Comparison between endoscopic laser and different surgical treatments for palliation of advanced rectal cancer

Eight years experience of high-powered endoscopic diode laser therapy for palliation of colorectal carcinoma

PURPOSE

Endoscopic laser therapy using neodymium: yttrium-aluminum-garnet (Nd:YAG) laser has been shown to be effective in palliating symptoms of obstruction, bleeding, and discharge in patients with colorectal cancer. These patients usually have advanced inoperable disease at presentation or are unfit for surgery. We have used high-powered diode laser to palliate patients with inoperable colorectal cancer since 1994. This study was designed to determine the success rate of high-powered diode laser in palliating inoperable colorectal carcinoma and compare these figures with those published for Nd:YAG laser.

METHODS

A retrospective analysis was performed of all patients undergoing high-powered diode laser therapy for colorectal carcinoma between June 1994 and October 2002 (inclusive) at St. George's Hospital, London, United Kingdom. Patient's notes and endoscopy records were reviewed to determine the indications for treatment, success of symptom palliation, complications, and survival for each patient.

RESULTS

Fifty-seven patients (28 males), with a median age at first treatment of 82 (range, 51-93) years, were identified who had been palliated with high-powered diode laser therapy for colorectal carcinoma. The median number of treatments received by each patient was three (range, 1-16 treatments), with a median interval between treatments of 9.5 (range, 1-25) weeks. Lifelong palliation of symptoms occurred in 51 patients (89 percent). Major complications were two perforations and one hemorrhage, giving an overall complication rate of 5.3 percent. One of the patients who experienced perforation died, giving an overall mortality rate of 1.8 percent for the procedure. The median survival of the 51 patients palliated completely by laser therapy was 8.5 (range, 0.6-52) months, with a probability of survival at 24 months of 15 percent.

CONCLUSIONS

High-powered diode laser therapy is an effective method of providing palliation for obstruction, bleeding, and discharge in those patients with inoperable colorectal carcinoma. It produces results comparable to therapy with Nd:YAG laser and the equipment is cheaper, more compact, and portable.

Endoscopic methods (other than stents) for palliation of rectal carcinoma

Patients with unresectable or metastatic rectal cancer may have symptoms of obstruction, bleeding, pain, or tenesmus. Insertion of a self-expandable metal stent is the most durable nonsurgical method for relieving obstruction and has been reviewed in the previous article. Other endoscopic methods of palliating obstruction have been largely replaced by expandable metal stent placement. However, laser ablation is still a useful therapy for some patients, particularly when the predominant symptom is rectal bleeding. The indications and results of endoscopic laser therapy along with other endoscopic treatments for the palliation of rectal cancer will be reviewed here.

Laparoscopic colorectal cancer surgery for palliation

PURPOSE

The aim of this study was to review our experience with laparoscopic colorectal cancer surgery for palliative purposes and to assess its safety and efficacy.

METHODS

This was a prospective analysis of 30 patients with incurable colorectal cancer considered for laparoscopic surgery for palliative purposes.

RESULTS

Resection of a single segment of the bowel was performed in 15 patients (6 right and 1 left colectomies and 8 proctosigmoidectomies). One patient underwent both right colectomy and sigmoidectomy because of double lesions. Stoma creation only was performed in 11 patients (5 colostomies and 6 ileostomies). Three patients were converted to an open procedure. For resection, median operative time was 170 minutes, and median estimated blood loss was 150 ml. For stoma creation, median operative time was 60 minutes, and median blood loss was 50 ml. There were no intraoperative complications. Postoperative death occurred in two severely debilitated patients after stoma creation. One patient developed a pulmonary embolism eight days postoperatively, later dying of pulmonary failure. Another patient died six hours after loop colostomy. Autopsy was refused. There were no other postoperative complications. Median time to passage of flatus was two days and of stool five days after resection and two days for both flatus and stool after stoma creation. Median time to discharge was eight days after resection and seven days after stoma creation. All patients were able to eat and recover normal bowel function. Among the resection group, six patients died (median time to death, 12 months) during a median follow-up period of 13 months. Among the stoma creation group, five patients died (median time to death, 8 months) during median follow-up period of ten months. There were no port-site recurrences.

CONCLUSION

The laparoscopic approach for patients with incurable colorectal cancer can provide effective palliation with avoidance of a major laparotomy in the majority of cases.

Local methods of treatment of rectal cancer

Over 11 000 new cases of rectal cancer are reported in the UK each year. Recent technical advances have increased interest in local management of the disease. The introduction of screening for colorectal cancer will potentially lead to an increased number of early rectal cancers suitable for local curative treatment. In addition, as the proportion of elderly patients in the population rises, local methods of treatment of rectal cancer will become increasingly important in this group of patients with comorbid disease. A literature search was performed on Medline database for English language publications on local treatments of rectal carcinoma. Preoperative assessment, selection of patients, local therapeutic and palliative methods of treatment were evaluated. Local methods of treatment can be used for potentially curative operations for rectal cancer. Preoperative endoanal ultrasound appears to be the most useful investigation for determining depth of local invasion. Transanal endoscopic microsurgery has extended the boundaries of local surgery and permits access to the mid and upper rectum with results similar to those of conventional local techniques. Laser therapy and transanal resection provide the best form of palliation for more advanced rectal carcinomas.

Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents

Metallic stents are currently an established component of the endoluminal treatment of stenoses within the blood vessels, bile ducts, esophagus, trachea, and bronchi. With the development of newer stent designs and delivery systems and the general momentum toward minimally invasive therapies, metallic stent placement has expanded into the nonsurgical therapy for gastroduodenal and colorectal obstructions. The use of metallic stents within the stomach, duodenum, or colon is intended not to be curative but to provide nonsurgical palliation for the symptoms of gastric or colonic obstruction. This palliation may be intended for the life of the patient in the case of unresectable disease or as a temporizing procedure prior to a definitive surgical procedure. In the latter clinical scenario, the benefits of a minimally invasive intestinal decompression procedure include (a) quick and noninvasive relief of the intestinal obstruction in an acutely ill patient that obviates a more extensive procedure; (b) allowance of time to improve a patient's overall medical condition and thus to allow a patient to better tolerate the definitive surgical procedure; and (c) reduction of the complexity of the definitive procedure by eliminating the need for staged procedures and allowing the definitive procedure to be performed at one setting.

Endoscopic laser therapy for palliation of patients with distal colorectal carcinoma: analysis of factors influencing long-term outcome

BACKGROUND

Incurable rectal cancer often reduces the quality of life because of obstruction, bleeding, pain and tenesmus. For such symptoms palliative therapy is often carried out.

METHODS

From 1986 to 1995, 219 patients, 118 men and 101 women, mean age 67 years, with distal colorectal adenocarcinoma were referred for palliative endoscopic laser therapy. In this retrospective analysis of outcome, patients were allocated to 3 subgroups according to their dominant symptom: obstruction, bleeding and others (soiling, diarrhea, tenesmus). After initial successful treatment, maintenance therapy was carried out in cases of obstruction at intervals of 2 to 4 months; patients with bleeding, tenesmus or diarrhea were retreated if there was recurrence of symptoms.

RESULTS

Initial successful palliation was obtained in 198 patients (92%), with similar results in the 3 subgroups. Long-term, effective palliation was achieved in 160 patients (75%) of the total study population. Seventy-six patients (65.0%) with obstruction, 63 (82.9%) with bleeding and 21 (80.8%) with other symptoms remained symptom free until death or this analysis of results. There was a significantly negative relation between long-term successful outcome and local spread of the tumor in the obstruction (p = 0.040) and bleeding groups (p = 0.014). The total number of treatments was significantly higher if obstruction was present at presentation (p< 0.05) and if tumors were circumferential (p = 0.05). Major complications were perforation (4.1%), fistula (3.2%), abscess (1.7%) and bleeding (4.1%). There were 5 (possibly) procedure-related deaths. The survival rate was 44.4% at 1 year and 20.4% at 2 years.

CONCLUSIONS

Laser therapy is effective for initial palliation but careful patient selection is necessary. Long-term palliation is less feasible in patients with obstruction.

Endocavitary Ir-192 radiation and laser treatment for palliation of obstructive rectal cancer

Endoscopic laser therapy (ELT) either alone or combined with endocavitary Ir-192 radiation is performed for advanced, inoperable rectal cancer and when patients are ineligible for surgery due to severe concomitant medical illness. During the period from January 1984 to January 1997 we treated 81 patients (51 males, 30 females). Sixty-seven patients had ELT only using a ND-Yag Laser system. Twenty-five patients (average age: 80.5 years) were ineligible for surgery (Group I). Forty-two patients (74.1 years) had an advanced locally inoperable tumour (Group II). Fourteen patients (76.5 years) underwent a combined therapeutic regime with endocavitary Ir-192 afterloading following ELT (Group III). Adequate desobliteration was achieved in 100% (groups I and III) and 97% (group II) of the patients. The average interval to aftertreatment was 8.4 weeks in group I and 9.4 weeks in group II, compared to 11.5 weeks in group III. Serious complications (perianal abscess, rectovaginal fistula) occurred in 3.7%, minor complications (laser-induced bleedings, unclear fever) in 12.3%. All laser-induced bleedings could be dealt with using laser therapy. The frequency of treatment was governed by tumour mass and the patient's survival. The results suggest that additional endocavitary radiation significantly prolongs the maintenance of normal bowel function compared with laser therapy alone.

Staged delivery of Nd:YAG laser therapy for palliation of advanced rectal carcinoma

PURPOSE

This study was designed to assess the degree of symptom relief, complication rate, and survival time of patients who undergo palliation with the neodymiumyttrium aluminum garnet (Nd:YAG) laser for advanced rectal cancer.

METHODS

Charts of 41 consecutive patients with advanced rectal cancer treated by this method were reviewed.

RESULTS

Thirty-three patients received laser treatment for a primary tumor, and eight received laser palliation for local recurrence following previous surgery. Mean number of treatments delivered was 2 (range, 1-6) for patients with a primary lesion and 2 (range, 1-4) for those patients with local recurrence. In patients in whom more than one delivery was required, subsequent procedures were deferred for more than six weeks. Morbidity rate was 2 percent, with no procedure-related mortality. Median survival time was 19 (range, 1-60) months for patients with a primary tumor and 7 (range, 3-38) months for patients with local recurrence. Four patients subsequently elected to undergo palliative surgery, and five other patients had a loop colostomy formed because of large-bowel obstruction after a mean of 24 (range, 18-41) months. Nd:YAG laser treatment offered adequate laser palliation for 78 percent of patients in this series. However, patients who survive for more than 24 months after their first laser treatment are more likely to require palliative surgery.

CONCLUSIONS

The majority of patients undergoing laser ablation for palliation do not require large numbers of treatment sessions. By delaying the interval between treatments, morbidity and mortality rates are negligible. Most patients avoid a stoma or defer the date of requiring one before their death with this therapy.

Role of transanal endoscopic microsurgery in the palliative treatment of rectal cancer

BACKGROUND

Palliative, minimal invasive treatment of rectal cancer is advocated in patients with advanced and incurable disease or poor clinical condition and in those who refuse radical surgery. Several methods have been used during recent years. We report our experience with palliative transanal endoscopic microsurgery.

MATERIALS

Between 1983 and 1995, 29 patients underwent transanal endoscopic microsurgery for palliation. Eleven patients had advanced malignant disease, nine were in poor clinical condition, and nine repeatedly refused radical surgery.

RESULTS

Intraoperatively one severe complication, an intra-abdominal perforation, occurred. The morbidity rate was 14%. Postoperatively, clinical signs were abolished or improved in all cases. Only three patients required further palliative resections after initial symptom relief.

CONCLUSIONS

Transanal endoscopic microsurgery is a successful approach in the palliative treatment of rectal cancer. The technique enables complete resection of rectal tumors. Although anesthesia is needed, the morbidity is low, even in patients with poor clinical condition.

Integrating medical and surgical treatments in gastrointestinal, genitourinary, and biliary obstruction in patients with cancer

Although local expertise needs to be considered, the following general guidelines for the palliation of malignant biliary obstruction have been proposed: (1) patients in good general condition with small tumors should undergo laparotomy to assess resectability and undergo surgical bypass; (2) patients with advanced disease and poor general condition are suitable for endoscopic stenting to reduce jaundice, pruritus, and risk of cholangitis; (3) patients with poor cognition and limited life expectancy should be managed pharmacologically as appropriate; and (4) research is required to assess optimal management for patients between these extremes; however, clinicians can use the previously described guidelines to make these difficult management decisions.

Palliative endoscopic therapy of rectal carcinoma

Curative surgery is not feasible in a considerable proportion of patients with rectal cancer because of extensive local spread or metastatic disease. However, most of these patients require palliative treatment to improve the symptoms of the disease, e.g. obstruction, pain and haemorrhage. Palliative surgery may be associated with a morbidity of 20-40% and a mortality of more than 10%. Endoscopic procedures can provide effective palliation with less complications. Before the development of lasers, endoscopic electrocoagulation and cryosurgery were used with some success. Currently, endoscopic Nd:YAG photocoagulation must be considered the treatment of choice in non-resectable rectal cancer. Laser therapy allows effective palliation in 85-95% of the patients, and generally, treatment-related complications occur in less than 10% of the patients and mortality is negligible. Transanal endoscopic resection may be effective in selected patients. New approaches to endoscopic palliation include photodynamic therapy (PDT) and implantation of self-expanding metal stents.

Local effects of colorectal cancer are well palliated by endoscopic laser therapy

We review the results of treating the local effects of 26 cases of inoperable colorectal cancer with Nd:YAG laser. There were 16 men and 10 women of mean age 75, with 17 (65%) rectal, eight (31%) sigmoid and one (4%) ascending colon cancer. They presented with symptoms primarily of obstruction in 12 patients (46%), bleeding in 10 (39%) and diarrhoea in four (15%). Initial therapy to relieve symptoms required a mean of 1.5 (1-3) laser treatments over a mean of 1.5 (1-2) weeks. Twelve patients (46%) had total relief and 12 (46%) had partial relief. Sixteen patients received follow-up maintenance therapy, with laser treatments performed over a mean interval of 7.3 (1-20) weeks. One died at first follow-up treatment; all but two of the others were well maintained by laser treatment alone. Three patients (12%) suffered complications, with two deaths (8%), one due to cardiac failure and the other due to stercoral perforation of the colon. Four patients remained alive after a mean follow-up period of 51 (9-84) months. The mean survival of the others was 5 (0-23) months. Laser palliation for colorectal cancer is efficacious and relatively safe, allows improved quality of survival in 92% of patients after initial treatment, and, alone, can satisfactorily keep patients relatively free of local symptoms in 88% of patients surviving into the follow-up period.

Transanal local resection for benign and malignant rectal tumours

Local therapy has been widely reported and accepted for benign tumours and carefully selected cancers of the rectum. Thirty-three patients with benign or malignant low rectal tumors have undergone a prospective evaluation after local resection with transanal electroresection as described by Faivre. Patients were divided in three groups: 1) local excision of benign tumours (12 patients), 2) curative resection for localised malignant tumours (7 patients) and 3) palliative local resection for malignant tumours (14 patients). The complications included transient incontinence and rectal bleeding. Patients have been followed for a mean period of 18 months (1-54). In group 3 there were four (28%) recurrences. The remainder of the patients with malignant tumours have been free of disease on follow-up. Although it is ideal for benign neoplasms, further follow-up is needed to determine its true indication in malignant lesions.