Malignant Acute Colonic Obstruction: Multidisciplinary Approach for Endoscopic Management

Abstract

Patients presenting with acute colonic obstruction are usually evaluated in the emergency department and multiple specialties are involved in the patients' management. Pre-treatment evaluation is essential in order to establish the correct endoscopic indication for stent implantation. Contrast-enhanced imaging could allow the exclusion of benign causes of colonic obstruction and evaluation of the length of malignant stricture. Endoscopic stenting is the gold standard of treatment for palliative indications whereas there are still concerns about its use as a bridge to surgery. Different meta-analyses showed that stenting as a bridge to surgery improves short-term surgical outcomes but has no role in improving long-term outcomes. Multidisciplinary evaluation is also essential in patients that may be started on or are currently receiving antiangiogenic agents because endoscopic stenting may increase the risk of perforation. Evidence in the literature is weak and based on retrospective data. Here we report on how to correctly evaluate a patient with acute colonic malignant obstruction in collaboration with other essential specialists including a radiologist, surgeon and oncologist, and how to optimize the technique of endoscopic stenting.

Keywords: CT scan; acute colonic obstruction; antiangiogenic agents; bridge to surgery; colorectal cancer; endoscopic stent; self-expandable metal stent.

Figure 1

Enhanced CT scan of acute colonic obstruction with presence of neoplastic stricture at the level of the descending colon. In the coronal section: (A) stenosis of the descending with marked thickening of its walls, non-homogeneous contrast enhancement, possible extra-visceral extension; in the ax, (B) overdistention of large and small bowel with air fluids levels. Yellow stars at the level of the neoplastic stricture.

Figure 2

Example of an endoscopic setting for the placement of a colonic stent. ① Endoscopist position with radiological and endoscopic monitor placed frontally and the endoscopic processor in the right position. ② Nurse position at the end of the radiological bed with an instrument shelf on his side. ③ Position of the assistant at the C-arm. ④ Anesthesiological position at the patient’s head with vital monitoring on his side.

Figure 3

Contrastography obtained with air insufflation showing colonic stricture (black arrow) at the level of ascending colon.

Figure 4

Colonic stenting of a malignant stricture at the level of the ascending colon. (A): Contrast injection at the level of the stricture with loop of the guidewire in the cecum; (B) radiological evidence of the self-expandable metal stent (SEMS) within the malignant stricture; (C) endoscopic view of the stricture with the metallic mesh of the distal part of the uncovered SEMS.