dysmotility. The main goal of treatment is to correct the underlying disorder, which involved botox injection to palliate the patient's achalasia. EIP is generally benign though complications include aspiration pneumonia, candidal infection, fistulas, mediastinitis, and perforation. We present this case to raise physician awareness of this rare condition to aid in prompt diagnosis and management, in hopes of avoiding complications that result in increased patient morbidity and mortality.

Endoscopic or percutaneous palliative treatment in malignant obstruction of biliary duct

Endoscopic or percutaneous palliative treatment in malignant obstruction of biliary duct

Endoscopic palliative treatment using a metallic stent in a patient with an obstructive jejunal metastasis

A 42-year-old man, receiving palliative treatment for lung cancer, presented with hyperemesis, abdominal pain, and intestinal subocclusion. Endoscopy showed a large volume of liquid stasis and gastric lesions compatible with metastasis (Video 1, available at www.giejournal.org). Computed tomography revealed intussusception in the jejunal loop. Single-balloon endoscopy demonstrated multiple metastatic lesions throughout the small bowel. At the midjejunum level, a 5-cm vegetative lesion was found, which partially prevented the endoscope transposition. It was decided to insert an uncovered self-expandable metal stent (SEMS) (22 mm × 9 cm, Wallflex duodenal stent, Boston Scientific, Natick, Mass). The obstructive lesion was demarcated with clips. After removal of the enteroscope, the overtube was kept in place with the inflated balloon, and the SEMS was deployed under fluoroscopy. The stent delivery system was 255-cm long, and the overtube was 140-cm long. On endoscopic review, immediate expansion of the stent was confirmed with a contrast-free flow through the lumen (Fig. 1). In the following days, the patient was able to consume an oral diet and had normal bowel movements until he died a month later. With the development of deep enteroscopy and the use of stent deployment through the overtube, patients with small-bowel neoplasia unreachable by conventional endoscopes have become eligible for endoscopic palliation.

Endoscopic palliative treatment versus surgical bypass in malignant low bile duct obstruction: A systematic review and meta-analysis

Aims: Despite technological advances, only about 20% of periampullary tumors are found to be resectable at the time of presentation. Biliary tree obstruction and consequent jaundice occur in 70–90% of those patients and has important consequences for a patient’s quality of life. Relief of biliary tree obstruction is the main goal for treatment, and few options for palliative therapy of biliary tree obstruction can be performed, including surgical bypass, percutaneous stenting, and endoscopic stenting. Objective: The aim of the present study was to acquire and analyze data to compare the success of procedures, procedure-related complication, mortality in 30

Role of Endoscopy in Primary Sclerosing Cholangitis

Primary sclerosing cholangitis is a chronic cholestatic liver disease characterized by progressive inflammation affecting the entire biliary tree and leading to biliary symptoms and complications. It is of unclear etiology and is usually associated with inflammatory bowel diseases. Despite advances in modern medicine, treatment options remain very limited, and without liver transplantation, survival rates are reduced. We aim in this review to highlight available endoscopic methods to evaluate, diagnose, and manage symptoms and complications associated with this disease, including diagnosis of cholangiocarcinoma and endoscopic palliative treatment for advanced cholangiocarcinoma not amenable to surgical resection.

Gastric tube cancer after esophagectomy for esophageal cancer: A single-center experience with meta-analysis of 145 cases.

e14573 Background: Gastric tube cancer (GTC) defined as carcinoma arising in the gastric conduit after esophagectomy, is often crucial in long-term survivors of esophageal cancer. The aim of this study was to determine the optimal approach to manage GTC. Methods: We reviewed data of 863 patients who underwent esophagectomy and reconstruction with the gastric conduit for esophageal cancer at Asan Medical Center from 1993 to 2011 and identified 28 cases of GTC. We also searched through the PubMed database and included additional 117 cases of GTC from 13 studies to conduct meta-analysis. Results: In our cases, the incidence rate of GTC was 3.2%. The median interval between esophagectomy and GTC detection was 3.1 (0.6-15.2) years. Twelve (42.9%) patients were asymptomatic and diagnosed by periodic endoscopy. The Most common histologic type of GTC was adenocarcinoma (57.1%) and fifteen (53.6%) were located on the lower third of gastric tube. Chemotherapy, total gastrectomy or palliative treatment was performed in 10, 5, 2 patients, respectively. Eleven (39.3%) patients refused the further treatment for GTC. Mean survival duration of 28 patients after the diagnosis of GTC was 29.1 months. In meta-analysis, The cumulative occurrence of 5, 8 years was 59.5%, 87.8%, respectively. Two-year survival rate of the patients who underwent endoscopic resection, surgical resection or palliative treatment was 100%, 61.6%, 5.2%, respectively. The patients who underwent endoscopic resection had a better prognosis than those who underwent surgical resection or those who received palliative treatment (p=0.047, p=0.000, respectively). Conclusions: After esophagectomy for esophageal cancer, patients had a constant risk of GTC occurrence up to 8 years approximately. The patients who diagnosed as advanced-state GTC had a poor prognosis. However, endoscopic resection as a minimally invasive treatment for early-GTC represented a feasible prognosis compared with those of operative resection or palliative treatment. Therefore, a long-term follow-up including detailed endoscopy is essential for the better outcomes in patients who underwent esophagectomy for esophageal cancer.

Endoscopic palliative treatment for advanced pancreatic cancer

Objective To investigate the therapeutic effects of endoscopy for palliative treatment of advanced pancreatic cancer. Methods A typical case of un-resectable advanced pancreatic cancer was reviewed, who underwent obstruction of upper gastrointestinal tract, obstructive jaundice and alimentary tract hemorrhage subsequently. The patient received multiple placement of intestinal tract stentts, common bile duct stents and hemostatic treatment endoscopically. Because of the obstruction of upper gastrointestinal tract, jejunalostomy and retrograde endoscopy through the orificium fistulae were performed to place bile duct stents. Resuits The patient survived for 10 months with good life quality after diagnosis, obstruction of upper gastrointestinal tract, obstructive jaundice and alimentary tract hemorrhage were cured and didn＇t recur till death. Conclusion Therapeutic endoscopy, safe and effective, is the first choice for advanced pancreatic cancer complicated with obstruction of digestive tract （ including gastrointestinal tract, bile duct and pancreatic duct）. Key words: Pancreatic neoplasmg; Bile duct obstruction; Cholangiopancreatography, endoscopic retrograde; Palliative care

Endoscopic radiofrequency ablation of cholangiocarcinoma: new palliative treatment modality (with videos)

Placement of self-expandable metal stents (SEMSs) is the standard of care for patients with malignant obstructive jaundice if their life expectancy is >3 months.1,2 However, in >50% of patients with SEMSs, stent blockage develops within 6 to 8 months,3 and newer endoscopic palliative treatment modalities are needed.

Palliative endoscopic and chemotherapeutic treatment

BACKGROUND: Colorectal cancer (CRC) is the second leading cause of cancer death in the western world. The aim of palliative therapy is the prolongation of survival and the improvement of quality of life. METHODS: The description of therapeutic options is based on systematically literature search and on the German S3 guideline for metastatic CRC treatment. RESULTS: In the case of gastrointestinal tumour obstruction, endoscopic self-expanding metal stents (SEMS) insertion is a non-surgery palliative treatment option. New and effective chemotherapeutic substances and biologics have improved the systemic treatment of patients with mCRC in the past decade. CONCLUSIONS: Endoscopic or intensive combination chemotherapy is indicated if the patient suffers from tumour symptoms or disease progression. Combination therapy with monoclonal antibodies leads to further improvement of survival. The introduction of the mutational status examination of the KRAS oncogene as the first predictive marker into clinical care is an important step towards the individualization of treatment.

Endoscopic retrograde cholangiopancreatography in biliary papillomatosis

Objective To evaluate the diagnostic and therapeutic effects of endoscopic retrograde cholangiopancreatography （ERCP） in biliary papillomatosis. Methods Data of 6 patients, who underwent ERCP and diagnosed as biliary papillomatosis from 2000 to 2008, were retrospectively analyzed. Results There were 3 males and 3 females, with the mean age of onset at 72. 8 years （range 52-83 years）. Recurrent cholangitis and jaundice were common presentations in all patients, with 5 patients having right upper abdom- inal pain and 3 others exhiting fever and algor. History of partial hepatectomy was observed in 2 patients. Endoscopic findings included dilated papillary orifice with mucin discharge in 5 patients and papillary-occupying lesion in 1 patient. Multiple filling defects in the lumen of the biliary system in dilated common bile duct were detected in all patients, accompanied with extra-hepatic ducts dilatation in 3, right intra-hepatic duct dilatation in 1, and major pancreatic duct dilation in 1. Of 6 patients, 5 underwent multiple ERCP, including stents and endoscopic nasobiliary drainage （ENBD）, and have survived for 10-30 months. Another 83- year-old patient underwent palliative endoscopic treatment with balloons, baskets and ENBD, but died of cholangitis 10 days after the procedure. Conclusion This case series reports the typical endoscopic findings of biliary papillomatosis. For inoperable or postoperative recurrent patients, endoscopic palliative treatment is a safe, convenient and effective procedure. Key words: Cholangiopancreatography, endoscopic retrograde ; Biliary papillomatosis ; Diagnosis ; Therapy

Pancreatic cancer — Palliative therapy: stenting

Pancreatic cancer remains a common and very lethal malignancy with a median survival of approximately 6 months. Surgical resection offers the only potentially curative approach but many patients (80% or more) are ineligible for this kind of therapy, because of age, comorbidities, or locally advanced or metastatic disease that does not benefit from resection. Thus, for many patients with pancreatic cancer treatment remains palliative and endoscopic therapy to relieve bile duct or gastric outlet obstruction becomes of special importance. Although both surgical and non surgical palliative procedures can relieve biliary and duodenal obstruction particularly endoscopic treatment with plastic prostheses or self expanding metal stents was shown to be not only highly effective but also to be burdened with only few complications. The present article summarizes the palliative endoscopic treatment in patients with non resectable pancreatic cancer.

395 POSTER Effectivity of palliative endoscopic treatment of colorectal carcinoma

395 POSTER Effectivity of palliative endoscopic treatment of colorectal carcinoma

Palliative endoscopic treatment of neoplastic biliary stenosis: Zilver stent

Palliative endoscopic treatment of neoplastic biliary stenosis: Zilver stent

The use of seldinger technique for replacement of multiple plastic stents during endoscopic palliative treatment of hilar malignant strictures

The use of seldinger technique for replacement of multiple plastic stents during endoscopic palliative treatment of hilar malignant strictures