Covered versus uncovered self-expandable metallic stents for palliation of malignant pyloric obstruction in gastric cancer patients: a randomized, prospective study

Maximizing oral intake tolerance in malignant gastric outlet obstruction - a Markov decision tree analysis comparing duodenal stenting, endoscopic ultrasound-guided gastroenterostomy and surgical gastrojejunostomy based on a meta-analysis of randomized controlled trials

INTRODUCTION

Malignant gastric outlet obstruction (GOO) has a significant impact on quality of life. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has shown promising results. Traditional isolated outcome measures do not sufficiently address critical considerations for end-of-life patients like oral intake tolerance. This study aimed to determine via a probabilistic approach, the optimal management strategy for GOO patients that maximizes their oral intake tolerance.

METHODS

A Markov decision model was developed, with input variables based on a systematic review and meta-analysis of randomized controlled trials (RCT) comparing duodenal stenting (DS), EUS-GE and surgical gastrojejunostomy (GJ). A prospective cohort study with a comparator group was also included for EUS-GE model given the scarcity of RCTs. Model assumption was a patient with malignant GOO, with equal probabilities of being allocated to 1 of 3 treatment options. Each data point was evaluated using pooled probabilities from the meta-analysis of clinical outcomes. Primary outcome was successful oral intake tolerance at various time points of 1-6 months post-intervention.

RESULTS

Fifteen studies were included into the Markov model. Based on 10 000 simulations in each arm, at a survival of 1-month, DS and EUS-GE had the highest likelihood of oral intake (81.2% and 80.4%) compared to GJ (75.5%). However, at a survival of 6-month, EUS-GE and GJ were better at palliating GOO, with likelihood of oral intake at 23.8% and 25.2%, compared to 21.3% for DS.

CONCLUSION

For patients with a prognosis of more than 1-month, a surgical GJ, or EUS-GE if technical expertise is available, is preferred for GOO palliation.

A national perspective on palliative interventions for malignant gastric outlet obstruction

BACKGROUND

Of note, 15% to 20% of patients with duodenal or periampullary malignancies develop gastric outlet obstruction (GOO). Although small randomized trials have reported more rapid recovery and shorter hospital stay with endoscopic stenting (ES), limited studies have evaluated outcomes at a national level. The current study characterized short-term clinical and financial outcomes associated with gastrojejunostomy (GJ) vs ES in malignant GOO.

METHODS

Adults with malignant GOO treated with ES or GJ were identified in the 2016-2020 Nationwide Readmissions Database. Entropy balancing was used to balance covariates between groups, and multivariate regression was used to evaluate the association between GJ or ES and in-hospital mortality, total parenteral nutrition (TPN) use, complications, length of stay (LOS), costs, and 90-day readmission.

RESULTS

Of 8186 patients with GOO, 5603 (68.4%) underwent ES, and 2583 (31.6%) underwent GJ. The cohorts were similar in age, female/male sex, and comorbidities. However, patients who underwent GJ were more commonly frail. After risk adjustment, mortality, composite complications, and 90-day readmission were comparable between patients who underwent GJ and those who underwent ES. GJ was associated with greater odds of blood transfusion (adjusted odds ratio [AOR], 1.74; 95% CI, 1.37-2.21) and postoperative TPN use (AOR, 3.76; 95% CI, 2.64-5.35). Furthermore, patients who underwent GJ experienced a significant increment of >$15,800 in costs and >6.9 days in LOS. In subgroup analysis of patients with metastatic disease, mortality, complications, and readmission remained comparable among palliation strategies.

CONCLUSION

ES seems to yield comparable short-term morbidity and mortality relative to GJ with significant cost reduction. Increasing access to endoscopic technology and regionalizing care to high-volume centers may help improve outcomes for patients with malignant GOO.

Manufacturing, Processing, and Characterization of Self-Expanding Metallic Stents: A Comprehensive Review

This paper aims to review the State of the Art in metal self-expanding stents made from nitinol (NiTi), showing shape memory and superelastic behaviors, to identify the challenges and the opportunities for improving patient outcomes. A significant contribution of this paper is its extensive coverage of multidisciplinary aspects, including design, simulation, materials development, manufacturing, bio/hemocompatibility, biomechanics, biomimicry, patency, and testing methodologies. Additionally, the paper offers in-depth insights into the latest practices and emerging trends, with a special emphasis on the transformative potential of additive manufacturing techniques in the development of metal stents. By consolidating existing knowledge and highlighting areas for future innovation, this review provides a valuable roadmap for advancing nitinol stents.

Endoscopic stenting for malignant gastric outlet obstruction: focusing on comparison of endoscopic stenting and surgical gastrojejunostomy

Malignant gastric outlet obstruction (GOO) is a condition characterized by blockage or narrowing where the stomach empties its contents into the small intestine due to primary malignant tumors or metastatic diseases. This condition leads to various symptoms such as nausea, vomiting, abdominal pain, and weight loss. To manage malignant GOO, different treatment options have been employed, including surgical gastrojejunostomy (SGJ), gastroduodenal stenting (GDS) using self-expandable metallic stent (SEMS), and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ). This review focuses on comparing the clinical outcomes of endoscopic stenting (GDS and EUS-GJ) with SGJ for malignant GOO. Studies have shown that GDS with SEMS provides comparable clinical outcomes and safety for the palliation of obstructive symptoms. The choice between covered and uncovered SEMS remains controversial, as different studies have reported varying results. EUS-GJ, performed via endoscopic ultrasound guidance, has shown promising efficacy and safety in managing malignant GOO, but further studies are needed to establish it as the primary treatment option. Comparative analyses suggest that GDS has higher recurrence and reintervention rates compared to EUS-GJ and SGJ, with similar overall procedural complications. However, bleeding rates were lower with GDS than with SGJ. Randomized controlled trials are required to determine the optimal treatment approach for malignant GOO.

Efficacy of hemostasis by gastroduodenal covered metal stent placement for hemorrhagic duodenal stenosis due to pancreatobiliary cancer invasion: a retrospective study

BACKGROUND/AIMS

Advanced pancreatic and biliary tract cancers can invade the duodenum and cause duodenal hemorrhagic stenosis. This study aimed to evaluate the efficacy of covered self-expandable metal stents in the treatment of cancer-related duodenal hemorrhage with stenosis.

METHODS

Between January 2014 and December 2016, metal stents were placed in 51 patients with duodenal stenosis. Among these patients, a self-expandable covered metal stent was endoscopically placed in 10 patients with hemorrhagic duodenal stenosis caused by pancreatobiliary cancer progression. We retrospectively analyzed the therapeutic efficacy of the stents by evaluating the technical and clinical success rates based on successful stent placement, degree of oral intake, hemostasis, stent patency, and overall survival.

RESULTS

The technical and clinical success rates were 100%. All 10 patients achieved a gastric outlet obstruction scoring system score of three within two weeks after the procedure and had no recurrence of melena. The median stent patency duration and overall survival after stent placement were 52 days (range, 20-220 days) and 66.5 days (range, 31-220 days), respectively.

CONCLUSIONS

Endoscopic placement of a covered metal stent for hemorrhagic duodenal stenosis associated with pancreatic or biliary tract cancer resulted in duodenal hemostasis, recanalization, and improved quality of life.

Laparoscopic Gastrojejunostomy Versus Endoscopic Stenting as a Palliative Treatment for Gastric Outlet Obstruction

Introduction: Gastric outlet obstruction (GOO) is a common complication in advanced stage upper gastrointestinal malignancies. The symptoms of severe nausea and protracted vomiting can lead to a decline in quality of life and cachexia. Symptoms of GOO can be effectively managed with either operative or nonoperative palliative interventions. In our article, we aim to compare laparoscopic gastrojejunostomy (GJ) to endoscopic stenting as palliative interventions for GOO. Methods: We retrospectively evaluated the charts of patients who underwent palliative procedure for gastric outlet obstruction. Group I included patients who underwent endoscopic stenting, and group II patients underwent Laparoscopic GJ. The groups' demographics (age, gender), length of procedure, length of stay, days to oral intake, overall survival, complications rate, and 30-day mortality rates were compared. Results: Overall, 38 patients were included in the study. Nineteen patients underwent endoscopic stenting and 19 underwent laparoscopic GJ. Comparing the groups, no significant differences were noted. Surgical time was significantly longer than the endoscopic procedures (83 minutes versus 25 minutes, P = .001). No significant differences were noted in days of oral intake initiation, overall survival and 30-day mortality rates. Five patients in the stenting group had complications (26.3%) versus none in the surgical group (P = .046). No postoperative complications were noted. Conclusion: Laparoscopic GJ is a safe and feasible treatment for GOO, demonstrating early resumption of oral intake. The relative short hospital stay, combined with an encouraging postoperative complications profile and low reintervention rate, should be kept in mind especially among patients with longer life expectancy.

Clinical outcomes of different types of metallic stents in malignant distal duodenum stenosis: A retrospective study

BACKGROUND/PURPOSE

Endoscopic stenting at malignant distal duodenum stenosis (MDDS) is challenging because of the duodenal C-loop configuration, the acute angle of the duodenojejunal junction, and the limited length of the endoscope. Few studies have investigated the clinical outcomes of stenting at the distal duodenum. Therefore, this study aimed to investigate the clinical outcomes of treating MDDS with different types of metallic stents.

METHODS

From January 2012 to December 2020, fifty-six patients with MDDS who underwent duodenal stenting were enrolled for analysis. Thirty-five patients received uncovered self-expandable metallic stents (UC-SEMS), and twenty-one patients received partially covered self-expandable metallic stents (PC-SEMS). All patients were followed up till death or for 18 months. The clinical success rate, stent dysfunction rate, and stent patency were compared between the groups. Multivariate analysis was conducted to identify factors related to stent dysfunction.

RESULTS

The clinical success rates were 85.7 % in both the UC-SEMS and PC-SEMS groups. Stent dysfunction rates (UC-SEMS: 34.3 %, PC-SEMS: 38.1 %, p = 0.773) and the average stent patency (UC-SEMS: 117.2 days, PC-SEMS: 100.0 days, p = 0.576) were not statistically different between the groups. Multivariate analysis disclosed the age ≥65 years was significantly related to stent dysfunction (odds ratio: 4.78, p = 0.031).

CONCLUSION

Both UC-SEMS and PC-SEMS are safe and effective treatment options for MDDS. However, stent dysfunction remains a significant issue to overcome, particularly in the elderly. Further research is needed to explore novel strategies that can improve the effectiveness of stent placement and reduce the risk of stent dysfunction.

Partially covered versus uncovered pyloro-duodenal stents for unresectable malignant gastric outlet obstruction: Randomized controlled study

OBJECTIVES

The aim of the current study was to compare the efficacy of partially covered duodenal stent (PCDS) vs. uncovered duodenal stent (UCDS) in patients suffering from unresectable primary malignant gastric outlet obstruction (GOO).

METHODS

This was a prospective international randomized controlled study conducted in 10 high-volume institutions. Consecutive patients suffering from malignant GOO were recruited. The primary outcome measurement was the reintervention rate. Secondary outcomes included technical and clinical success, 30-day adverse events, 30-day mortality, causes of stent dysfunction, and the duration of stent patency.

RESULTS

Between March 2017 and October 2020, 115 patients (59 PCDS, 56 UCDS) were recruited. The 1-year reintervention was not significantly different (PCDS vs. UDCS = 12/59, 20.3% vs. 14/56, 25%, P = 0.84). There was a trend to fewer patients with tumor ingrowth in the PCDS group (6/59 [10.2%]) vs. 13/56 [23.2%], P = 0.07). There were no significant differences in the technical success (100% vs. 100%, P = 1), clinical success (91.5% vs. 98.2%, P = 0.21), procedural time (21.5 [interquartile range [IQR] 17-30] vs. 20.0 [IQR 15-34.75], P = 0.62), hospital stay (4 [IQR 3-12] vs. 5 [IQR 3-8] days, P = 0.81), 30-day adverse events (18.6% vs. 14.3%, P = 0.62), or 30-day mortality (6.8% vs. 5.2%, P = 1.00).

CONCLUSION

The use of PCDS was associated with a lower risk of tumor ingrowth but did not improve on reintervention rates or stent patency. Both kinds of stents could be used in this group of patients.

Efficacy and safety of self-expandable metal stent placement for treatment of primary and metastatic gastric outlet obstruction

BACKGROUND AND GOALS: Gastric outlet obstruction (GOO) usually occurs at the pylorus or the duodenum through primary gastric, duodenal, or pancreatic tumors. However, metastatic GOO is relatively rare. Although self-expandable metal stent (SEMS) placement is often performed as an alternative and practical palliative approach for primary GOO, there are few reports of metastatic GOO treatment with SEMS. This study aimed to investigate the efficacy, safety, stent patency, and complications of SEMS for treating primary and metastatic GOO.

METHODS

The data of 42 patients with GOO who received SEMS from November 2016 to April 2022 were reviewed retrospectively. Patients were divided into primary group (n = 25) and metastatic group (n = 17) according to the cause of GOO. The rates of technical and clinical success, stent patency, and complications were compared between the two groups.

RESULTS

The overall technical and clinical success rates were 97.9% and 93.5%, respectively. The total SEMS implantation time was 48.2 ± 33.5 (10.0-140.0) minutes. The primary technical success rate was 100.0% in both primary and metastatic groups, and the primary clinical success rate was 96.0% (24/25) in the primary group vs 88.2% (15/17) in the metastatic group (P = 0.350). After reintervention, the secondary technical success rate was 100.0% (27/27) in the primary group vs 95.0% (19/20) in the metastatic group (P = 0.330); and the secondary clinical success rate was 96.3% (26/27) in the primary group vs 89.5% (17/19) in the metastatic group (P = 0.367). No serious complications, such as gastrointestinal perforation, stent migration, bleeding, or aspiration pneumonia, were observed in these patients.

CONCLUSIONS

SEMS under fluoroscopic guidance is an effective and safe treatment for primary and metastatic GOO. The etiology of obstruction did not influence stent patency or complications. Therefore, stent implantation is recommended for patients with metastatic GOO caused by multiple peritoneal metastases to improve their quality of life.

Feasibility and safety of inserting transient biodegradable stents in the pylorus during pylorus-preserving gastrectomy for gastric cancer: a preliminary study in a porcine for proof of concept

BACKGROUND

To evaluate whether insertion of self-biodegradable stent into the pylorus to prevent delayed-gastric emptying after pylorus-preserving gastrectomy is feasible and safe through porcine experiment.

METHODS

Self-biodegradable dumbbell-shaped pyloric stents were designed from absorbable suture materials: poly(glycolide-co-caprolactone) (PGCL) or poly-p-dioxanone (PPDO). After gastrotomy on ten pigs, each stent was inserted: two shams, four PGCL stents, and four PPDO stents. Body weight (Bwt), body temperature (BT), complete blood cell (CBC) count, and plain X-ray were evaluated. On postoperative day (POD) 13, euthanasia was performed for histologic evaluation.

RESULTS

Operation was successfully performed in all ten pigs. Without tagging suture, both stents migrated before POD 3. The migration was delayed up to POD 13, when the tagging sutures (-t) were applied between stent and stomach wall. Self-degradation of PGCL started from POD 3, and stents were completely excreted from the abdomen by POD 8. Although PPDO were also weakened as self-degradation progressed, its shape was maintained in gastrointestinal tract for 13 days. Unexpected sudden death occurred in the pig with PPDO-t2 on POD 10, which is more likely due to acute volvulus rather than stent-related complication. There was no significant difference between three groups in terms of Bwt, BT, CBC, and histology (sham vs. PGCL vs. PPDO, all p > 0.05).

CONCLUSION

The concept of biodegradable stents made of absorbent suture material seems feasible in porcine experiment. Among them, PGCL which has shown rapid absorption, appears to be a more suitable material for transient pyloric absorbable stent when considering safety aspect.

Uncovered versus covered expandable metal stents for malignant gastric outlet obstruction caused by intrinsic and extrinsic tumors: meta-analysis and meta-regression analysis

BACKGROUND AND AIMS

Malignant gastric outlet obstruction (GOO) can be palliated by endoscopic placement of self-expandable metal stents (SEMSs). Studies comparing uncovered (USEMSs) and covered (CSEMSs) SEMSs have yielded inconclusive results. This meta-analysis compared USEMSs with CSEMSs in patients with GOO caused by intrinsic and extrinsic tumors.

METHODS

Potentially relevant articles were identified by searching PubMed, the Cochrane Library, and Medline. The primary outcome was stent dysfunction. Relationships between characteristics of tumors causing GOO and the stent dysfunction rate following USEMSs and CSEMS placement were assessed.

RESULTS

Overall, six randomized controlled trials and 12 observational studies, including 2431 patients, were identified. Rate of stent dysfunction did not differ significantly between USEMSs and CSEMSs (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.73-1.25, I² = 44%), but there was heterogeneity. Meta-regression analysis showed that heterogeneity of stent dysfunction was caused by a difference in the ratio of intrinsic-to-extrinsic tumors causing GOO between studies (coefficient, 0.944; 95% CI, 0.30-1.58). Studies were divided into intrinsic and extrinsic tumor groups. Subgroup analysis showed that the stent dysfunction rate did not differ between USEMSs and CSEMSs in the intrinsic tumor group (OR, 1.10; 95% CI, 0.85-1.41; I² = 32%). In the extrinsic tumor group, USEMS was associated with a lower rate of stent dysfunction than CSEMS (OR, 0.64; 95% CI, 0.47-0.87; I² = 25%).

CONCLUSION

USEMS and CSEMS placement generally showed comparable outcomes among patients with GOO. USEMS was more effective than CSEMS for patients with GOO caused by extrinsic tumors.

Treating an Intractable Jejunocutaneous Fistula by Endoscopic Metallic Stent Placement: A Case Report of Successful Palliative Endoscopic Treatment in a Case Demonstrating Peritoneal Dissemination with Terminal Stage Gastric Cancer

A 74-year-old woman with recurrent gastric cancer underwent laparotomy for peritoneal dissemination, and the damaged jejunum formed a jejunocutaneous fistula. Because conservative treatment alone could not cure the fistula, we performed an endoscopic placement of a partially covered self-expandable metallic stent (SEMS) to cover the fistula. After the procedure, the contrast medium no longer leaked from the intestinal lumen. One month after stent placement, the cutaneous opening had closed. This case report demonstrates the potential for using partially covered SEMS to treat intractable jejunocutaneous fistula in patients with terminal-stage malignant tumors.

Endoscopic Management of Luminal Strictures: Beyond Dilation

Luminal strictures can occur as part of many different gastrointestinal (GI) disorders anywhere along the GI tract and affect all age groups. The end goal of managing any stricture is to re-establish an adequate and durable luminal patency that is sufficient to resolve the presenting clinical symptoms. Treatment options can be generally categorized into medical, endoscopic, and surgical. However, within each of these categories, multiple different options are available. Therefore, choosing the best treatment modality is often challenging and depends on multiple factors including the type, location, and complexity of the stricture, as well as the preference of the treating physician. In this article, we will review the most current literature regarding foregut strictures, particularly esophageal and gastric, beyond dilation.

A pilot study of novel duodenal covered self-expandable metal stent fixation

Migration of duodenal covered self-expandable metal stents (C-SEMSs) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction (mGOO). Because endoscopic SEMS placement is frequently selected in patients with poor performance status, we concurrently focused on the safety of the treatment. This pilot study included 15 consecutive patients with mGOO who underwent duodenal partially covered SEMS (PC-SEMS) placement with fixation using an over-the-scope-clip (OTSC). Technical feasibility, clinical success for oral intake estimated by the Gastric Outlet Obstruction Scoring System (GOOSS) score, and adverse events including stent migration were retrospectively assessed. All procedures were successful, and clinical success was achieved in 86.7% (13/15). Mean GOOSS scores were improved from 0.07 to 2.53 after the procedure (P < 0.001). Median survival time was 84 days, and all patients were followed up until death. Stent migration occurred in one case (6.7%) at day 17, which was successfully treated by removal of the migrated PC-SEMS using an enteroscope. For fixation using an OTSC, additional time required for the procedure was 8.9 ± 4.1 min and we did not observe OTSC-associated adverse events. Poor performance status was associated with clinical success (P = 0.03), but we could provide the treatment safely and reduce mGOO symptoms even in patients with poor performance status. In conclusion, duodenal PC-SEMS fixation using an OTSC is feasible for preventing stent migration in patients with mGOO including those with poor performance status.

Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction

OBJECTIVE

Stenting is an established endoscopic therapy for malignant gastric outlet obstruction (mGOO). The choice of stent (covered vs uncovered) has been examined in prior randomised studies without clear results.

DESIGN

In a multicentre randomised prospective study, we compared covered (CSEMS) with uncovered self-expandable metal stents (UCSEMS) in patients with mGOO; main outcomes were stent dysfunction and patient survival, with subgroup analyses of patients with extrinsic and intrinsic tumours.

RESULTS

Overall survival was poor with no difference between groups (probability at 3 months 49.7% for covered vs 48.4% for uncovered stents; log-rank for overall survival p=0.26). Within that setting of short survival, the proportion of stent dysfunction was significantly higher for uncovered stents (35.2% vs 23.4%, p=0.01) with significantly shorter time to stent dysfunction. This was mainly relevant for patients with extrinsic tumours (stent dysfunction rates for uncovered stents 35.6% vs 17.5%, p<0.01). Subgrouping was also relevant with respect to tumour ingrowth (lower with covered stents for intrinsic tumours; 1.6% vs 27.7%, p<0.01) and stent migration (higher with covered stents for extrinsic tumours: 15.3% vs 2.5%, p<0.01).

CONCLUSIONS

Due to poor patient survival, minor differences between covered and uncovered stents may be less relevant even if statistically significant; however, subgroup analysis would suggest to use covered stents for intrinsic and uncovered stents for extrinsic malignancies.

Optimal Management of Gastric Outlet Obstruction in Unresectable Malignancies

The aim of this article is to review the different treatment options for malignant gastric outlet obstruction (GOO) and compare their safety and efficacy. We describe the history and evolution of gastrojejunostomy (GJ), endoscopic stenting and endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) and analyze the current evidence regarding these three methods available in the literature, comparing their applicability, safety, complications and cost when used for the treatment of malignant GOO. We conclude that given the benefits of endoscopic techniques and the ability to place a stent away from the tumor, EUS-GE is a promising technique that may yield an efficacy similar to that of surgical GJ and duodenal stenting, with lower reintervention rates and fewer adverse events.

Endoscopic management of malignant gastric outlet obstruction

Malignant gastric outlet obstruction (MGOO) is a late complication of advanced malignancies, mostly occurring due to gastrointestinal cancers or external compression outside the lumen. It causes nausea, vomiting, poor appetite, weight loss, and decreased quality of life. In the past, surgical bypass was the gold standard for the management of MGOO. However, the introduction of self-expandable metallic stent (SEMS) provides several advantages over surgical bypass, including earlier oral intake, rapid symptom relief, less invasiveness, and shorter hospital stays; therefore, it has replaced surgical bypass as the mainstream management approach in most situations. Although SEMS placement is a safe and effective way for palliation of MGOO, stent dysfunction with obstruction or migration limits the utilization and increases repeated intervention. Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stent has emerged as an alternative way to bypass the obstruction site and restore the oral intake of patients. Although a lower stent dysfunction rate was reported, further prospective studies are warranted to validate its effectiveness and safety.

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Covered versus uncovered metal stents for malignant gastric outlet obstruction: a systematic review and meta-analysis

BACKGROUND AND AIMS

Self-expandable metal stents (SEMSs) are used for palliation of malignant gastric outlet obstruction (GOO). Studies comparing covered SEMSs (C-SEMSs) and uncovered SEMSs (U-SEMSs) have led to inconclusive results. We compared efficacy and safety of C-SEMSs versus U-SEMSs in patients with GOO.

METHODS

We searched MEDLINE, EMBASE, and Cochrane Library from 2000 to 2019 to identify available studies comparing C-SEMSs versus U-SEMSs in patients with GOO. Primary outcomes were stent survival and patient survival, whereas secondary outcomes were clinical and technical success, Gastric Outlet Obstruction Score System (GOOSS) score after the procedure, overall adverse events, reintervention rate, dysfunction rate, stent occlusion, and stent migration.

RESULTS

Overall, 7 randomized controlled trials and 9 observational studies were identified that included 1741 patients. C-SEMSs were associated with higher stent survival (hazard ratio, .68; 95% confidence interval [CI], .48-.96), whereas patient survival did not statistically significantly differ between C-SEMS and U-SEMS groups (hazard ratio, .96; 95% CI, .75-1.23). Clinical and technical success were not statistically different between groups (odds ratios, 1.1 [95% CI, .76-1.61] and .69 [95% CI, .21-2.3], respectively). There were no differences in terms of overall adverse events, reintervention rate, dysfunction rate, and GOOSS rate ≥2 after SEMS placement. U-SEMSs were associated with a higher rate of occlusion (odds ratio, .34; 95% CI, .21-.53) and C-SEMSs with a higher rate of migration (odds ratio, 4.28; 95% CI, 2.79-6.57).

CONCLUSIONS

C-SEMSs were associated with higher stent survival (time between stent deployment and stent dysfunction) compared with U-SEMSs, whereas no differences in terms of patient survival (time between stent deployment and patient's death) emerged. However, U-SEMSs were associated with higher risk of occlusion and C-SEMSs with higher risk of migration. Further studies using new C-SEMSs with an antimigration system are needed.

Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy using double balloon occlusion methods: a clinical retrospective study in 36 patients with malignant gastric outlet obstruction

Background and study aims  Gastric outlet obstruction (GOO) is common in the late stage of many malignant tumors of the digestive system. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is commonly used for palliative treatment of malignant GOO. The objective of this study was to investigate the safety, efficacy, and prognosis of EUS-GE in treatment of malignant GOO in Chinese patients. Patients and methods  This was a retrospective, single-center study with 36 consecutive patients with malignant GOO who were treated with EUS-GE. The main outcome measures were technical success rate, clinical success rate, incidence of adverse events (AEs), and median survival time. Results  A total of 36 patients with malignant GOO underwent double-balloon-assisted EUS-GE between March 2017 and June 2019 in our hospital. GOO occurred mainly in elderly men (mean age 69.0 years, M:F 0.89). The most common etiology of GOO was pancreatic cancer (41.7 %). The most common obstruction site was the second part of the duodenum (63.9 %). The technical success rate was 100 % (36/36). The clinical success rate was 94.4 % (34/36). Median time for the total procedure was 52 minutes (range 34 - 156 min). Median time for determination of puncture site was 20 minutes (range 15 - 28 min). Median time between puncture and successful delivery of the stent was 38 minutes (range 19 - 128 min). The GOOSS score was 0.2 before EUS-GE. The GOO Scoring System (GOOSS) score was 2.2 at 15 days after the EUS-GE ( P  = 0.001). The GOOSS score was still higher than 2 during a median follow-up period of 89 days. AEs were observed in nine patients (25.0 %) and 13 total AEs occurred. One patient died as a result of delayed stent migration and bleeding. Mean length of hospital stay was 5.8 ± 4.7 days. The median survival period was 103 days. The rate of GOO recurrence was 2.7 % (1/36). Conclusion  EUS-GE was associated with increased safety and efficacy for treatment of malignant GOO in Chinese Mainland.

Endoscopic retrograde cholangiopancreatography guided interventions in the management of pancreatic cancer

Pancreatic cancer is the leading cause of cancer-related morbidity and mortality with an overall five-year survival of less than 9% in the United States. At presentation, the majority of patients have painless jaundice, pruritis, and malaise, a triad that develops secondary to obstruction, which often occurs late in the course of the disease process. The technical advancements in radiological imaging and endoscopic interventions have played a crucial role in the diagnosis, staging, and management of patients with pancreatic cancer. Endoscopic retrograde cholangiopancreatography (ERCP)-guided diagnosis (with brush cytology, serial pancreatic juice aspiration cytologic examination technique, or biliary biopsy) and therapeutic interventions such as pancreatobiliary decompression, intraductal and relief of gastric outlet obstruction play a pivotal role in the management of advanced pancreatic cancer and are increasingly used due to improved morbidity and complication rates compared to surgical management. In this review, we highlight various ERCP-guided diagnostic and therapeutic interventions for the management of pancreatic cancer.

Palliative care for advanced gastric cancer

INTRODUCTION

Proactive palliative care can effectively relieve symptoms early and effectively as well as improve the quality of life of patients with gastric adenocarcinoma (GAC).

AREAS COVERED

The review summarizes palliative care for GAC. GAC caused specific symptoms, such as malignant gastric outlet obstruction (GOO), bleeding, weight loss, and/or ascites, therefore, these symptoms must be addressed specifically.

EXPERT OPINION

Palliative care should start early to control general symptoms, thus may improve the patient's condition to make the patient eligible for anti-cancer treatment. As some stage IV GAC patients can now live longer, palliative interventions become more important. A multimodality interdisciplinary approach is strongly encouraged.

Management of gastric outlet obstruction: Focusing on endoscopic approach

Gastric outlet obstruction (GOO) is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction. The obstructions typically involved in GOO can be benign or malignant. Peptic ulcer disease is the most common cause of benign GOO, and malignant causes include gastric cancer, lymphoma, and gastrointestinal stromal tumor. With the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors, the predominant causes have changed from benign to malignant diseases. Treatment of GOO depends on the underlying cause: Proton pump inhibitors, H. pylori eradication, endoscopic treatments including balloon dilatation or the placement of self-expandable stents, or surgery.

Clinical outcomes after multiple self-expandable metallic stent placement using stent-in-stent technique for malignant gastric outlet obstruction

Self-expandable metallic stent (SEMS) placement is widely used for relieving symptoms in malignant gastric outlet obstruction (MGOO). This study aimed to evaluate the efficacy and safety of multiple gastroduodenal stent placement using the stent-in-stent technique and to identify factors predictive of stent patency.We retrospectively analyzed data from 170 patients with GOO receiving SEMS using the stent-in-stent technique between July 2006 and July 2018. Of these, 90 had been treated with SEMS placement for MGOO. Technical and clinical success rates were evaluated. Clinical outcomes and predictors of stent patency were also analyzed.Second SEMS placement was used in 34.4% of cases and 9.7% were treated with third SEMS placement because of prior stent dysfunction. Median stent patency time was 15.7 weeks for the first SEMS, 10.4 weeks for the second, and 11.3 weeks for the third. The technical and clinical success rates were 100% and 97.8% for the first SEMS, 100% and 90.3% for the second, respectively, and both 100% for the third. Multivariable analysis showed that use of covered SEMS and chemotherapy after first and second SEMS placement was significant predictors of stent patency. Serious complications such as bleeding or perforation did not occur in any patient.Second and third gastroduodenal SEMS placement using the stent-in-stent technique is safe and effective for management of first stent dysfunction in MGOO. Stent patency is significantly associated with the use of covered SEMS and chemotherapy after SEMS placement.

Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction

INTRODUCTION AND OBJECTIVES

Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement.

MATERIAL AND METHODS

A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction.

RESULTS

The study included 43 patients, technical success was 97.7% (n=42), and clinical success was 88.3% (n=38). SEMS dysfunction presented in 30.2% (n=13) of the patients, occurring in<6 months after placement in 53.8% (n=7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p=0.02) and the use of uncovered SEMS (p=0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months).

CONCLUSIONS

SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors.

Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction

BACKGROUND

Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes.

METHODS

Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured.

RESULTS

A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028).

CONCLUSION

In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.

Outcomes of enteral metallic stent in patients with pancreatic carcinoma and gastric outlet obstruction: A single center experience

BACKGROUND

Duodenal obstruction is uncommon in patients with pancreatic cancer. However, the obstruction rate is increasing as a result of advancements in chemotherapy and target therapy. This study aimed to investigate the effect of self-expandable metal stent placement on outcomes of patients with duodenal obstruction secondary to pancreatic carcinoma.

METHODS

Twenty-nine consecutive inoperable patients with pancreatic cancer and gastric outlet obstruction who received metallic stent placement in our hospital between September 2009 and October 2017 were enrolled for analysis.

RESULTS

Fifteen male patients and 14 female patients receiving stent placement with a median age of 68 years (range, 50-85 years) were included. The technical and clinical success rates of the procedure were 100% and 89.7%, respectively. The Gastric Outlet Obstruction Scoring System scores were significantly improved at day 1 (1.14 ± 0.51) and days 7 (2.21 ± 0.9) after the implantation compared to those prior to the procedure (0.38 ± 0.49) (p < 0.001). Aspiration pneumonia and bleeding developed in 1 patient (3.4%) after the procedure. Stent dysfunction developed in 6 of 29 patients (20.6%). The median stent patency time was 109 days (range, 10-314 days). The median survival time was 114 days (range, 15-323 days). Post-stent chemotherapy predicted better survival (hazard ratio: 0.2, 95% confidence interval: 0.08-0.51, p = 0.001).

CONCLUSION

Metallic stent placement is an effective treatment for patients with inoperable pancreatic cancer leading to gastric outlet obstruction. Chemotherapy may be considered following stent placement.

A Study of Clinical Presentation and Management of Malignant Gastric Outlet Obstruction (Northeast India-Based Single-Centre Experience)

Gastric outlet obstruction (GOO) occurs when there is mechanical obstruction impending gastric emptying. GOO has both benign and malignant aetiologies. In this paper we want to discuss, clinical presentation and management of malignant GOO. This is a retrospective observational study of 5 years in patients presenting with malignant GOO. Study was conducted in Dr. B. Borooah Cancer Institute, Guwahati, India. Patients with malignant GOO who were operated were included in this study. Chi-square test was used to evaluate association between categorical values. Independent t test and one-way ANOVA (analysis of variance) was used for continuous variables. A p value < 0.05 was considered statistically significant at 95% confidence interval. Data were analysed using SPSS (Statistical Package for the Social Sciences) software. A total of 107 patients were included in the study. Mean age of patients was 51 years. Carcinoma stomach was the most common cause of GOO, followed by carcinoma gall bladder, pancreatic cancer and duodenal cancer in decreasing order of frequency. Gastrojejunostomy was done in 96 patients, and palliative gastrectomy with gastrojejunostomy was done in 11 patients. There was improvement in gastric outlet obstruction score in most of the patients after GJ with acceptable patency rates at the end of 90 days. Low albumin levels and poor preoperative performance status were associated with increased 90-day mortality. Patients with malignant GOO usually present in poor general condition. Carcinoma stomach was the major cause of GOO in our setup. Adequate preoperative resuscitation, nutritional assessment and correction of malnourishment are of utmost importance for improving outcome of patients. Surgical gastroenterostomy was effective for palliation of obstructive symptoms in our study with improvement in post-operative oral intake and improved quality of life. Our study of 107 patients with GOO has shown that surgical palliation of GOO in the form of gastrojejunostomy improves oral intake of patients with improved post-operative gastric-outlet obstruction scores. Low albumin levels and poor preoperative poor performance status were associated with increased mortality at the end of 90 days.

Big End Double-Layer Stents for the Treatment of Gastric Outlet Obstruction Caused by Stomach Cancer

Objectives

This study is aimed at evaluating the efficacy and safety of the big end double-layer uncovered self-expanding metal stents (SEMS) for the treatment of gastric outlet obstruction (GOO) caused by distal stomach cancer.

Methods

Seventy three patients receiving big end double-layer uncovered SEMS for the treatment of GOO caused by distal gastric cancer will be included in this multicenter prospective clinical trial. The main outcome measures included the functional outcome, the complications, the reinterventional rates, the average treatment charges, and the mean survival time. Monthly telephone calls were needed to assess the food intake until the patients died.

Results

The technical and the clinical success rates were 98.6%. The stent obstruction caused by tumor ingrowth was observed in one patient (1.4%). The incidence of food impaction was 2.9% (2/70) and the reinterventional rate was 4.3% (3/70). However, stent migration and obstruction caused by overgrowth were not observed. No perforation and severe bleeding were observed. The median cost of endoscopic stenting and total hospitalization (including reinterventions) for the big end double-layer uncovered SEMS in this study was $2945 and $3408, respectively. The mean survival time was 212.5 days.

Conclusions

The placement of big end double-layer uncovered SEMS is a safe and effective modality and has the potential to be one of the options for the treatment of GOO caused by the distal gastric cancer.

Complications After Endoscopic Stenting for Malignant Gastric Outlet Obstruction: A Cohort Study

BACKGROUND

Gastric stenting has become a common place in clinical practice. The aim of our study was to evaluate the factors influencing the clinical outcome in patients who received endoscopic stenting for malignant gastric outlet obstruction (GOO).

MATERIALS AND METHODS

We prospectively evaluated the clinical course of 87 patients who presented to our attention with malignant GOO.

RESULTS

There was neither mortality nor major morbidity after endoscopic stenting. Survival was reduced (average, 2 mo) in patients with an obstruction due to no resectable pancreatic cancer. In patients with primary no resectable pyloric adenocarcinoma, the crude survival was >1 year. Almost half of the patients required a new endoscopy. Food obstruction was common after 6 months from stent placement, limiting the quality of life of the patients.

CONCLUSIONS

Endoscopic stenting represents a valid treatment in patients with symptoms of GOO from metastatic cancer. Patients with metastatic pyloric adenocarcinoma and normal liver function tests have survival rates longer than 1 year. In this selected group of patients, laparoscopic surgical gastrojejunostomy can be a valid alternative to avoid a close and exhausting follow-up, with the possibility of a better quality of life (res Registry 808).

Endoscopic management of gastric outlet obstruction disease

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient's prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Endoscopic management of gastric outlet obstruction disease

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient’s prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Feasibility and safety of duodenal covered self-expandable metallic stent fixation: an experimental study

BACKGROUND AND AIMS

Migration of duodenal covered self-expandable metallic stents (C-SEMS) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction. However, the ideal method to prevent migration has not been clarified. We aimed to evaluate the feasibility and safety of duodenal C-SEMS fixation in this experimental study.

METHODS

We used the over-the-scope clip (OTSC), suture, and clip methods to fix duodenal C-SEMS and evaluated the gripping force of each device and invasion depth based on pathological findings.

RESULTS

The OTSC and suturing systems had a significantly higher mean gripping force compared with the clipping system (OTSC vs. clip: 13.2 vs. 1.0 Newtons [N], P < 0.001; suture vs. clip: 8.5 vs. 1.0 N, P < 0.001). OTSC compression was stronger compared with suturing (OTSC vs. suture: 13.2 vs. 8.5 N, P = 0.006). The submucosal layer, but not the muscle layer, was compressed more widely and deeply by OTSC compared with clips based on pathological findings by hematoxylin and eosin staining.

CONCLUSION

Both OTSC and suturing methods used for duodenal C-SEMS fixation were feasible compared with the clipping method. The pathological evaluation of invasion depth indicated that OTSC may be safe even for preventive use. This study suggested that these methods can be applied clinically for duodenal C-SEMS fixation.

Winged Partially Covered Self-Expandable Metal Stent to Prevent Distal Migration in Malignant Gastric Outlet Obstruction

BACKGROUND

Through-the-scope implantation of self-expandable metal stents can be used for the palliation of malignant gastric outlet obstruction. Although covered stents were developed to prevent tumor ingrowth, often seen with uncovered stents, migration is still a major problem. Especially, surgical treatment is required for some patients if distal migration occurs.

AIMS

To evaluate the usefulness of the newly designed winged stent that was developed to prevent distal stent migration.

METHODS

This was a single-center, single-arm, retrospective study. A total of 63 inoperable cancer patients with symptomatic gastric outlet obstruction were reviewed to evaluate the safety and efficacy of a newly designed partially covered self-expandable metal stent with star-shaped wing flaps at the proximal end to reduce distal stent migration.

RESULTS

Technical and clinical successes were achieved in 100% and 87.3% of patients, respectively. The gastric outlet obstruction scoring system score significantly improved after stent placement (from median 1 to 2, P < 0.001). The median duration of stent patency was 147 days (interquartile range 76-201), and median duration of overall survival was 176 days (interquartile range 79-325). Stent migration was observed in seven patients (11.1%), and restenosis was developed in 12 patients (19.0%). All cases of migration were proximal, and no distal migration was observed. Endoscopic removal of migrated stents was performed successfully in all cases.

CONCLUSIONS

The newly designed winged stent showed feasible efficacy and safety for malignant gastric outlet obstruction. Furthermore, it effectively prevented distal stent migration.

Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy

AIM

To investigate the efficacy and safety of endoscopic stent insertion in patients with delayed gastric emptying after gastrectomy.

METHODS

In this study, we prospectively collected data from patients who underwent stent placement for delayed gastric emptying (DGE) after distal gastrectomy between June 2010 and April 2017, at a tertiary referral academic center. Clinical improvement, complications, and consequences after stent insertion were analyzed.

RESULTS

Technical success was achieved in all patients (100%). Early symptom improvement was observed in 15 of 20 patients (75%) and clinical success was achieved in all patients. Mean follow-up period was 1178.3 ± 844.1 d and median stent maintenance period was 51 d (range 6-2114 d). During the follow-up period, inserted stents were passed spontaneously per rectum without any complications in 14 of 20 patients (70%). Symptom improvement was maintained after stent placement without the requirement of any additional intervention in 19 of 20 patients (95%).

CONCLUSION

Endoscopic stent placement provides prompt relief of obstructive symptoms. Thus, it can be considered an effective and safe salvage technique for post-operative DGE.

Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer

BACKGROUND

Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment.

AIMS

To compare the efficacy and safety of GJJ and DS for GOO with APC.

METHODS

Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis.

RESULTS

GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS.

CONCLUSIONS

There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.

The Palliative Effect of Endoscopic Uncovered Self-expandable Metallic Stent Placement Versus Gastrojejunostomy on Malignant Gastric Outlet Obstruction: A Pilot Study with a Retrospective Chart Review in Saga, Japan

Objective Endoscopic self-expandable metallic stent (SEMS) placement and gastrojejunostomy (GJY) are palliative treatments for malignant gastric outlet obstruction (GOO). The aim of the present study was to compare the palliative effects of these treatments and identify predictors of a poor oral intake after treatment. Methods and Patients In total, 65 patients with GOO at multiple centers in Saga, Japan, were evaluated. Thirty-eight patients underwent SEMS placement, and 27 underwent GJY from January 2010 to December 2016. The characteristics and outcomes of the two groups were compared to detect predictors of treatment failure. Results No significant differences in the technical success, clinical success, post-treatment total protein, hospital discharge, duration from eating disability to death, or post-treatment overall survival were present between the SEMS and GJY groups. More patients in the GJY group than in the SEMS group received chemotherapy (51.4% vs. 26.3%, respectively; p=0.042). The period from treatment to the first meal was longer in the GJY group than in the SEMS group (4.5 vs. 3.0 days, respectively; p=0.013). The present study did not identify any risk factors for failure of SEMS placement. Although the stent length tended to be associated with a poor prognosis, the correlation was not statistically significant (odds ratio: 0.60, 95% confidence interval: 0.36-1.01, p=0.053). Conclusion Patients with GOO started meals more promptly after SEMS than after GJY, but the clinical outcomes were not markedly different between the SEMS and GJY groups. These findings suggest that endoscopic uncovered SEMS placement might be a feasible palliative treatment for GOO.

Comparison on the Efficacy between Partially Covered Self-Expandable Metal Stent with Funnel-Shaped Enlarged Head versus Uncovered Self-Expandable Metal Stent for Palliation of Gastric Outlet Obstruction

Background

Shape modification has been one of the methods adopted to improve stent patency but has not always translated into positive outcome. The aim of this study was to compare the efficacy of shape-modified partially covered self-expandable metal stent (SEMS) that has enlarged head versus uncovered SEMS for palliation of gastric outlet obstruction (GOO).

Methods

A total of 48 patients underwent insertion of either enlarged-head SEMS (n = 24) or uncovered SEMS (uSEMS) (n = 24) for palliation of GOO from July 2009 to July 2016. Patients with inoperable or advanced malignancy were included. Technical feasibility and clinical outcomes were compared.

Results

Technical success rate was 100% (24/24) and 95.8% (23/24) for enlarged-head SEMS group and uSEMS group, respectively. Clinical success rate was 87.5% (21/24) and 87.0% (20/23) for enlarged-head SEMS group and uSEMS group, respectively. The gastric outlet obstruction scoring system score significantly improved in both groups (p < 0.001 for both). Mean survival was similar between the groups: enlarged-head SEMS group, 99.3 days (range, 19–358 days) versus uSEMS group, 82.1 days (range, 11–231 days) (p = 0.418). The mean stent patency also showed no difference between the groups: enlarged-head SEMS group, 87.1 days (range, 8–358 days) versus uSEMS group, 60.4 days (range, 2–231 days) (p = 0.204). With enlarged-head SEMS, distal migration did not occur, but proximal migration was observed in four cases.

Conclusions

Distal migration was prevented by shaping the SEMS to have an enlarged head, but improvement in stent patency could not be observed.

Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction

BACKGROUND AND AIM

Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction. The aim of the current study was to investigate the patency and adverse events of duodenal and biliary stents in patients with DS.

METHODS

Patients who underwent DS from April 2004 to March 2017 were analyzed retrospectively with regard to clinical outcomes and predictive factors of recurrent biliary and duodenal obstruction (recurrent biliary obstruction [RBO] and recurrent duodenal obstruction [RDO]).

RESULTS

A total of 109 consecutive patients was enrolled. Technical success of DS was achieved in 108 patients (99.1%). Symptoms due to biliary and duodenal obstruction were improved in 89 patients (81.7%). RBO occurred in 25 patients (22.9%) and RDO in 13 (11.9%). The median times to RBO and RDO from DS were 87 and 76 days, respectively. Placement of a duodenal uncovered self-expandable metal stent (U-SEMS) was significantly associated with RBO in the multivariable analysis (P = 0.007). Time to RBO was significantly longer in the duodenal covered self-expandable metal stent group than in the U-SEMS group (P = 0.003). No predictive factors of RDO were detected, and duodenal stent type was not associated with the time to RDO (P = 0.724).

CONCLUSIONS

Double stenting was safe and effective for malignant bilioduodenal obstruction. Duodenal U-SEMS is a risk factor for RBO. The covered self-expandable metal stent is the preferred type of duodenal SEMS in patients with DS (Clinical trial registration number: UMIN000027606).

Endoscopic Palliation of Pancreatic Cancer

OPINION STATEMENT

Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.

A Novel Partially Covered Self-Expandable Metallic Stent with Proximal Flare in Patients with Malignant Gastric Outlet Obstruction

BACKGROUND/AIMS

Endoscopic placement of self-expandable metal stents (SEMSs) has emerged as a palliative treatment for malignant gastric outlet obstruction (GOO). Although covered SEMSs can prevent tumor ingrowth, frequent migration of covered SEMSs may offset their advantages in preventing tumor ingrowth.

METHODS

We conducted this multicenter, single-arm, retrospective study at six tertiary referral centers to evaluate the safety and efficacy of a partially covered SEMS with an uncovered large-bore flare at the proximal end as an antimigration system in 41 patients with symptomatic malignant GOO. The primary outcome was clinical success, and the secondary outcomes were technical success, stent dysfunction, adverse events, and survival after stent placement.

RESULTS

The technical and clinical success rates were 100% and 95%, respectively. Stent dysfunctions occurred in 17 patients (41%), including stent migration in nine (23%), tumor ingrowth in one (2%), and tumor overgrowth in four (10%). Two patients (5%) developed adverse events: one pancreatitis and one perforation. No procedure-related death was observed.

CONCLUSIONS

A novel partially covered SEMS with a large-bore flare proximal end was safe and effective for malignant GOO but failed to prevent stent migration. Further research is warranted to develop a covered SEMS with an optimal antimigration system.

Botulinum Toxin Injection for the Treatment of Delayed Gastric Emptying Following Pylorus-Preserving Gastrectomy: an Initial Experience

Purpose

To report our experience of endoscopic botulinum toxin injection in patients who experienced severe delayed gastric emptying after pylorus-preserving gastrectomy (PPG).

Materials and Methods

We reviewed the medical records of 6 patients who received the botulinum toxin injection. They presented with severe delayed gastric emptying in the early postoperative period. Endoscopic botulinum toxin was administered as 4 injections of 25−50 IU into each of the 4 quadrants of the prepyloric area.

Results

All botulinum toxin injections were successful without any complications, enabling 5 patients to tolerate soft solid diets and one to tolerate a soft fluid diet within 10 days. The endoscopic criteria of 4 patients improved. Symptom recurrence caused 2 patients to undergo repeat injections that were successful. The median follow-up period was 27 months, and all patients could ingest normal regular diets at the last follow-up.

Conclusions

Endoscopic botulinum toxin injection is a feasible treatment option for early delayed gastric emptying after PPG.

Covered versus uncovered metal stents for malignant gastric outlet obstruction: Systematic review and meta-analysis

BACKGROUND AND AIM

Self-expandable metal stents (SEMS) are used for non-resectable malignant gastric outlet obstruction (GOO). Studies of covered versus uncovered SEMS have yielded inconsistent results as a result of heterogeneity in design and patient population. We carried out a meta-analysis to compare covered and uncovered gastroduodenal SEMS.

METHODS

Using MEDLINE, Embase, and the Cochrane database, we identified 1624 patients from 13 prospective and retrospective studies that evaluated covered and uncovered SEMS for malignant GOO and were published until October 2016. We pooled data on SEMS dysfunction, technical and clinical success, and adverse events using the fixed-effect or random-effects model.

RESULTS

Compared with uncovered SEMS, covered SEMS did not show any significant difference in stent dysfunction risk (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.79-1.32). A subgroup analysis of five randomized trials suggested a trend toward a lower dysfunction risk in covered SEMS (RR, 0.63; 95% CI, 0.45-0.88). Covered SEMS were associated with a lower occlusion risk (RR, 0.44; 95% CI, 0.28-0.68), but with a higher migration risk (RR, 4.28; 95% CI, 2.89-6.34). Technical and clinical success rates were comparable between the groups. Overall adverse events tended to be more frequent in covered SEMS (RR, 1.75; 95% CI, 1.09-2.83).

CONCLUSIONS

Outcomes of covered and uncovered gastroduodenal SEMS were comparable, although the lower dysfunction rate of covered SEMS observed in the analysis of randomized trials needs further investigation. Antimigration mechanisms for covered SEMS and identification of patients who can achieve longer patency from uncovered SEMS would help improve the outcomes of gastroduodenal SEMS.

Predictive Factors for the Migration of Endoscopic Self-Expanding Metal Stents Placed in the Foregut

BACKGROUND

With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aimed to determine predictive factors for stent migration.

METHODS

Consecutive procedures involving SEMS placed with and without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic, surgical history, rate of stent migration, and stent characteristic data were collected. Rates of stent migration were compared.

RESULTS

We reviewed 214 consecutive procedures involving stents placed in the foregut. Median duration of stent placement was 4.0 ± 10.3 weeks. Forty-three (20%) stents migrated after placement. Of those, 27 (63%) required stent replacement. Eleven (5%) procedures utilized stent fixation and 203 (95%) did not. Fixation techniques included endoscopic clips (9%), endoscopic sutures (73%), and transnasal sutures (18%). Stent migration rate was not different between those with and those without fixation ( P = .2). Rate of migration was significantly higher in procedures involving fully covered stents ( P < .001). Migration occurred after esophagectomy and gastric bypass ( P < .001 and P < .05, respectively) and in patients with diabetes ( P < .01).

CONCLUSIONS

A challenge with SEMS use is stent migration. Diabetes and using fully covered stents were associated with migration as were SEMS used to treat complications of esophagectomy and gastric bypass. Stent fixation was not associated with the prevention of stent migration. No pattern was found that favors an approach to reduce stent migration.

Recent advancements in stent therapy in patients with malignant gastroduodenal outlet obstruction

Gastric outlet obstruction (GOO) is one of severe comorbidities caused by many kinds of malignant diseases and is associated with not only degradation of patients' quality of life but also mortality. Although surgical bypass is one of the main therapies for malignant GOO, it is often difficult to perform in end-stage patients. The deployment of self-expandable metallic stents (SEMSs) has recently become a viable alternative to surgical bypass for malignant GOO. This technique is less invasive and more effective, particularly in patients with poor prognoses. Many reports have referred to the feasibility, effectiveness, and safety of the placement of SEMSs for malignant GOO. According to these reports, the rates of technical and clinical success were reported to be relatively high and the rate of adverse events to be acceptable. However, precautions against severe adverse events such as massive bleeding and perforation are necessary. Several reports have described the differences in clinical results among different kinds of SEMSs. The presence of a covered design for SEMSs may affect the patency of SEMSs and the rate of stent dysfunction. Selection of the SEMS according to axial force may affect successful achievement of long patency of SEMSs and avoidance of gastroduodenal perforation at the bending site of the duodenum. Compared with high technical success rates nearing 100%, clinical success rates were usually lower than technical success. Therefore, determination of predictive factors for failure of clinical success is important. Several papers reported that low performance status could be associated with failure of clinical success. However, the association of clinical success with other factors such as carcinomatosa and ascites remains controversial, which is a problem to be solved. Reintervention with SEMS using the stent-in-stent method after stent dysfunction can be performed effectively as well as placement of the first SEMS.