Endoscopic Laser Palliation for Rectal Cancer[*]

Zusammenfassung

Hintergrund: Trotz aller medizinischen Fortschritte ist die Behandlung des fortgeschrittenen Rektumkarzinoms nach wie vor eine Herausforderung. Wir untersuchten die kurzfristigen klinischen Ergebnisse, therapiebedingte Komplikationen und den Langzeitverlauf nach palliativer Lasertherapie.

Methodik: Über einen Zeitraum von 10 Jahren wurden 83 Patienten (medianes Alter: 81 〈46-93 Jahre〉 43 weiblich) wegen Rektumkarzinoms lasertherapiert. Hauptindikationen waren Obstruktion und/oder rektale Blutung. Eingesetzt wurde ein Nd:YAG-Laser.

Resultate: Kurzfristig wurden 96,4 % (80 von 83) Patienten erfolgreich behandelt. Nur eine Patientin wurde initial wegen einer unzugänglichen, hochgradigen Rektumstenose kolostomiert. Im Nachbeobachtungszeitraum mussten sich acht weitere Patienten wegen Therapieversagen (meist Rezidivobstruktionen) oder Komplikationen einem operativen Eingriff unterziehen (Langzeiterfolg: 86,7 %). Die mediane Überlebenszeit betrug neun Monate. Patienten, die wegen Obstruktion behandelt wurden, benötigten mehr Therapiesitzungen und wurden im Verlauf häufiger palliativ operiert als Patienten mit Blutungen. Schwere Komplikationen traten bei drei Patienten (3,6 %) auf. Ein Patient starb nach Rektumperforation (therapiebedingte Gesamtmortalität: 1,2 %).

Schlussfolgerungen: Die Lasertherapie ist effektiv zur Palliation von Rektumkarzinomen mit einer hohen kurz- und langfristigen Erfolgsrate. Die Laserpalliation ist auch im Zeitalter neuerer endoskopischer Techniken, wie Metallstents, immer noch eine wertvolle Behandlungsoption.

Abstract

Objective: The treatment of advanced rectal cancer is still a challenge. We analysed the short-term success, treatment-related complications and the long-term outcome after laser palliation for rectal cancer.

Methods: Over a ten-years period eighty-three consecutive patients (median age 81 (46-94) yrs; 43 female) were treated mainly for obstructive symptoms or tumour bleeding. Laser palliation was performed using a Neodymium:Yttrium-Aluminium-Garnet (Nd:YAG) laser.

Results: The immediate overall-success rate was 96.4 % (80 of 83 patients) and only one female received a diverting colostomy because of an inaccessible high-grade rectal stenosis, initially. During follow-up, eight additional patients had to undergo surgery on their rectal cancer because of treatment failures (most of them recurrent obstruction) or complications (long-term success rate: 86.7 % (72 of 83 pts.)). The median survival period was nine months.

Patients treated for obstruction had more treatment sessions and had a higher rate of surgical palliation in comparison to those pts. therapied for bleeding. Major complications were seen in three patients (3.6 %). One patient died after rectal perforation following bougienage before laser treatment (overall mortality: 1.2 %).

Conclusion: Laser therapy is effective for the palliation of advanced rectal cancer with a high short-term and long-term success rate and only few complications. Laser treatment therefore is still a valuable alternative to newer endoscopic techniques and surgery.

Rektumkarzinom - Laser - Palliation - Endoskopie - Obstruktion - Blutung

Rectal Cancer - Laser - Palliation - Endoscopy - Obstruction - Bleeding

References

• 1 Eickhoff A, Riemann J F. Das Kolonkarzinom.  Internist. 2000;  41 860-867
• 2 Lieberman D A, Weiss D G, Bond J H. et al . Use of colonoscopy to screen asymptomatic adults for colorectal cancer.  N Engl J Med. 2000;  343 162-168
• 3 Lau P WK, Lorentz T G. Results of surgery for malignant bowel obstruction in advanced unresectable, recurrent colorectal cancer.  Dis Colon Rectum. 1993;  36 61-64
• 4 Baigrie R J, Berry A R. Management of advanced rectal cancer.  Br J Surg. 1994;  81 343-352
• 5 Tacke W, Paech S, Kruis W. et al . Comparison between endoscopic laser and different surgical treatments for palliation of advanced rectal cancer.  Dis Colon Rectum. 1993;  36 377-382
• 6 Sugarbaker P H. Carcinoma of the left colon: prognosis and operative choice.  Curr Prob Surg. 1981;  18 753-802
• 7 Hoffmann J, Jensen H E. Tube cecostomy and staged resection for obstructing carcinoma of the left colon.  Dis Colon Rectum. 1984;  27 34-42
• 8 Tack J, Gevers A M, Rutgeerts P. Self-expandable metallic stents in the palliation of rectosigmoidal carcinoma: a follow-up study.  Gastrointest Endosc. 1998;  48 267-271
• 9 Camunez F, Echenagusia A, Simo G. et al . Malignant colorectal obstruction treated by means of self-expanding metallic stents: effectiveness before surgery and in palliation.  Radiology. 2000;  216 492-497
• 10 Bruneteaud J M, Maunoury V, Cochelard D. Lasers in rectosigmoid tumors.  Seminars in Surgical Oncology. 1995;  11 319-327
• 11 Eckhauser M L, Mansour E G. Endosocpic laser therapy for obstructing and/or bleeding colorectal carcinoma.  American Surgeon. 1992;  58 358-363
• 12 Loizou L A, Grigg D, Boulos P B, Bown S G. Endoscopic Nd: YAG laser treatment of rectosigmoid cancer.  Gut. 1990;  31 812-816
• 13 Unger S W, Stern J D, Arroyo P J, Russin D J. Endosocpic Nd: YAG laser treatment of colorectal neoplasms.  Am Surgeon. 1990;  56 153-157
• 14 Boyd J B, Bradford B, Wayne A L. Operative risk factors of colon resection in the elderly.  Ann Surg. 1980;  192 743-746
• 15 Rantala A, Ovaska J. Palliative laser treatment of rectal cancer.  Scand J Gastroenterol. 1995;  30 177-179
• 16 Chen H, George B D, Kaufman H S. et al . Endoscopic transanal resection provides palliation equivalent to transabdominal resection in patients with metastatic rectal cancer.  J Gastrointest Surg. 2001;  5 282-286
• 17 Dohmoto M, Hünerbein M, Schlag P M. Palliative endoscopic therapy of rectal carcinoma.  Eur J Cancer. 1996;  32 25-29
• 18 Khulusi S, Morris T. Endoscopic palliation of gastrointestinal malignancy.  Eur J Gastroenterol Hepatol. 2000;  12 397-402
• 19 Barr H, Krasner N, Boulos P B, Chatlani P, Bown S G. Photodynamic therapy for colorectal cancer: a quantitative pilot study.  Br J Surg. 1990;  77 93-96
• 20 Mathus-Vliegen E MH, Tytgat G NJ. Laser photocoagulation in the palliation of colorectal malignancies.  Cancer. 1986;  57 2212-2216
• 21 Tan C C, Iftikhar S Y, Allan A, Freeman J G. Local effects of colorectal cancer are well palliated by endoscopic laser therapy.  Eur J Surg Oncol. 1995;  21 648-652
• 22 Mlkvy P, Vrablik V, Kralik G, Laborecky M. Endoscopic Nd: YAG laser treatment of rectosigmoidal cancer.  Neoplasma. 1994;  41 285-289
• 23 Schulze S, Lyng K M. Palliation of rectosigmoid neoplasms with Nd: YAG laser treatment.  Dis Colon Rectum. 1994;  37 882-884
• 24 Gevers A M, Macken E, Hiele M, Rutgeerts P. Endoscopic laser therapy for palliation of patients with distal colorectal carcinoma: analysis of factors influencing long-term outcome.  Gastrointest Endosc. 2001;  51 580-585
• 25 Spinelli P, Mancini A. Use of self-expanding metal stents for palliation of malignant rectosigmoid cancer.  Gastrointest Endosc. 2001;  53 203-206
• 26 Repici A, Reggio D, De Angelis C. et al . Covered metal stents for management of inoperable malignant colorectal strictures.  Gastrointest Endosc. 2000;  52 735-740
• 27 Canard J M, Vedrenne B. Clinical Application of Argon Plasma Coagulation in Gastrointestinal endoscopy: Has the time come to replace the laser?.  Endoscopy. 2001;  33 353-357
• 28 Wahab P, Mulder C, den Hartog G, Thies J. Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences.  Endoscopy. 1997;  29 176-181
• 29 Vedrenne B, Canard J M, Bader R. Traitement symptomatique de cancers du rectum par coagulation au plasma d’argon.  Gastroenterol Clin Biol. 2000;  24 A35
• 30 Kashtan H, Papa M Z, Wilson B C, Deutch A A, Stern H S. Use of photodynamic therapy in the palliation of massive advanced rectal cancer.  Dis Colon Rectum. 1991;  34 600-605
• 31 Barr H, Dix A J, Kendall C, Stone N. Review article: the potential role for photodynamic therapy in the management of upper gastrointestinal disease.  Aliment Pharmacol Ther. 2001;  15 311-321
• 32 Sauer R, Fietkau R, Wittekind C. et al . Adjuvant versus neoadjuvant radiochemotherapy for locally advanced rectal cancer. A progress report of a phase-III randomized trial (protocol CAO/ARO/AIO-94).  Strahlenther Onkol. 2001;  177 173-181
• 33 Onaitis M W, Noone R B, Hartwig M. et al . Neoadjuvant chemoradiation for rectal cancer: analysis of clinical outcomes from a 13-year institutional experience.  Ann Surg. 2001;  233 778-785
• 34 Russell A H, Harris J, Rosenberg P J. et al . Anal sphincter conservation for patients with adenocarcinoma of the distal rectum: long-term results of radiation therapy oncology group protocol 89 - 02.  Int J Radiat Oncol Biol Phys 2000. 15; 
• 35 Valentini V, Coco C, Cellini N. et al . Preoperative chemoradiation with cisplatin and 5-fluorouracil for extraperitoneal T3 rectal cancer: acute toxicity, tumor response, sphincter preservation.  Int J Radiat Oncol Biol Phys 1999. 1; 

1 Presented in parts at the annual meeting of the Amercian Gastroenterological Association (Digestive Disease week), San Diego 1998.