Welcome to ASG Global Spotlight, a webinar series created with our global audience in mind and at a different time from our usual offerings to make sure that you all have a chance to join live. These webinars will feature global experts in their field and I'm very excited for today's presentation. Our attendees are joining us from all over the world and the American Society for Gastrointestinal Endoscopy greatly appreciates your participation. Today's event is entitled Indications and Patient Selection for Colonic Stenting. My name is Reddy Akova and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. There will be a discussion and questions and answer at the close of the presentation. If you have any questions during the presentation, you may submit them at any time online by clicking the Q&A feature at the bottom of your screen. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. And now it is my pleasure to introduce our two panelists for today. Professor Fawzi Malouf-Firouho, who is the Director of Endoscopy Unit of the Cancer Institute of Sao Paulo and the Department of Gastroenterology of the University of Sao Paulo in Brazil. Professor Malouf-Firouho received his training in many international centers around the world and has been awarded multiple awards for his work in gastroenterology. Professor Malouf-Firouho currently serves on many committees and national and international organizations and we greatly appreciate his work on our own ASG International Committee. Professor Malouf-Firouho is also an Associate Editor of our own Gastrointestinal Endoscopy or GIE Journal. And we are very fortunate and honored to have Professor Malouf-Firouho here with us today. Our other panelist is Dr. Bruno Da Costa Martins, who is a physician at the Cancer Institute of Sao Paulo and Professor of Medicine at the University of Sao Paulo in Brazil. Dr. Martins has also completed his training in various institutions in Brazil and around the world and his main research interests include advanced diagnostic and therapeutic endoscopy as a treatment for obesity and gastrointestinal neoplasms. Both Professor Malouf-Firouho and Martins have authored and co-authored many articles on several international peer-reviewed journals and we are very fortunate and honored to have both of them with us today. I will now hand the presentation over to Professor Faust Malouf-Firouho. Thank you, Reddy, for this extra kind introduction. So hello, everyone. Thank you for joining this webinar. I hope you are all safe and healthy. So I'm deeply honored by the invitation. So I'd like to thank ASG for this kind invitation. Professor Douglas Hex, ASG President, and as well as Mostafa Ibrahim, Chair of the International Committee, and sure, they are doing a terrific job in ASG. And also thank Reddy Iacova, the ASG staff liaison for this committee, for the International Committee, for his terrific job, great job organizing all the activities of International Committee. I've been serving the ASG International Committee since 2012, almost 10 years. So I am testimony of all ASG efforts to foster, to build solid relations with all GI societies across the world through the actions of this committee. So it's a great, great honor. And thank Professor Bruno da Costa Martins, who's going to help us in this webinar. He works with me at the Institute of Cancer at Sao Paulo, and a great friend and a very skilled endoscopist. So let's talk about colorectal stenting. Here are my conflicts of interest that pertinent to my presentation. And just out of curiosity, the name stent is a proper name after Charles Thomas Stent, who developed dental prosthesis. So we use as a synonym of prosthesis, right, but is a proper name, stent. I'm going to cover indications and results of colorectal stenting, as well as technique and post-procedure management. We are talking about self-expandable metallic stents introduced mainly in the left colon and rectum. So this is the chapter that we're going to cover. The main indications are patients with malignant colorectal structures in two different situations, as bridge to surgery and palliation. Bridge to surgery, the patient presents with acute obstructive abdomen. And for this situation, the gold standard treatment is colostomy. And then the patient is staged. And after this, the patient is sent to resection. So with colorectal stenting, you can relieve the acute obstruction, so you don't need colostomy. And then we stage the patient and send to definitive treatment. So this is the indication of colorectal stenting as a bridge to surgery. The second indication is palliation, the patient who has a stage four disease and obstruction and needs some palliative treatment. There are some benign conditions, indications for colorectal stenting, for the treatment of leaks, stricture in Crohn's disease, and other benign strictures. But you notice that I put, excuse me, I put a red question mark here, because as you're going to see in the presentation, the results are not so good. So I'm not sure that benign strictures or benign conditions are good indication for colorectal stenting. So I just wanted to underline this information right at the beginning of my presentation. There are clear contraindications to colorectal stenting, perforation, or when there is imminent perforation. For example, when the cecum is distended above 10 centimeters on plain x-ray films. When the lesion, when the obstructive malignant lesion is located below 5 centimeters from the anal verge. Otherwise, if you put a stent in this situation, the patients will experience some problems with anal and erectal continence. And the use of this chemo agent, Bevacizumab, maybe there is some increase in perforation rate when you put the stent and give this chemo treatment for the patient. This is also a matter of some controversy, but we can talk later about this. The patients who present with acute obstructive abdomen usually is an older patient and the urgent surgical intervention has high morbidity and high mortality in this population. The risk of anastomotic leaks and colostomy is also higher in this population of patients. The alternative treatment, you can perform a CD scan, stage the disease, be sure that there are no other synchronic lesions. You can better delineate the cancer. And then under endoscopy, you see here the distal border of the cancer. You can manage the stricture using ERCP catheter and hydrophilic guidewire, inject some contrast to delineate the stricture, and then you deploy the stent. And at the same admission, after staging, you send the patient to definitive treatment, to resection. And you may see here the surgical specimen and the stent inside the surgical specimen. So the first results from this observational studies published 15 years ago were very promising, very good. And they prompt the randomized controlled trials comparing self-expanding metal stents as bridge to surgery versus upfront surgery. And the results of these randomized controlled trials were summarized in this systematic review and meta-analysis. So you see here eight randomized controlled trials comparing SEMS versus surgery. And here are the results. In the SEMS group, we observed, we noticed a lower rate of temporary stoma, higher rate of primary anastomosis, and lower morbidity. No difference in 30-day mortality rates between the groups, 30-day hospital mortality. Unfortunately, in the following years, we saw in the literature small observational comparative studies showing that maybe in the SEMS group, there were worst oncologic outcomes, namely a higher five-year recurrent disease rate. But no difference in five-year overall survival rate. So this higher recurrent disease rate didn't impact overall survival rate. But anyway, because of these papers, of these studies, we saw a reduction in the indication of colorectal stenting as a bridge to surgery. So it was even a contraindication. The rationale behind this occurrence is the fact that maybe the colorectal stent induces micro-perforation and seeding of malignant cells in the pelvic cavity. And even in the surgical specimen, there were more cases of neural invasion in patients who received colorectal stenting. So this fear of worst oncologic outcomes was expressed in the European Endoscopic Society guidelines about colorectal stenting, published in 2014. In this guideline, the authors recommended colorectal stenting only for older patients with comorbidity. So colorectal stenting as a bridge to surgery only in older patients with comorbidity. Fortunately, in the following years, the literature showed new evidence. As you may see here, this paper compared the overall survival in stented patients versus the survival from the Belgian Cancer Registry. Absolutely no difference. In this meta-analysis that pulled the results of 11 studies comparing stents for bridge to surgery versus up-front surgery, no difference in overall survival, free disease survival, and recurrent disease rates. Another systematic review meta-analysis with more studies, 17 studies, showing that no difference, showing no difference in three and five-year recurrent disease and mortality rates. And more recently, the larger systematic review meta-analysis pulling the results of 21 studies. And once again, absolutely no difference between stenting as bridge to surgery versus up-front surgery for three and five-year recurrent disease, mortality, and five-year free disease survival rates. So based on these studies, we looked at our own data. So we inserted SAMs in 21 patients as bridge to surgery and compared the outcomes of these patients with 67 patients who were sent directly to surgery. They all had acute malignant obstruction, colorectal obstruction. And our results are a repetition of previous studies, as you may see here, higher rates of primary anastomosis in the SAMs group, lower rate of temporary permanent colostomy fistula. And as we follow these patients, more than five years, absolutely no difference in local, distant, and global recurrence rates expressed in the survival curves, as you may see here, overall survival, comparing here, the red group, here is surgery, and the blue line here is SAMs, no difference in overall survival, and the five-year disease-free survival, absolutely no difference between the groups. So at this point, I would say that colorectal stenting is a bridge to curative surgery, is a good indication. These patients are good indications, are good candidates to colorectal stenting, or at least it merits a nice randomized control trial with good, with adequate sample size. And there is this such trial. The CREST trial was conducted in the United Kingdom, and we have just partial results that were published by their health organization, the United Kingdom health organization is called NICE. So in the NICE guidelines of last year, they published the partial results of this randomized control trial. And you see a large trial, more than 100 patients in each arm of the study, and most of them, they were very potential curative treatment, they could be cured by the treatment. And the only results that were published by these NICE guidelines was the stoma rate. And as expected, the stoma rate was higher in the emergency surgery versus the stenting group. So we look forward to the long-term results of this large trial. The second good indication for colorectal stenting is the palliative, palliative treatment of patients with malignant colorectal obstruction. So patients with stage four disease and obstruction, and you have to offer something to improve the symptoms and offer better quality of life. In the systematic review and meta-analysis, the authors compared to the results of four randomized control trials who compared stenting versus surgery to palliate stage four disease, colorectal cancer. And these four randomized control trials comprised of more than 100 patients. And in terms of mortality, mean survival, length of staying in the ICU, and other complications, there was absolutely no difference between colorectal stenting and surgery. And the authors also observed that hospital stay was shorter and the risk of permanent stoma was lower in the SEMS group. And more important, when we talk about patients with stage four disease, quality of life is our main objective. And in this study, the authors evaluated the impact of the disease on the quality of life of stented patients versus operated patients. And they observed that the impact of the disease on quality of life was lower in the stenting group. As you may see here, the red bars show better quality of life in the stent group. And here, negative impact on quality of life, red bars, stenting group. What you see here, the surgical group, always blue bars showing worst quality of life in all items. So stenting offers a better quality of life. This is the bottom line, stenting offers a better quality of life compared to surgery in patients who needs palliation for obstruction caused by colorectal cancer. So once again, this is a very good indication. Patients in this situation are good candidates for colorectal stenting. Most of colorectal cancers are adenocarcinoma, but sometimes the colorectal structure is caused by extra colonic malignancy. So this paper addressed the issue, this issue of the results of colorectal stenting in this group of patients. So you see more than 180 patients, mostly women with urogenicologic cancer. And in this group, colorectal stenting had a lower technical and clinical success rates. We expected at least 85, 90% of technical success rates and at least 80 to 90% of clinical success rates. So the bottom line here is that colorectal stenting for extra colonic malignancy has not as good results as when we are dealing with patients with colorectal adenocarcinoma. And the authors also found that peritoneal carcinomatosis, excuse me, and multifocal disease were associated with decreased technical and clinical success. In this cohort, the median survival was only 3.3 months. So maybe for these patients, colorectal stenting is the only treatment that can be offered, but be aware that the results are suboptimal compared with patients with obstruction caused by adenocarcinoma. And here is an example of the patient with extra colonic malignancy. So you appreciate in the video, the long stricture. You see the mucosa is normal here, normal. It's edemaciated, there is a perineum, but there is no intraluminal cancer and only a long extrinsic compression. So we have negotiated the stricture with the hydrophilic guidewire, and now we are introducing the stent over the guidewire, always under fluoroscopic control. And now we are deploying the stent, as you may see here, an uncovered stent measuring nine centimeter in length. And here is the final aspect. And you notice the distal border of the stent is here, and there is still some degree of obstruction. So this is not okay. We decide to introduce again the guidewire and introduce a second stent to overlap the first one. So once again, under fluoroscopic and endoscopic control, we introduced the stent, and you may appreciate the deployment of the stent under endoscopic control. And you see after the release, complete release of the stent, you see this gush of fecal material. This is a good sign. And the final aspect of the stented segment with good endoscopic result. Switching gears to use of colorectal stenting for benign colorectal strictures. This paper and these papers, they compare balloon dilatation versus stenting for the treatment of benign colorectal strictures. As you may appreciate here, clinical success rate was similar between the groups and stricture recurrence exactly the same. But duration effect in the balloon group was longer, five years versus only two months for stenting. And as you must introduce fully covered metal stents in this situation, the stent migration rate was not surprisingly very high. So that's why I think that benign stricture is not a good indication for colorectal stenting. When you go to the literature, you're gonna find a lot of small case series using, describing the use of biodegradable stents for restricting Crohn's disease. You're gonna find fully covered metal stents for the treatment of postoperative fistula with high migration rates. So again, I think that this is not a good indication, maybe for very particular situations, you can offer colorectal stenting for benign strictures, but is not a good indication in my opinion. So let's talk a little bit about the technique and post-procedure management. We are talking about a therapeutic procedure. And I think that you all agree that all therapeutic endoscopy procedures should be performed under CO2 insufflation and with the help of anesthesiologists. And here is my checklist, consenting, surgical consultation is very important. I think that all the indications of colorectal stenting should be discussed in a multidisciplinary cancer board. CO2 insufflation, general anesthesia, or at least deep sedation provided by anesthesiologists should be available. Fluoroscopy, a large channel, gasoscope at least 3.2, because the stents, they come in a delivery system that are at least 10 French or 8.5 French. You need hydrophilic guide wire, ERCP catheter, and we make available in the room all the lengths of the stents, six, nine, 12 centimeter uncovered colorectal enteral stents. And contrast is always used. So here are short video on the technique. You may appreciate here the distal border of the cancer, and I'm using a therapeutic gastroscope. I negotiate this fixture with a hydrophilic guide wire, and now I'm advancing the ERCP catheter over the guide wire, pretty much the same when we do stenting in the biliary tree. Now under fluoroscopic view, I inject some contrast, and you appreciate here the stricture and the long segment of dilated bowel. And under fluoroscopic and endoscopic control, we are introducing the stent. You see here the fluoroscopic image, and very easy to pass, introduce the stent over the guide wire. And now you are deploying the stent under fluoroscopic, but mainly under endoscopic guidance. You see here the end of the stent. So I want that the stent to be at least two centimeters distal to the distal border of the tumor. So at least two centimeters of stent below the distal border of the tumor. And so here is the point of no return, and you see the fully deployment of the stent, the stricture, and now injecting some contrast, and you see the cancer is bypassed with the stent. In this editorial by Todd Barron, the author raised the aspect that this is an advanced procedure. The operator should have some training in biliopancreatic endoscopy. There is a learning curve involved, and with a dedicated team, the results are probably better. So in this paper, the authors made very clear that the results are better, the technical success rate is improved after the 11 first cases. So yes, there is a learning curve when you perform colorectal stent. There are predictors of clinical failure for this technique. Complete obstruction, when the length of the obstructed segment is long, probably longer than four centimeter, or is very angulated, the stricture is very angulated, or the patient has more than a week of clinical history. But making clear, these are not contraindications. These are just warning that you're gonna face more difficult cases. This is the bottom line of this slide. And unfortunately, colorectal stenting are not without adverse events. So unfortunately, the patient experiences perforation and re-obstruction in around 5% of the cases, as well as migration in 5% to 10% of the cases, even using uncovered metal stents. My final slides. The first is about post-procedure management. This is very important. Some doctors think that we should use laxatives for these patients. It's exactly the opposite. We don't want to stimulate the contraction. By stimulating the contraction of the bowel, you are increasing the chance of migration and complication. So we soften this tool using enema and offer the patient poor residue diet. And we keep the patient in the hospital for two or three days just to be sure that the picture of acute obstruction has been fully resolved. So this is very important because when the patient comes to our attention with acute obstruction, and you insert with the standard bowel vomiting, you insert the stent, 24 hours later, the patient is eating. So it seems that everything is okay, but that's not the case. There is still a lot of fecal material above the stent. And we have to ease the elimination of this fecal material through the stent. So it's very important to offer enema during the following days, following days after procedure, offer no laxatives and give poor residue diets for these patients. And in two or three days, the patient can be discharged or may be sent to surgery at the same admission. And maybe for the future, we're gonna use bioprinters to create tailored stents that will accommodate better for each patient, for each stricture. So this was my last slide. I thank you for a kind attention and for sure, I'd like to receive your questions and begin a discussion. Thank you very much. Thank you, Professor Malu Filho for this excellent presentation. And now I would like to invite Professor Martins to help facilitate a discussion and help answer any questions from the audience. Professor Martins. Thank you. Thank you. Good morning, everyone. Congratulations for your talk, Professor Maluf, very nice presentation, very clear and you cover all the aspects of the colorectal stenting. I think there's still no questions from the audience. So I'm gonna start asking about some technical details of the procedure. So you point out that you select a 3.2 channel endoscope. You select a 3.2 channel endoscope. Why don't you use a colonoscope? Okay, thank you. Thank you, Dr. Martins for your question, for joining this webinar. So basically because the delivery system is very long. So if you use a colonoscope, you're using a 230 centimeter scope and the delivery system is has, if I'm not wrong, has 240 centimeter in length. So I would say that is a little bit tight to use a colonoscope, but you can use for sure a short colonoscope if you have it available, that would work the same way. But I think that a therapeutic gastroscope is better for this situation. But that poses a problem. Most of the cases you are dealing with obstruction in the left colon or the rectum, proximal rectum. But sometimes in the unfrequent situations we are dealing with lesions in the transverse colon, more proximal lesions. So in these situations, a short colonoscope would work better for these situations. Okay, so- Do you have a problem? Okay. Yeah, we have a problem with the length of the guide wire and the length of the delivery system. When you sum up everything, you lose your guide wire. Yes. Yeah. So the guide, we use biliary guide wires for more than four meters long. And the therapeutic gastroscope is short enough so we don't have problems with the length of the delivery system. Okay, okay. Switching to another topic, what do you think about the optimal time for surgery? So if you have a patient that using surgery stent for as a bridging surgery, how long do you wait until you're sent to the operating room? Thank you for a very good question, once again. I'll say that, as I mentioned before, it's amazing how the patients improve in a short period of time. The patient comes with the standard abdomen vomiting, you insert the stent, you visit the patient and then the following day, the next day and the patient is eating. So it seems that the patient's cured, but that's not the case. So I would say that you need at least two or three days so all the fecal material or most of the fecal material will be evacuated through the stent with the aid of enemas, never laxative enema. And you can then, you have two options. You can look for a synchronic cancer using CD scan and a virtual colonoscopy, or you can also perform colonoscopy in this patient. You wait three to four days for fully expansion of the stent. The stent will be probably fully expanded in three or four days. So you can offer colon prep for this patient and then you can use a pediatric colonoscope and do a full colonoscopy and be sure that there are no other relevant lesions proximal to the main tumor, to the primary tumor. And then after this, the patient is staged. That was staged by colonoscopy, by CD scan, and then the patient can be offered surgery. So taking all together, I would say that five to seven days are an optimal or enough time, enough period to send the patient to surgery. So five to seven days between stenting and surgery. Okay, thank you. We have a question from Selaja Pisipati. Excellent presentation, thank you. In fact, I have a patient currently on the floor with esophageal malignancy, gynecological malignancy with hypertoneal carcinomatosis. We've been caught between colon stent versus surgical diversion for palliation. However, surgeons seem to be hesitant to offer palliative colostomy given the peritoneal carcinomatosis and would like us to pursue colon stenting. Any studies comparing the two modalities in this stenting, in this setting? Sorry, okay. Thank you, Dr. Selaja Pisipati for this very nice question. Yes, there are studies showing they are not randomized control trials, but they are observational studies showing that the surgery, if possible, they have better results compared with colon extent. So if your patient can be operated and the surgeon thinks that there is a loop that can be transformed in a colostomy, I mean, a ostomy is possible in this patient, I think that this patient should be offered a colostomy or any kind of ostomy, if possible. But as I mentioned before, in patients with gynecological malignancy, peritoneal carcinomatosis, sometimes it's impossible to do any kind of surgical treatment. So unfortunately, the only option for this patient is colon extent, and you may expect worst results, poor results compared to the results that we obtain when we deal with adenocarcinoma. Thank you. Okay, another question from the audience, Mois Ahmed. You talk about the optimal timing to send the patient for surgery, but now Mois is asking, how long when you use a stent for bridge to surgery, how long can it be left in place? Okay. Thank you, Dr. Mois Ahmed for your nice question. So if we look at the studies who evaluated patients who received stenting for palliative intention, you can leave the stent for a month, but the longer you leave the stent, the higher the rate of adverse events. So if the patient stay with the stent for three, four, six months, probably there is a higher chance of re-obstruction. So you can leave the stent longer, but probably you are exposing your patient to a higher rate of adverse events. So if you can operate the patients in this timeframe of one to two weeks, I think that's perfect, that's okay. If you cannot operate the patient within this timeframe, okay, you can postpone the surgery, two months, three months, that's okay, no problem, but you're gonna expose the patient to a higher adverse event rate. And you can put the stent, and then when you stage the patient, you discover that the patient has advanced disease, is not a good candidate to surgery. So you have already treated the patient, have at least treated the obstruction, okay? So you leave the stent as the definitive palliative treatment. Thank you. Very nice. Professor Faust, there's still some more questions here, but I'm gonna make one from my own. Getting in line, if you alleviate the obstruction of this patient, and you feel the patient needs chemotherapy in these moments, and it's not the time for surgery, you mentioned before that Bevacizumab is a contraindication, and Bevacizumab, on the other hand, is one of the first lines of the treatment or the first lines of chemotherapy for these patients. How is this discussion? It's absolutely contraindication. It's forbidden to provide the patient with Bevacizumab. Thank you for this kind question. So there is this meta-analysis published in GIE by European group, Janine Van Hoof, Alessandro Repiti, and they show that the Bevacizumab was a risk factor for perforation. So based on this meta-analysis, we try to avoid Bevacizumab in stented patients. But then after this paper, the literature, in the literature, we found several other studies with single center experience showing that that's not the case. For example, there is a study published in 2019 showing the experience of the MD Anderson group, a paper by Jeff Lee and colleagues, and his colleagues at MD Anderson Cancer Institute. So almost 200 patients who are stented, and in this paper, Bevacizumab was not related with increased perforation rate and only 2% of the patients who received Bevacizumab had perforation compared to 3% of the patients who did not receive. So at this point, I would say that if the patient needs chemotherapy before surgery, if you can offer a regimen, a chemotherapy regimen without Bevacizumab, I think it's advisable. But if the best chemotherapy regimen for this patient is Bevacizumab and you are happy with the stent placement, the stent, it was in a good position, technically speaking, was perfect clinical, result was very good, I would say that go for it. So maybe the bottom line here, if the best chemotherapy agent is Bevacizumab for a patient, do it. If you can offer an alternative chemotherapy regimen, chemotherapy regimen, okay, then you should select an alternative regimen. Oh, very clear. Thank you. I didn't know about it. Another anonymous participant asked about the graph comparing the credit of life between patients who had surgery versus stenting. Do you know how those results were measured? Thank you, thank you. Thank you for your question. Yes, they use the famous SF-36 quality of life questionnaire. So, and you know that this questionnaire, they are tailored for different kinds of cancer. So they are, I, sorry, sorry, no. They use the SF-36 and they have also used the EORCT questionnaire, this European questionnaire. And there is versions of the questionnaire for esophageal cancer, gastric cancer, colorectal cancer. So they use it, they employed two different tools, the SF-36 and this EORCT questionnaire, European questionnaire dedicated to cancer. Okay, so two different questionnaires. So what it makes is stronger, it resists stronger. Yes, definitely, definitely, definitely. Stukit Patarajeda, sorry if I missed his name. Is there any tip for SAMS insertion on acute angulated segments? I found that increased risk of failure and perforation. Thank you, Stukit Patarajeda for your kind, for a nice question. And I agree with you, angulated and long strictures, you have, you're gonna experience an increased risk of failure and perforation. And my tip for this situation is to introduce longer stents or even two stents, one overlapping the other. One overlapping the other. Because when you have an angulated segment, if you put a short or a stent that has just a little bit more length than the stricture segment, probably the distal and proximal parts of the stent will be within the angulated segment, increasing the risk of failure and perforation. So for this situation, we should use a longer stent, nine, 12 centimeter if necessary. And if necessary, to overlap two stents. So by doing this, you want to be sure that distal and proximal parts of the stent are away from the angulated segment of the stricture. So my short answer for this is to use longer stents. Okay, Professor Fauzi, maybe there is some kind of new stents with reduced axial force. Maybe it's a good indication in this case to explain a little further. Yeah, yes, that's very good. You're very good information that you provided us with, Dr. Martins. And in this meta-analysis that I mentioned, published in GIE in 2014, the doctors evaluated predictive factors of failure. And they found that Bevacizumab was a predictive factor of perforation. And they also find that not all the stents are the same. So stents with higher radial force, the stents made with platinum, with these stents, you have a higher perforation rate. They are more rigid. So not all the stents are the same. And as you mentioned, Dr. Martins, there are some stents with better accommodation along tortuous strictures. So maybe we should use this nitinol stents with better designs that are tailored to these angulated strictures. So bottom line here, not all the stents are the same. You should look for the stents who are more dedicated to colorectal strictures. Great. Still about choosing the stents, Dr. Ricardo Uemura is asking if there's any trick to choose the length, the length of the stents. Yeah. So basically we use the same rule that we use for esophageal stents, right? You want the stents that be at least two centimeter above and two centimeter below. In the column, we may be more generous with these numbers, with these figures. So as I mentioned before, you have a very angulated long stricture. You want the distal and proximal part be left in a location when there is no angulation. So this is also common when you place duodenal stents, you place a short stent and the distal part becomes in an angulation. If you leave the distal part of the stent within an angulation, in an angulated area, you increase the chance of perforation, you increase the chance of failure of the stent. So this rule of two centimeters above and two centimeters below the stricture is not a definitive rule, it's a flexible rule, right? You can use a longer stent in this situation. And if you leave a stent with the distal part in an angulated area and you did not like, you didn't like the final result, you should put a second stent overlapping the first one. Thank you. Okay. There's another question from Uma Mahesh Rahal. It's a very nice talk, sir. How to manage post-stenting case, not expanding even after three days? Okay. Thank you, Dr. Srinivasa Rappu. Sorry if I didn't pronunciate correctly your name, sorry. But very good question, thank you very much. First, even if we face a tight stricture at the moment of stent deployment, we never dilate the stricture before stenting, never. We never dilate the stricture. So we just put the stent over the guide wire and deliver and deploy the stent. If after three days after stenting, the stent is not fully expanded. So I think that it would be possible to introduce a balloon and dilate very gently this stent. But first you should put the scope and try to understand the reason for this adverse event. Maybe it's not expanded because the distal part was located in an angulated area or because the stent have migrated. And part of the stent or most of the stent is within the stricture. If this is the case, you can put a second stent. But if you notice that the stent is in good position, you have distal part, proximal part that are beyond the limits of the stricture, then you should try to gently dilate the stent, right? And remember that you are talking about 20 millimeter, 18 millimeter diameter stents. So you can use large balloons for this situation, but do it very gently, right? To prevent complications. I don't know if it's the case, but we have some cases here of extra-colonic malignancy in patients with the tumor in the pelvis. And it tends to be harder and more difficult to expand. Maybe that's the case, I don't know. Yes, probably. And you remember the results of that paper showing that the clinical success rates are very reduced in this group of patients. Okay, thank you. We appreciate it. Okay, any more questions from the audience? Thank you again, Professor Maleofilho and Professor Martins for this excellent discussion and then very informative presentation. And again, thank you for being here with us today. Before we close out, any final comments or concluding statements? I'd like to thank ASG, ASG International Committee and you already for this great job. It was a real honor to be with you. I hope it was informative. It was useful for you and your patients. And for sure, I hope you are all health and safe in these pandemic times. And I hope to see you in the future in person in DDW and other meetings. Thank you very much. Thank you, Dr. Bruno Martins for excellent moderation and thanks to all my team at the Institute of Cancer of University of Sao Paulo. Without you, we wouldn't have this experience in colorectal standing. Thank you so much. Thank you so much, Professor Maleofilho. And as a final reminder, please do check ASG's calendar of events as we will continue to feature relevant sessions to our Global Spotlight Series. Our next event is scheduled for Thursday, September 30th, same time. We also will have a webinar in Spanish in September. So that's exciting as well. In closing, obrigado and thank you again, Professor Maleofilho and Professor Martins for this excellent event. And thank you to our audience for making this session interactive. We hope this information has been useful to you and your practice. And with this, we'll conclude our presentation. Thank you. Thank you, bye-bye.

Indications

Patient Selection

Colonic Stenting

ASG Global Spotlight

Professor Fawzi Maluf-Firojo

Professor Bruno Da Costa Martins

Colorectal Stenting

Bridge to Surgery

Palliative Care