Transhepatic insertion of a metallic stent for the relief of malignant afferent loop obstruction

Advanced Endoscopic Techniques for the Diagnosis of Pancreatic Cancer and Management of Biliary and GastricOutlet Obstruction

Following high-quality imaging studies for staging, endoscopic ultrasound examination fine needle aspiration/biopsy is the preferred modality for tissue diagnosis of pancreatic cancer. Endoscopic retrograde cholangiopancreatography with metal stent placement is used for palliation of malignant biliary obstruction. Metal stents can be placed in patients with resectable pancreatic cancer in whom surgery is going to be delayed. For palliation of gastric outlet obstruction, endoscopic enteral stenting is often selected because of its less invasiveness. Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction or gastrojejunostomy for gastric outlet obstruction are emerging less invasive techniques as compared with palliative surgery.

Clinical management for malignant afferent loop obstruction

Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

Transhepatic Approach for Retrograde D2 Duodenal Stent Placement: New Technique and Case Series

Transhepatic duodenal stent placement may be a solution when endoscopy fails or when duodenal and biliary stents are needed simultaneously. This approach is usually not considered as an option when the duodenal stent must be deployed across the ampulla of Vater. The authors present a series of 10 patients who underwent a novel transhepatic technique to place a duodenal stent across the ampulla of Vater by establishing a wire scaffold from the liver toward the jejunum and then curving back on itself retrogradely through the duodenal tumor and out the mouth. Technical success was 90% with no associated mortality.

Enteral stent placement for malignant afferent loop obstruction by the through-the-scope technique using a short-type single-balloon enteroscope

Background and study aims  A short-type single-balloon enteroscope with a 3.2-mm working channel makes it possible to insert an enteral stent by the through-the-scope technique in patients with malignant afferent loop obstruction. Here, we report five cases of malignant afferent loop obstruction treated with endoscopic enteral stenting. We also propose a new classification for three types of malignant afferent loop obstruction. Type 1: The obstruction site is located distal to the papilla or the bilioenteric anastomosis. Type 2: The obstruction site is located at the papilla or the bilioenteric anastomosis. Type 3: The obstruction site is located between the bilioenteric and pancreaticoenteric anastomosis. The patients with type 1 and 3 were simply treated by inserting an enteral stent endoscopically. The patient with type 2 was treated with an endoscopic enteral stent for malignant afferent loop obstruction and with percutaneous transhepatic biliary stenting for malignant biliary obstruction. Although double stenting for type 2 remains a difficult endoscopic procedure, the endoscopic approach has become the standard approach for malignant afferent loop obstruction.

Percutaneous Transhepatic Self-expanding Metallic Stent Placement for the Treatment of Malignant Afferent Loop Obstruction

We report the case of a 71-year-old man with afferent loop obstruction (ALO) after Roux-en-Y reconstruction due to gastric cancer. Computed tomography showed a distended afferent loop and a dilatated bile duct. We could not reach the stricture site in the afferent loop using a gastroscope. We performed percutaneous transhepatic biliary drainage (PTBD) and placed a self-expanding metallic stent (SEMS) in the duodenal stricture through the PTBD route. Although an endoscopic approach is preferable, when PTBD can be performed, percutaneous transhepatic SEMS placement might be an alternative option for treating ALO in cases in which it is not possible to reach the site of stenosis with an endoscope.

Efficacy of Endoscopically Created Bypass Anastomosis in Treatment of Afferent Limb Syndrome: A Single-Center Study

Afferent limb syndrome is a postoperative complication of gastrointestinal surgery, resulting from obstruction of a biliary-enteric limb. Surgery has been the cornerstone of treatment for this condition, but advances in endoscopic and percutaneous techniques could offer less-invasive options. Creation of an internal endoscopic anastomosis between the obstructed afferent limb and an adjacent gastrointestinal lumen can relieve symptoms and might provide a long-term solution. We report the efficacy of endoscopic treatment of afferent limb syndrome using lumen-apposing self-expandable metal stents to create 3 types of enteric anastomoses: a jejunojejunostomy, 2 gastrojejunostomies, and a duodenuojejunostomy in patients who developed afferent limb obstruction following a resection for pancreaticobiliary cancer.

Endoscopic metal enteral stent placement for malignant afferent loop syndrome after pancreaticoduodenectomy

INTRODUCTION

Afferent loop syndrome (ALS) is a rare and dreaded complication after pancreaticoduodenectomy (PD). Malignant ALS after PD is usually difficult to manage due to patients' poor condition. Effective and safe therapeutic strategies for these patients are reported scarcely at present.

AIM

To analyze and evaluate the clinical characteristics and treatment of these patients.

MATERIAL AND METHODS

We analyzed 3 patients with malignant ALS after PD. They were treated by endoscopic enteral metal stent placement in our hospital. Meanwhile we retrospectively reviewed 49 cases with ALS after PD through available English literature. All these patients' clinical features, laboratory study, treatment and outcome were evaluated.

RESULTS

A total of 52 cases were analyzed in the study. The most common presenting symptoms of ALS after PD were jaundice (56.5%), upper abdominal pain (45.7%), fever (26.1%), and vomiting (23.9%). Sixty percent of ALS cases were caused by tumor recurrence. The mean time from prior surgery to diagnosis of ALS was 13.3 months. The rates of treatment with the endoscopic approach, percutaneous stenting or drainage, surgery, and the conservative method were 40.4%, 32.7%, 11.5%, and 15.4%, respectively. Endoscopic enteral metal stent placement proved more effective and less invasive in the treatment of malignant ALS after PD.

CONCLUSIONS

Cholangitis and cholangiectasis are the major manifestations of malignant ALS after PD. Invasive interventions are enjoying more and more acceptance for treatment. Endoscopic enteral metal stent placement appears to be a promising technique with effective palliation in these patients.

Effectiveness of endoscopic self-expandable metal stent placement for afferent loop obstruction caused by pancreatic cancer recurrence after pancreaticoduodenectomy

Afferent loop obstruction caused by cancer recurrence after pancreaticoduodenectomy (PD) can be managed by either surgical or nonsurgical treatment. The general condition of patients with recurrent pancreaticobiliary cancer is often not good enough for them to undergo surgery, so less invasive nonsurgical treatment is desirable. We report a case of a 66-year-old male who had undergone PD for pancreatic head adenocarcinoma 10 months previously and who presented at our hospital with fever and jaundice due to afferent loop obstruction caused by pancreatic cancer recurrence. An endoscopic self-expandable metal stent (SEMS) was placed for afferent loop obstruction without any complications. He quickly recovered after SEMS placement. He retained a good quality of life by receiving chemotherapy until his death due to cancer progression. Our case indicates that this method could be an easy, effective, safe, and less invasive treatment, which may confer a better quality of life for patients with afferent loop obstruction due to cancer recurrence after PD.

An assessment of radiologically inserted transoral and transgastric gastroduodenal stents to treat malignant gastric outlet obstruction

INTRODUCTION

Self-expanding metallic stents (SEMS) are used to palliate malignant gastric outlet obstruction (GOO) and are useful in patients with limited life expectancy or severe medical comorbidity, which would preclude surgery. Stenting can be performed transorally or by a percutaneous transgastric technique. Our goal was to review the outcome of patients who underwent radiological SEMS insertion performed by a single consultant interventional radiologist.

METHODS

Patients were identified from a prospectively collected database held by one consultant radiologist. Data were retrieved from radiological reports, multidisciplinary team meetings, and the patients' case notes. Univariate survival analysis was performed.

RESULTS

Between December 2000 and January 2011, 100 patients (63 males, 37 females) had 110 gastroduodenal stenting procedures. Median age was 73 (range 39-89) years. SEMS were inserted transorally (n = 66) or transgastrically (n = 44). Site of obstruction was the stomach (n = 37), duodenum (n = 50), gastric pull-up (n = 10), or gastroenterostomy (n = 13). Seven patients required biliary stents. Technical success was 86.4 %: 83.3 % for transoral insertion, 90.9 % for transgastric insertion. Eleven patients developed complications. Median GOO severity score: 1 pre-stenting, 2 post-stenting (p = 0.0001). Median survival was 54 (range 1-624) days. Post-stenting GOO severity score was predictive of survival (p = 0.0001).

CONCLUSIONS

The technical success rate for insertion of palliative SEMS is high. Insertional technique can be tailored to the individual depending on the location of the tumor and whether it is possible to access the stomach percutaneously. Patients who have successful stenting and return to eating a soft/normal diet have a statistically significant increase in survival.

Mid-gut stents

PURPOSE OF REVIEW

Gastrointestinal stents offer a feasible, safe, cost effective, and minimally invasive method for reestablishing luminal patency. Previous clinical reports and systematic reviews have demonstrated the role of enteral stents in both the upper and lower gastrointestinal tract. Over the last two decades, the rapid development of deep enteroscopy in concert with the evolution of various stent devices/deployment mechanisms has enabled placement of enteral stents in the mid-gut; hence this has been increasingly reported. The present article focuses on stenting in the mid-gut, a relatively novel term, referring to the small bowel between the ampulla and the ileocecal valve.

RECENT FINDINGS

Mid-gut stenting is technically more difficult than stenting in the upper and lower gastrointestinal tract, and therefore requires particular expertise, restricting its widespread utility. In total, 86 reported cases involving mid-gut stent deployment, by either endoscopic approaches (80.2%) or percutaneous approaches (19.8%), have been published. Although limited, these results have demonstrated that mid-gut stenting is reliable, effective, and a minimally invasive method for palliating malignant obstruction, as well as sealing leaks and fistulae.

SUMMARY

This article reviews the current status of mid-gut stenting, including endoscopic technique. The article also speculates about the potential for future advances within this field.

Percutaneous transhepatic metallic stent insertion for malignant afferent loop obstruction following pancreaticoduodenectomy: a case report

INTRODUCTION

Malignant afferent loop obstruction following pancreaticoduodenectomy is a rare complication and may be fatal if suppurative cholangitis or obstructive jaundice develops. Effective and safe therapeutic strategies for malignant afferent loop obstruction following pancreaticoduodenectomy are scarce at present.

CASE PRESENTATION

A 51-year-old Japanese man underwent pancreaticoduodenectomy for carcinoma of the papilla of Vater. Seven months postoperatively, he developed a high-grade fever, jaundice, and right upper abdominal pain. Abdominal contrast-enhanced computed tomography showed afferent loop obstruction and intrahepatic bile duct dilatation due to nodal recurrence. Percutaneous transhepatic biliary drainage was performed, and a self-expanding metallic stent (WallFlex™ duodenal stent) was placed across the stricture using the transhepatic route.

CONCLUSIONS

There are surgical and nonsurgical treatments for malignant afferent loop obstruction following pancreaticoduodenectomy. Nonsurgical treatments include either an endoscopic or percutaneous approach to the afferent loop. Of these methods, percutaneous transhepatic insertion of a self-expanding metallic stent is the preferred treatment for malignant afferent loop obstruction following pancreaticoduodenectomy because it is more prompt and less invasive.

Afferent limb syndrome and delayed GI problems after pancreaticoduodenectomy for pancreatic cancer: single-center, 14-year experience

BACKGROUND

There are limited data on the incidence of afferent limb syndrome and other delayed GI problems in pancreatic cancer (PaC) patients, especially among long-term survivors (>2 years).

OBJECTIVE

To evaluate the incidence of afferent limb syndrome (chronic afferent limb obstruction resulting in pancreatobiliary obstruction) and delayed GI problems in PaC patients after pancreaticoduodenectomy (PD).

DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

PATIENTS

PaC patients treated with PD (N = 186) over a 14-year period (January 1995-October 2009).

INTERVENTIONS

Endoscopic balloon dilation and stent placement, percutaneous biliary drainage.

MAIN OUTCOME MEASUREMENTS

Incidence of afferent limb syndrome and delayed GI complications (marginal ulcers, radiation enteropathy, anastomotic strictures).

RESULTS

Mean age was 63 ± 10 years; 55% of patients were male. Afferent limb syndrome was noted in 24 patients (13%). Median time to diagnosis was 1.2 years (range 0.03-12.3 years); obstruction was primarily caused by recurrent PaC (8 patients, 33%) and radiation enteropathy (9 patients, 38%). Afferent limb syndrome was more likely to develop in patients with 2 years or longer of follow-up (n = 71, [38%]) compared with patients with 2 years or less of follow-up, after controlling for age, sex, surgery type, and adjuvant treatment (adjusted odds ratio, 4.5; 95% CI, 1.8-11.7). Other delayed GI problems included radiation enteropathy (6%), marginal ulcers (5%), anastomotic strictures (4%), cholangitis/liver abscesses (5%), and GI bleeding (6%).

LIMITATIONS

Retrospective, single-center study.

CONCLUSIONS

GI problems, including afferent limb syndrome, are relatively common in PaC patients after surgery and adjuvant therapy. Clinicians should recognize and effectively treat these delayed GI problems, especially in long-term survivors.

Gastroduodenal stenting

Palliative procedures for patients with malignant gastroduodenal obstruction must be readily available, have a rapid onset of action, and be well tolerated by a patient with terminal cancer. Laparoscopic gastroenterostomy and insertion of self-expanding stents are emerging as the current methods of choice.An increasing number of dedicated enteral stents with different properties are now available. These can be placed under fluoroscopic guidance alone or with the help of an endoscope. Endoscopic placement has several advantages but requires good collaboration between the endoscopists and the radiology department. Appropriate imaging and work-up of each case at multidisciplinary meetings is required. Coexisting biliary obstruction may be dealt with endoscopically, but frequently requires percutaneous biliary stent placement prior to duodenal stenting. Reintervention is required in up to 25% of patients, usually due to stent occlusion by further tumor growth. This article suggests strategies for patient assessment, procedure planning, and stent insertion.

Obstructive jaundice after bilioenteric anastomosis: transhepatic and direct percutaneous enteral stent insertion for afferent loop occlusion

Recurrent tumour after radical pancreaticoduodenectomy may cause obstruction of the small bowel loop draining the liver. Roux-loop obstruction presents a particular therapeutic challenge, since the postsurgical anatomy usually prevents endoscopic access. Careful multidisciplinary discussion and multimodality preprocedure imaging are essential to accurately demonstrate the cause and anatomical location of the obstruction. Transhepatic or direct percutaneous stent placement should be possible in most cases, thereby avoiding long-term external biliary drainage. Gastropexy T-fasteners will secure the percutaneous access and reduce the risk of bile leakage. The static bile is invariably contaminated by gut bacteria, and systemic sepsis is to be expected. Enteral stents are preferable to biliary stents, and compound covered stents in a sandwich construction are likely to give the best long-term results. Transhepatic and direct percutaneous enteral stent insertion after jejunopexy is illustrated and the literature reviewed.

Stenting of the upper gastrointestinal tract: current status

Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

Percutaneous transhepatic placement of covered, self-expandable nitinol stent for the relief of afferent loop syndrome: report of two cases

The author reports successful outcomes after percutaneous transhepatic placement of covered, self-expandable nitinol stents in two patients who had afferent loop syndrome caused by recurrent gastric carcinoma. A 46-year-old woman and a 60-year-old man who had undergone subtotal gastrectomy and gastrojejunostomy (Billroth II) were both admitted with symptoms of afferent loop syndrome. In each patient, enhanced abdominal computed tomography showed marked dilation of the jejunal limb and intrahepatic bile ducts incident to recurrent gastric carcinoma. Percutaneous transhepatic biliary drainage was successfully performed, and a multi-sidehole drainage catheter was placed beyond the papilla of Vater. Successful palliation of the afferent loop obstruction was achieved by placing a covered, self-expandable nitinol stent through the transhepatic biliary drainage route. There were no procedure-related complications, and both patients showed clinical improvement.

Percutaneous jejunostomy and stent placement for treatment of malignant Roux-en-Y obstruction: a case report

Nineteen months after a Whipple procedure for pancreatic carcinoma, a 79-year-old woman developed recurrent tumoral strictures of the bile ducts and afferent Roux-en-Y limb with resultant jaundice, cholangitis, and liver abscess. Transhepatic abscess and biliary drainages were performed first. Afferent loop obstruction was too far from biliary anastomosis to be crossed via the transhepatic route. Percutaneous jejunostomy and stenting were performed to relieve the malignant afferent loop syndrome. After initial relief of symptoms, jaundice recurred in relation to peritoneal carcinomatosis progression and was treated with percutaneous jejunostomy drainage until patient's death. Therapeutic options of tumoral occlusion of afferent loops are reviewed.

Malignant afferent loop obstruction following pancreaticoduodenectomy: report of two cases

We report two cases of malignant afferent loop obstruction following pancreaticoduodenectomy (PD). Case 1. A 70-year-old woman, who had undergone PD for pancreatic cancer, was referred to our hospital because of fever, jaundice, and abdominal pain. Ultrasonography and abdominal computed tomography demonstrated dilatation of a small bowel loop in the right upper quadrant. Laparotomy confirmed the diagnosis of local recurrent tumor causing occlusion of the afferent limb, and Roux-en-Y bypass was performed. Case 2. A 72-year-old man, who had undergone PD for cancer of the major papilla, was hospitalized with a high-grade fever and epigastric pain. Ultrasonography and abdominal computed tomography revealed a dilated afferent loop and multiple masses in liver. At laparotomy, widespread carcinomatosis was found to have caused afferent loop obstruction, and surgical bypass was performed. In conclusion, the surgical bypass seems to be an effective palliative treatment for afferent loop syndrome after PD.

Self-Expanding Metal Stents in Gastrointestinal Interventional Radiology: Technical Problems

Aims and background

To analyze the procedural difficulties in the placement of metal stents in stenoses of the digestive tract and optimize the technique.

Methods

Twenty-nine patients with digestive tract stenoses were treated from January 1999 to December 2004. In 14 cases the stricture was anastomotic (9 colorectal, 3 esophageal, 1 gastroesophageal and 1 gastrojejunal), in 13 esophageal, in 1 gastric and in 1 duodenal. The stenosis was due to scarring in 5 patients and was malignant in 24 patients (primary in 17 cases and secondary in 7 cases).

Results

The procedure achieved technical success in all cases but 2. For each of the different segments the technical difficulties and the adopted procedural solutions were analyzed.

Conclusions

The interventional radiology approach yielded results comparable to those reported for the endoscopic method and was always well tolerated. The need to rely on materials mostly designed for endoscopic use can make radiological use difficult in some cases.

Balloon sheaths for gastrointestinal guidance and access: a preliminary phantom study

Objective

We wanted to evaluate the feasibility and usefulness of a newly designed balloon sheath for gastrointestinal guidance and access by conducting a phantom study.

Materials and Methods

The newly designed balloon sheath consisted of an introducer sheath and a supporting balloon. A coil catheter was advanced over a guide wire into two gastroduodenal phantoms (one was with stricture and one was without stricture); group I was without a balloon sheath, group ll was with a deflated balloon sheath, and groups III and IV were with an inflated balloon and with the balloon in the fundus and body, respectively. Each test was performed for 2 minutes and it was repeated 10 times in each group by two researchers, and the positions reached by the catheter tip were recorded.

Results

Both researchers had better performances with both phantoms in order of group IV, III, II and I. In group IV, both researchers advanced the catheter tip through the fourth duodenal segment in both the phantoms. In group I, however, the catheter tip never reached the third duodenal segment in both the phantoms by both the researchers. The numeric values for the four study groups were significantly different for both the phantoms (p < 0.001). A significant difference was also found between group III and IV for both phantoms (p < 0.001).

Conclusion

The balloon sheath seems to be feasible for clinical use, and it has good clinical potential for gastrointestinal guidance and access, particularly when the inflated balloon is placed in the gastric body.

HDR-192Ir intraluminal brachytherapy in treatment of malignant obstructive jaundice

AIM: To determine the feasibility and safety of intraluminal brachytherapy in treatment of malignant obstructive jaundice (MOJ) and to evaluate the clinical effect of intraluminal brachytherapy on stent patency and patient survival.

METHODS: Thirty-four patients with MOJ were included in this study. Having biliary stent placed, all patients were classified into intraluminal brachytherapy group (group A, n = 14) and control group (group B, n = 20) according to their own choice. Intraluminal brachytherapy regimen included: HDR-¹⁹²Ir was used in the therapy, fractional doses of 4-7 Gy were given every 3-6 d for 3-4 times, and standard points were established at 0.5-1.0 cm. Some patients of both groups received transcatheter arterial chemoembolization (TACE) after stent placement.

RESULTS: In group A, the success rate of intraluminal brachytherapy was 98.0%, RTOG grade 1 acute radiation morbidity occurred in 3 patients, RTOG/EORTC grade 1 late radiation morbidity occurred in 1 patient. Mean stent patency of group A (12.6 mo) was significantly longer than that of group B (8.3 mo) (P < 0.05). There was no significant difference in the mean survival (9.4 mo vs 6.0 mo) between the two groups.

CONCLUSION: HDR-¹⁹²Ir intraluminal brachytherapy is a safe palliative therapy in treating MOJ, and it may prolong stent patency and has the potentiality of extending survival of patients with MOJ.

Gastroduodenal Stent Placement: Current Status

Gastroduodenal obstruction is a preterminal event in patients with advanced malignancies of the stomach, pancreas, and duodenum. It severely limits the quality of life in affected patients due to constant emesis and associated malnutrition. Surgical gastrojejunostomy has been the traditional palliative treatment but is associated with a high complication rate, and delayed gastric emptying is a frequent problem. Gastroduodenal stent placement is a very safe and effective palliation method in patients with unresectable malignant tumors causing gastric outlet obstruction, with adequate palliation obtained in most cases. The procedure can be performed under fluoroscopic guidance or with a combination of fluoroscopic and endoscopic techniques. Advantages of gastroduodenal stent placement over surgical palliation include suitability as an outpatient procedure, more rapid gastric emptying, greater cost effectiveness, fewer complications, and improved quality of life. Covered duodenal stents are currently being evaluated and may play an increasingly important role in preventing recurrent obstruction secondary to tumor ingrowth. Moreover, simultaneous palliation of biliary and duodenal malignant strictures is possible with the use of metallic stents. Gastroduodenal stent placement is a promising new alternative for the palliation of malignant gastroduodenal obstruction.

Transhepatic contemporary palliation of biliary and duodenal stenoses by means of metallic stents

We describe the treatment of a stenosing lesion of the horizontal duodenum by means of a large-bore metallic stent inserted percutaneously in a patient with transhepatic biliary drainage. In the same session, we used an expandable metallic stent in the biliary tree to relieve jaundice. We recommend the transhepatic approach for duodenal metallic stent insertion in patients with percutaneous biliary drainage.

Palliative percutaneous tube enterostomy in afferent-loop syndrome presenting as jaundice: clinical effectiveness

The purpose of this study was to investigate the clinical effectiveness of percutaneous tube enterostomy in afferent loop syndrome presenting as jaundice. Tube enterostomy was successfully performed in seven patients without procedural complications. The serum bilirubin level normalized in five patients but remained elevated in the other two, presumably related to more proximal bile duct obstruction. Percutaneous tube enterostomy is an effective palliative treatment in afferent loop syndrome presenting as an obstructing jaundice. However, coexisting biliary obstruction might be problematic for relieving jaundice with tube enterostomy.

Non-surgical treatment for afferent loop syndrome in recurrent gastric cancer complicated by peritoneal carcinomatosis: percutaneous transhepatic duodenal drainage followed by 24-hour infusion of high-dose fluorouracil and leucovorin

Afferent loop syndrome (ALS) is a debilitating complication of recurrent gastric cancer. Surgical intervention is usually not feasible in the face of poor general performance, presence of advanced peritoneal carcinomatosis and limited survival of the patients. Non-surgical approaches include internal drainage by stenting at the stenotic or anastomotic site and external drainage via the percutaneous routes. Percutaneous transhepatic duodenal drainage (PTDD) has been shown to provide effective palliation for ALS, but long-term catheterization is usually inevitable. We hereby present two cases of recurrent gastric cancer whose ALS was successfully treated with PTDD followed by weekly 24-h infusion of high-dose 5-fluorouracil and leucovorin (HDFL). PTDD rapidly ameliorated the incapacitating symptoms of ALS, and the effective, low-toxicity chemotherapy subsequently led to tumor regression, restoration of bowel patency and removal of the drainage tube. At present, both patients have remained ALS-free and drainage-free for 16 and 17 months, respectively. Our results indicate that this non-surgical approach with PTDD followed by weekly HDFL could serve as a safe and effective treatment for ALS in recurrent gastric cancer complicated by peritoneal carcinomatosis.

Use of stents in the palliative treatment of malignant gastric outlet and duodenal obstruction

AIM

To evaluate the efficacy of stenting in the palliation of malignant duodenal and gastric outlet obstruction.

MATERIALS AND METHODS

We retrospectively reviewed our series of patients who underwent stenting for malignant upper gastrointestinal obstruction between March 1998 and December 1999. From January 2000 data have been acquired prospectively. Our series comprises 21 stents successfully deployed in 15 patients.

RESULTS

The technical and clinical success was 93% (14/15 patients). One patient required endoscopic negotiation of recurrent gastric carcinoma at the gastrojejunostomy site after failure to cross the lesion fluroscopically. Two patients required re-intervention 2 and 5 weeks after initial stent placement, for migration and ingrowth respectively. Eighteen stents were placed transorally, two stents transhepatically and one via a transgastric approach. Early complications (pain < 3 days) occurred in two patients (13%) and late complications (ingrowth, overgrowth and migration) occurred in three patients (20%). The median survival was 2.4 months (range 2-4 months).

CONCLUSION

Stenting provides a less invasive palliative option than surgery with the advantage of lower morbidity and complication rates. It has the advantage of high technical and clinical success rates facilitated by alternative routes of access into the upper gastrointestinal tract via transgastric and transhepatic routes in addition to the traditional peroral route.

Use of metallic stents and balloons in the esophagus and gastrointestinal tract

The majority of malignant and benign strictures in the esophagus and GI tract can be treated with use of minimally invasive alternatives to surgery such as balloon dilation or metallic stents. Virtually any obstructing lesion in the esophagus, stomach, duodenum, colon, and rectum can be treated with these methods with use of interventional radiologic or endoscopic techniques. In general, metallic stents are reserved for malignant strictures and balloon dilation is indicated for benign lesions. Patients with malignant esophageal fistulas and perforations can be palliated effectively and promptly by sealing the fistula or leak by deployment of a covered stent. Patients with malignant disease may benefit from a treatment regime that includes metallic stent placement, chemotherapy, radiation therapy and/or brachytherapy, although the efficacy of such combined therapies has yet to be defined. Further refinements to stent design are required. The ideal stent would be resistant to tumor ingrowth and migration. Placing a coating material on uncovered stents to prevent tumor ingrowth may achieve these aims. Finally, a biodegradable stent that dissolves before the development of intimal hyperplasia might enable stents to be used to treat benign strictures.

The transhepatic route for the placement of a duodenojejunal stent: application in a postoperative closed loop obstruction of the duodenum

A patient who had undergone gastric resection for carcinoma, had closed loop obstruction of the duodenum due to neoplasia at the duodenojejunal junction. The obstruction was relieved successfully by transhepatic placement of a duodenojejunal stent. We were compelled to use the transhepatic route because a Roux-Y reconstruction had been performed. Transhepatic placement may be the only chance of palliation in a small subset of patients with malignant intestinal obstruction.