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Riccò B, Martinelli G, Bardasi C, Dominici M, Spallanzani A, Salati M. Optimizing the Continuum of Care in Gastric Cancer. Onco Targets Ther 2023; 16:995-1012. [PMID: 38021446 PMCID: PMC10680466 DOI: 10.2147/ott.s365505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Gastric cancer (GC) still ranks as the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide. Despite the recent progress in the therapeutic algorithm of the advanced disease with the advent of immune checkpoint inhibitors (ICIs) and next-generation HER2-directed therapies, survival rates remain poor, with a median survival hardly exceeding 12 months. Furthermore, only 40% of patients remain eligible for second- and later-line treatments due to the aggressiveness of the disease and the rapid deterioration of performance status (PS). Thus, current research is focusing either on the identification of novel treatment options or the development of personalized strategies to optimize the continuum of care and ultimately improve patients' outcome. In this article, we provide an overview of the current treatment landscape for advanced GC with a particular emphasis on later-line treatments and outline novel perspectives on the horizon.
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Affiliation(s)
- Beatrice Riccò
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Giulio Martinelli
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Camilla Bardasi
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Massimo Dominici
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Andrea Spallanzani
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
| | - Massimiliano Salati
- Department of Oncology and Hematology, University Hospital of Modena, Modena, Italy
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Lai H, Wu K, Liu Y, Li D, Peng T, Zhang B. Efficacy and safety of self-expandable metal stent placement for treatment of primary and metastatic gastric outlet obstruction. Ir J Med Sci 2023; 192:2077-2084. [PMID: 36441448 DOI: 10.1007/s11845-022-03195-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/15/2022] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Haiyang Lai
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Ketong Wu
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Yang Liu
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Dan Li
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Tao Peng
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Bo Zhang
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China.
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Maetani I. How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction? Front Med (Lausanne) 2022; 9:967740. [PMID: 36017000 PMCID: PMC9395687 DOI: 10.3389/fmed.2022.967740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.
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Mulazzani GE, Corti F, Della Valle S, Di Bartolomeo M. Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade. Nutrients 2021; 13:nu13082766. [PMID: 34444926 PMCID: PMC8400027 DOI: 10.3390/nu13082766] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/04/2021] [Accepted: 08/10/2021] [Indexed: 02/07/2023] Open
Abstract
Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients’ selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment’s tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients.
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Affiliation(s)
- Giulia E.G. Mulazzani
- Clinical Nutrition Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy; (G.E.G.M.); (S.D.V.)
| | - Francesca Corti
- Gastrointestinal Medical Oncology, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy;
| | - Serena Della Valle
- Clinical Nutrition Unit, Department of Critical and Supportive Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy; (G.E.G.M.); (S.D.V.)
| | - Maria Di Bartolomeo
- Gastrointestinal Medical Oncology, Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan, Italy;
- Correspondence: ; Tel.: +39-02-2390-2882
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Arnstadt B, Allescher HD. [Palliative endoscopy]. Chirurg 2021; 93:310-322. [PMID: 34137905 DOI: 10.1007/s00104-021-01426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/07/2022]
Abstract
Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.
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Affiliation(s)
- Benno Arnstadt
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland.
| | - Hans-Dieter Allescher
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland
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Abstract
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.
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Affiliation(s)
- Bing-Wei Ye
- Division of Gastroenterology, Department of Medicine, Taiwan Adventist Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
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7
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Patita M, Castro R, Libânio D, Bastos RP, Silva R, Dinis-Ribeiro M, Pimentel-Nunes P. Covered Metal Stent after Dysfunction of Uncovered Stents for Palliation of Gastrointestinal Malignant Obstruction. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:383-390. [PMID: 33251287 DOI: 10.1159/000507200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/20/2020] [Indexed: 12/24/2022]
Abstract
Background Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastrointestinal tract obstruction. However, restenosis or incomplete expansion of a first stent is a frequent complication, and the effectiveness of reintervention with placement of a second stent is still controversial. Objective To evaluate the clinical outcomes of covered SEMS (cSEMS) placement after dysfunction of uncovered SEMS (uSEMS) by the stent-in-stent technique. Patients and Methods We retrospectively studied a consecutive series of patients receiving palliative treatment for malignant gastrointestinal obstruction with cSEMS placement after uSEMS dysfunction in a tertiary center from January 2013 to August 2018. Technical and clinical success, time of patency, and adverse events were analyzed. Results Twelve patients were included; their mean age was 60 ± 9 years. Eleven patients had gastric outlet obstruction, and 1 patient had compression of the transverse colon due to gastric neoplasia. In 5 cases, there was absence of early clinical success with uSEMS and stent dysfunction in 7 cases (median patency time: 81 days). There was 100% technical success and 91.7% clinical success after cSEMS placement. There were no adverse events nor need for reintervention. The median patency time after placement of both stents was 163 days (vs. 71 days with the initial stent). Conclusion cSEMS placement after uSEMS dysfunction is technically feasible and a clinically effective treatment for patients with recurrent malignant gastrointestinal obstruction, with good stent patency in the medium/long term. This approach seems to be safe and without increase in adverse effects.
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Affiliation(s)
- Marta Patita
- Gastroenterology Department, Hospital Garcia de Orta, Almada, Portugal
| | - Rui Castro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Diogo Libânio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems, Porto, Portugal
| | - Rui Pedro Bastos
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Rui Silva
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal.,Center for Research in Health Technologies and Information Systems, Porto, Portugal.,Surgery and Physiology Department, Faculty of Medicine, University of Porto, Porto, Portugal
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Suder-Castro L, Ramírez-Solís M, Hernández-Guerrero A, de la Mora-Levy J, Alonso-Lárraga J, Hernández-Lara A. Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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9
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Suder-Castro LS, Ramírez-Solís ME, Hernández-Guerrero AI, de la Mora-Levy JG, Alonso-Lárraga JO, Hernández-Lara AH. Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:275-281. [PMID: 32229056 DOI: 10.1016/j.rgmx.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/16/2019] [Accepted: 08/08/2019] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- L S Suder-Castro
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México.
| | - M E Ramírez-Solís
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - A I Hernández-Guerrero
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - J G de la Mora-Levy
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - J O Alonso-Lárraga
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - A H Hernández-Lara
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
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Nunes G, Fonseca J, Barata AT, Dinis-Ribeiro M, Pimentel-Nunes P. Nutritional Support of Cancer Patients without Oral Feeding: How to Select the Most Effective Technique? GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 27:172-184. [PMID: 32509923 DOI: 10.1159/000502981] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 07/27/2019] [Indexed: 12/18/2022]
Abstract
Background Digestive tumours are among the leading causes of morbidity and mortality. Many cancer patients cannot maintain oral feeding and develop malnutrition. The authors aim to: review the endoscopic, radiologic and surgical techniques for nutritional support in cancer patients; address the strategies for nutritional intervention according to the selected technique; and establish a decision-making algorithm to define the best approach in a specific tumour setting. Summary This is a narrative non-systematic review based on an electronic search through the medical literature using PubMed and UpToDate. The impossibility of maintaining oral feeding is a major cause of malnutrition in head and neck (H&N) cancer, oesophageal tumours and malignant gastric outlet obstruction. Tube feeding, endoscopic stents and gastrojejunostomy are the three main nutritional options. Nasal tubes are indicated for short-term enteral feeding. Percutaneous endoscopic gastrostomy (PEG) is the gold standard when enteral nutrition is expected for more than 3-4 weeks, especially in H&N tumour and oesophageal cancer patients undergoing definite chemoradiotherapy. A gastropexy push system may be considered to avoid cancer seeding. Radiologic and surgical gastrostomy are alternatives when an endoscopic approach is not feasible. Postpyloric nutrition is indicated for patients intolerant to gastric feeding and may be achieved through nasoenteric tubes, PEG with jejunal extension, percutaneous endoscopic jejunostomy and surgical jejunostomy. Oesophageal and enteric stents are palliative techniques that allow oral feeding and improve quality of life. Surgical or EUS-guided gastrojejunostomy is recommended when enteric stents fail or prolonged survival is expected. Nutritional intervention is dependent on the technique chosen. Institutional protocols and decision algorithms should be developed on a multidisciplinary basis to optimize nutritional care. Conclusions Gastroenterologists play a central role in the nutritional support of cancer patients performing endoscopic techniques that maintain oral or enteral feeding. The selection of the most effective technique must consider the cancer type, the oncologic therapeutic program, nutritional aims and expected patient survival.
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Affiliation(s)
- Gonçalo Nunes
- Gastroenterology Department, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal
| | - Jorge Fonseca
- Gastroenterology Department, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal.,CiiEM - Center for Interdisciplinary Research Egas Moniz, Monte da Caparica, Portugal
| | - Ana Teresa Barata
- Gastroenterology Department, GENE - Artificial Feeding Team, Hospital Garcia de Orta, Almada, Portugal
| | - Mário Dinis-Ribeiro
- Gastroenterology Department, Instituto Português de Oncologia Francisco Gentil, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Pimentel-Nunes
- Gastroenterology Department, Instituto Português de Oncologia Francisco Gentil, Porto, Portugal.,Center for Research in Health Technologies and Information Systems (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
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Feasibility and safety of duodenal covered self-expandable metallic stent fixation: an experimental study. Surg Endosc 2019; 33:4026-4031. [PMID: 30759276 DOI: 10.1007/s00464-019-06694-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/06/2019] [Indexed: 12/18/2022]
Abstract
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.
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Endoscopic stenting for palliation of intra-abdominal gastrointestinal malignant obstruction: predictive factors for clinical success. Eur J Gastroenterol Hepatol 2018; 30:1033-1040. [PMID: 29851864 DOI: 10.1097/meg.0000000000001178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic stenting proved to be a safe alternative to surgery for malignant intra-abdominal gastrointestinal obstruction. Although high technical success rates have been reported, some patients do not experience relief in symptoms. AIM This study aimed to analyse the factors predicting the effectiveness of stent placement in patients with gastrointestinal obstruction. PATIENTS AND METHODS A retrospective study was carried out including 160 patients who underwent palliative stenting for intra-abdominal obstruction in a tertiary centre from December 2012 to July 2017. Technical and clinical success, stent dysfunction and adverse events were analysed. RESULTS The rate of technical success was 98%. The rate of early clinical success was 69 and 81% in upper and lower gastrointestinal obstructions, respectively (P=0.107). In the upper tract, obstruction caused by carcinomatosis was the only independent factor predicting early and late clinical failure [odds ratio (OR): 9.7, 95% confidence interval (CI): 2.5-38.4, P=0.001 and OR: 7.6, 95% CI: 1.8-31.9, P=0.006, respectively]. In the colon, Eastern Cooperative Oncology Group score of at least 3 was an independent factor for early clinical failure (OR: 29.8, 95% CI: 1.9-464.9, P=0.002) and obstruction caused by carcinomatosis was an independent factor for late clinical failure (OR: 14.4, 95% CI: 1.7-119.6, P=0.013). Perforation occurred in 4 patients (2.5%) and stent dysfunction occurred in 15% of patients (4% stent migration; 9% restenosis). Carcinomatosis was a risk factor for perforation (P=0.039) and migration was higher with shorter 6 cm stents (P=0.044). CONCLUSION Stents are effective and safe for palliation of intra-abdominal obstruction. Carcinomatosis predicts an unfavourable clinical outcome. Palliative stenting as an option should be weighed carefully in these patients.
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The utility and efficacy of self-expandable metal stents for treating malignant gastric outlet obstructions in patients under best supportive care. Support Care Cancer 2018; 26:3587-3592. [PMID: 29725801 DOI: 10.1007/s00520-018-4221-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 04/25/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE Self-expandable metallic stents (SEMSs) may be used to effectively palliate malignant gastric outlet obstructions (GOOs), but their utility and efficacy in patients under best supportive care (BSC) have not been explored. METHOD In this multicenter retrospective study, we reviewed data on patients under BSC who underwent endoscopic SEMS placement to treat malignant GOO without chemotherapy. We evaluated the safety and efficacy of the procedure. RESULTS We enrolled a total of 208 patients. SEMS placement was technically successful in 207 (99.5%) and clinically successful in 164 (78.8%). The mean procedure time was 25.6 ± 2.8 min. Stent dysfunction later developed in 30 (14.4%) patients, of whom 90% (27/30) underwent reintervention. The procedure-related mortality rate was 1.44%; all deaths were due to pneumonia. Subgroup analysis by Karnofsky performance status (KPS) revealed that neither technical success, stent dysfunction, reintervention rate, procedure-related pneumonia or death, nor death within 14 days differed between patients with good and poor KPS. However, the clinical success rate and the median survival time were significantly lower and shorter, respectively, in those with poor KPS (p < 0.001). CONCLUSIONS Duodenal SEMS placement is an effective palliative treatment for malignant GOO in BSC patients. Although the GOO score did not dramatically improve in patients with poor KPS, the procedure was safe and palliatively feasible. Procedure-related pneumonia was fatal; thus, it is essential to proceed with great caution. TRIAL REGISTRATION Clinical trial registration number: UMIN000028367.
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Abstract
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.
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Affiliation(s)
- Vishal B Gohil
- Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Jason B Klapman
- Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.
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Park JH, Tsauo J, Song HY. Self-expandable metal stent placement for recurrent cancer in a surgically-altered stomach. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kato H, Tsutsumi K, Okada H. Recent advancements in stent therapy in patients with malignant gastroduodenal outlet obstruction. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:186. [PMID: 28616401 DOI: 10.21037/atm.2017.02.11] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Predictors of stent dysfunction after self-expandable metal stent placement for malignant gastric outlet obstruction: tumor ingrowth in uncovered stents and migration of covered stents. Surg Endosc 2017; 31:4165-4173. [DOI: 10.1007/s00464-017-5471-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/15/2017] [Indexed: 10/25/2022]
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Rademacher C, Bechtler M, Schneider S, Hartmann B, Striegel J, Jakobs R. Self-expanding metal stents for the palliation of malignant gastric outlet obstruction in patients with peritoneal carcinomatosis. World J Gastroenterol 2016; 22:9554-9561. [PMID: 27920476 PMCID: PMC5116599 DOI: 10.3748/wjg.v22.i43.9554] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/08/2016] [Accepted: 10/10/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the efficacy of self-expanding metal stents (SEMS) for the palliation of malignant gastric outlet obstruction in patients with and without peritoneal carcinomatosis (PC).
METHODS We performed a retrospective analysis of 62 patients who underwent SEMS placement for treatment of malignant gastroduodenal obstruction at our hospital over a six-year period. Stents were deployed through the scope under combined fluoroscopic and endoscopic guidance. Technical success was defined as successful stent placement and expansion. Clinical success was defined as an improvement in the obstructive symptoms and discharge from hospital without additional parenteral nutrition. According to carcinomatosis status, patients were assigned into groups with or without evidence of peritoneal disease.
RESULTS In most cases, obstruction was caused by pancreatic (47%) or gastric cancer (23%). Technical success was achieved in 96.8% (60/62), clinical success in 79% (49/62) of all patients. Signs of carcinomatosis were identified in 27 patients (43.5%). The diagnosis was confirmed by pathology or previous operation in 7 patients (11.2%) and suspected by CT, MRI or ultrasound in 20 patients (32.2%). Presence of carcinomatosis was associated with a significantly lower clinical success rate compared to patients with no evidence of peritoneal disease (66.7% vs 88.6%, P = 0.036). There was no significant difference in overall survival between patients with or without PC (median 48 d vs 70 d, P = 0.21), but patients showed significantly longer survival after clinical success of SEMS placement compared to those experiencing clinical failure (median 14.5 d vs 75 d, P = 0.0003).
CONCLUSION Given the limited therapeutic options and a clinical success rate of at least 66.7%, we believe that SEMS are a reasonable treatment option in patients with malignant gastric outlet obstruction with peritoneal carcinomatosis.
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Yamao K, Kitano M, Kayahara T, Ishida E, Yamamoto H, Minaga K, Yamashita Y, Nakajima J, Asada M, Okabe Y, Osaki Y, Chiba Y, Imai H, Kudo M. Factors predicting through-the-scope gastroduodenal stenting outcomes in patients with gastric outlet obstruction: a large multicenter retrospective study in West Japan. Gastrointest Endosc 2016; 84:757-763.e6. [PMID: 27055762 DOI: 10.1016/j.gie.2016.03.1498] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 03/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Endoscopic gastroduodenal stenting for malignant gastric outlet obstruction recently has become more effective, but the factors that predict gastroduodenal stenting outcomes are poorly defined. This multicenter retrospective cohort study evaluated the clinical outcomes of gastroduodenal stenting in malignant gastroduodenal obstruction and identified factors predicting clinical ineffectiveness, stent dysfunction, and adverse events. METHODS All consecutive patients with malignant gastroduodenal obstruction who underwent through-the-scope gastroduodenal stenting from 2009 to 2014 at 4 tertiary-care medical centers were identified. Clinically ineffective stenting was defined as symptom recurrence and a gastric outlet obstruction scoring system (GOOSS) score <2. RESULTS Of the 278 patients (mean age ± standard deviation [SD] 71.7 ± 11.4 years), 121 (43.5%) and 87 (31.3%) had pancreatic and gastric cancer, respectively. Technical success was achieved in 277 patients (99.6%). GOOSS scores rose from 0.5 ± 0.6 to 2.6 ± 0.8. Stenting was ineffective in 32 patients (12.6%). Stent dysfunction that caused symptom recurrence during follow-up developed in 46 patients (16.6%). Adverse events occurred in 49 patients (17.7%). Three or more stenosis sites (odds ratio [OR] = 6.11; P < .01) and Karnofsky performance scores ≤50 (OR = 6.63; P < .01) predicted clinical ineffectiveness. Karnofsky performance scores ≤50 predicted stent dysfunction (hazard ratio [HR] = 3.63; P < .01). Bile duct stenosis (HR = 9.55; P = .02) and liver metastasis (HR = 9.42; P < .01) predicted stent overgrowth. Covered stent predicted stent migration (HR = 12.63; P < .01). Deployment of 2 stents predicted perforation (HR = 854.88; P < .01). CONCLUSIONS Through-the-scope gastroduodenal stenting tended to be ineffective in patients with poor performance status and long stenosis sites. Stent dysfunction occurred more frequently in patients with poorer performance status. Deployment of 2 stents was a risk factor for perforation. Identification of these risk variables may help yield better gastroduodenal stenting outcomes.
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Affiliation(s)
- Kentaro Yamao
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka-sayama, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka-sayama, Japan
| | - Takahisa Kayahara
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Okayama, Japan
| | - Etsuji Ishida
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Okayama, Japan
| | - Hiroshi Yamamoto
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Okayama, Japan
| | - Kosuke Minaga
- Department of Gastroenterology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Yukitaka Yamashita
- Department of Gastroenterology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Jun Nakajima
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Masanori Asada
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yoshihiro Okabe
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yukio Osaki
- Department of Gastroenterology and Hepatology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yasutaka Chiba
- Clinical Research Center, Kinki University Hospital, Osaka-sayama, Japan
| | - Hajime Imai
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka-sayama, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kinki University School of Medicine, Osaka-sayama, Japan
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20
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Kato H, Kawamoto H, Matsumoto K, Moriyama I, Kamada H, Tsutsumi K, Goto D, Fukuba N, Kato K, Sonoyama H, Isomoto H, Okada H. Outcome of self-expandable metallic stent deployment in patients with malignant gastroduodenal outlet obstruction and Niti-S and WallFlex comparison: a multicenter retrospective clinical study. J Dig Dis 2016; 17:518-525. [PMID: 27383654 DOI: 10.1111/1751-2980.12377] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/20/2016] [Accepted: 06/30/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Several studies report on the outcomes of self-expandable metallic stents (SEMSs) deployment for malignant gastric outlet obstruction (GOO). However, data was mostly based on the analysis of single-center studies including only a small number of patients. This study aimed to evaluate clinical outcomes after the deployment of SEMS in patients with malignant GOO and to compare the clinical outcomes of two metallic stents with different designs. METHODS Altogether 125 consecutive patients from five institutions were included. Clinical outcomes were evaluated according to technical success, clinical success, stent patency period, survival period and complications. A comparison of clinical outcomes between Niti-S pyloric/duodenal and WallFlex duodenal stents was also undertaken. RESULTS Rates for clinical and technical success were 100% and 92.0%, respectively. The median stent patency and survival periods were 72.0 days (range 3-775 days) and 75.0 days (range 3-775 days), respectively. The rate of overall adverse events was 28.8%. The rate of stent dysfunction was 16.8%, and that of adverse events, except stent dysfunction was 12.0%. Massive bleeding occurred in two patients as a late complication. The clinical success rate for Niti-S stent was significantly higher than that for WallFlex stent (96.2% vs 84.8%, P = 0.023). CONCLUSIONS We successfully deployed a SEMS in malignant GOO. The selection of a SEMS with a lower axial force may be important for patients to resume the oral food intake. Additionally, consideration must be given to the appropriate management of fatal bleeding as a late complication.
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Affiliation(s)
- Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan. .,Hakushusanbi Endoscopic Workshop Group, Japan.
| | - Hirofumi Kawamoto
- Department of General Internal Medicine 2, Kawasaki Medical School, Okayama, Japan.,Hakushusanbi Endoscopic Workshop Group, Japan
| | - Kazuya Matsumoto
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan.,Hakushusanbi Endoscopic Workshop Group, Japan
| | - Ichiro Moriyama
- Division of Clinical study of Oncology, Shimane University School of Medicine, Izumo, Japan.,Hakushusanbi Endoscopic Workshop Group, Japan
| | - Hideki Kamada
- Department of Gastroenterology and Neurology, Kagawa University, Kagawa, Japan.,Hakushusanbi Endoscopic Workshop Group, Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Daisuke Goto
- Department of Gastroenterology and Hepatology, Tottori Municipal Hospital, Tottori, Japan
| | - Nobuhiko Fukuba
- Department of Internal Medicine II, Shimane University School of Medicine, Izumo, Japan
| | - Kiyohito Kato
- Department of Gastroenterology and Neurology, Kagawa University, Kagawa, Japan
| | - Hiroki Sonoyama
- Department of Internal Medicine II, Shimane University School of Medicine, Izumo, Japan
| | - Hajime Isomoto
- Department of Gastroenterology, Tottori University Hospital, Yonago, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Lee F, Lee F, Abdul-Halim R, Abdul-Halim R, Dickinson O, Dickinson O, Maetani I. Malignant gastroduodenal obstruction: An endoscopic approach. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
| | - Fred Lee
- Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Rehan Abdul-Halim
- Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK
| | | | - Owen Dickinson
- Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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22
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Kobayashi S, Ueno M, Kameda R, Moriya S, Irie K, Goda Y, Tezuka S, Yanagida N, Ohkawa S, Aoyama T, Morinaga S, Morimoto M. Duodenal stenting followed by systemic chemotherapy for patients with pancreatic cancer and gastric outlet obstruction. Pancreatology 2016; 16:1085-1091. [PMID: 27424479 DOI: 10.1016/j.pan.2016.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/13/2016] [Accepted: 07/09/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Endoscopic duodenal stenting has recently been proposed as a substitute for surgical gastrojejunostomy for the treatment of gastric outlet obstruction. We aimed to evaluate the efficacy and safety of duodenal stenting followed by systemic chemotherapy for patients with advanced pancreatic cancer with gastric outlet obstruction. METHODS This was a single-center, retrospective cohort study, conducted at an academic medical center, of 71 patients with advanced pancreatic cancer and gastric outlet obstruction (mean age: 67.6 years; range: 31-92 years) who underwent duodenal stenting with or without subsequent chemotherapy. Overall survival, duration of oral intake of foods, the rate of introduction of chemotherapy, progression-free survival, and adverse events were evaluated. RESULTS Stent placement was technically successful in 69 (97%) patients. Thirty-six (51%) patients were treated with chemotherapy: 17 with gemcitabine alone, 15 with S-1 alone, 3 with FOLFIRINOX, and 1 with paclitaxel. Median progression-free survival and overall survival after chemotherapy were 2.6 months (95% confidence interval: 1.3-3.9 months) and 4.7 months (95% confidence interval: 2.6-6.8 months), respectively. Cases of grade 3 anemia were frequently observed during chemotherapies following duodenal stenting (32%). Tumor stage, performance status, neutrophil-to-lymphocyte ratio, and introduction of chemotherapy were independent prognostic factors for survival (hazard ratios of 3.73, 2.21, 2.69, and 1.85 with p-values of <0.001, 0.010, <0.001, and 0.045, respectively). CONCLUSIONS The findings of this study suggest that endoscopic duodenal stenting is an advantageous treatment in advanced pancreatic cancer patients with gastric outlet obstruction regarding its safety and smooth conduction of subsequent chemotherapies.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan.
| | - Makoto Ueno
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Ryo Kameda
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Satoshi Moriya
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Kuniyasu Irie
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshihiro Goda
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Shun Tezuka
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Naoki Yanagida
- Department of Gastroenterology, Yamato Municipal Hospital, Yamato, Japan
| | - Shinichi Ohkawa
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Toru Aoyama
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Soichiro Morinaga
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Manabu Morimoto
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
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Shin YS, Choi CW, Kang DH, Kim HW, Kim SJ, Cho M, Hwang SH, Lee SH. Factors associated with clinical failure of self-expandable metal stent for malignant gastroduodenal obstruction. Scand J Gastroenterol 2016; 51:103-10. [PMID: 26139518 DOI: 10.3109/00365521.2015.1064992] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Endoscopic self-expandable metal stent (SEMS) placement has emerged as an effective palliative treatment for inoperable malignant gastric outlet obstruction (GOO). In spite of successful stent placement, some patients complain of ongoing dysphagia and vomiting. Most reported data on SEMS to date are about technical success of different types of stents and low complication rates. The aim of this study was to evaluate the associated factors of clinical failure after endoscopic SEMS placement for inoperable malignant GOO. METHODS A total 122 patients who underwent successful endoscopic SEMS placement for malignant GOO in an academic referral center were included in the analyses. We retrospectively evaluated variables associated with clinical outcomes after successful SEMS placement. RESULTS The clinical success rate was 81.1%. The common causes of GOO were pancreatic (39%) and gastric cancers (32%). The mean length of the stents (± standard deviation) was 10.06 ± 2.42 cm. Multivariate analysis revealed that gallbladder cancer (p = 0.016, OR 6.486, 95% CI, 1.509-59.655), poor performance status (ECOG ≥ 3) (p = 0.001, OR 10.200, 95% CI, 2.435-42.721), the presence of carcinomatosis peritonei (p < 0.001, OR 35.714, 95% CI, 5.556-250.000) and the failure of endoscope passage (p = 0.039, OR 6.945, 95% CI, 1.101-43.818). CONCLUSION Our results suggest that gallbladder cancer, poor performance status (ECOG ≥ 3) and the presence of carcinomatosis peritonei related with clinical failure of palliative SEMS placement.
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Affiliation(s)
- Young Shin Shin
- a 1 Department of Internal Medicine, Dongrae-Bongseng Hospital , Busan, Korea.,b 2 Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Cheol Woong Choi
- b 2 Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Dae Hwan Kang
- b 2 Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Hyung Wook Kim
- b 2 Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Su Jin Kim
- b 2 Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Mong Cho
- b 2 Department of Internal Medicine, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Sun Hwi Hwang
- c 3 Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
| | - Si Hak Lee
- c 3 Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital , Yangsan, Korea
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Lee JE, Lee K, Hong YS, Kim ER, Lee H, Min BH. Impact of Carcinomatosis on Clinical Outcomes after Self-Expandable Metallic Stent Placement for Malignant Gastric Outlet Obstruction. PLoS One 2015; 10:e0140648. [PMID: 26465920 PMCID: PMC4605738 DOI: 10.1371/journal.pone.0140648] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/29/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND It is still unclear whether the peritoneal carcinomatosis had a negative effect on the clinical outcomes of patients who underwent self-expandable metallic stent (SEMS) placement for malignant gastric outlet obstruction (GOO). Although carcinomatosis may be associated with the development of multifocal gastrointestinal (GI) tract obstruction or decreased bowel movement, previous studies investigated the occurrence of stent failure only and thus had limitation in evaluating clinical outcomes of patients with carcinomatosis. METHODS Between 2009 and 2013, 155 patients (88 patients without carcinomatosis and 67 patients with carcinomatosis) underwent endoscopic SEMS placement for malignant GOO. Factors affecting clinical success and obstructive symptom-free survival (time period between SEMS placement and the recurrence of obstructive symptoms due to multifocal GI tract obstruction or decreased bowel movement as well as stent failure) were assessed. RESULTS Patients with carcinomatosis showed higher Eastern Cooperative Oncology Group (ECOG) scale than those without carcinomatosis. Clinical success rates were 88.1% in patients with carcinomatosis and 97.7% in patients without carcinomatosis. In multivariate analysis, only ECOG scale was identified as an independent predictor of clinical success. During follow-up period, patients with carcinomatosis showed significantly shorter obstructive symptom-free survival than those without carcinomatosis. In multivariate analysis, the presence of carcinomatosis, chemotherapy or radiation therapy after SEMS placement, and obstruction site were identified as independent predictors of obstructive symptom-free survival. For patient without carcinomatosis, stent failure accounted for the recurrence of obstructive symptoms in 84.6% of cases. For patients with carcinomatosis, multifocal GI tract obstruction or decreased bowel movement accounted for 37.9% of cases with obstructive symptom recurrence and stent failure accounted for 44.8% of cases. CONCLUSIONS Carcinomatosis predicts unfavorable long-term clinical outcomes in patients undergoing SEMS placement for malignant GOO. This is mainly due to the development of multifocal GI tract obstructions or decreased bowel movement as well as stent failure.
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Affiliation(s)
- Ji Eun Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keol Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Soo Hong
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
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25
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Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer. Gastrointest Endosc 2015; 82:460-8.e2. [PMID: 25851162 DOI: 10.1016/j.gie.2015.01.026] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 01/08/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma. OBJECTIVE To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer. DESIGN Retrospective study. SETTING Single tertiary hospital. PATIENTS A total of 292 patients with malignant GOO. INTERVENTION Stent placement. MAIN OUTCOME MEASUREMENTS Post-stent placement survival and clinical outcome. RESULTS In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post-stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post-stent placement chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P < .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009). LIMITATIONS Retrospective study. CONCLUSIONS In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post-stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups.
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Kim SH, Chun HJ, Yoo IK, Lee JM, Nam SJ, Choi HS, Kim ES, Keum B, Seo YS, Jeen YT, Lee HS, Um SH, Kim CD. Predictors of the patency of self-expandable metallic stents in malignant gastroduodenal obstruction. World J Gastroenterol 2015; 21:9134-9141. [PMID: 26290640 PMCID: PMC4533045 DOI: 10.3748/wjg.v21.i30.9134] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 04/12/2015] [Accepted: 05/07/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the predictive factors of self-expandable metallic stent patency after stent placement in patients with inoperable malignant gastroduodenal obstruction.
METHODS: A total of 116 patients underwent stent placements for inoperable malignant gastroduodenal obstruction at a tertiary academic center. Clinical success was defined as acceptable decompression of the obstructive lesion within the malignant gastroduodenal neoplasm. We evaluated patient comorbidities and clinical statuses using the World Health Organization’s scoring system and categorized patient responses to chemotherapy using the Response Evaluation Criteria in Solid Tumors criteria. We analyzed the relationships between possible predictive factors and stent patency.
RESULTS: Self-expandable metallic stent placement was technically successful in all patients (100%), and the clinical success rate was 84.2%. In a multivariate Cox proportional hazards model, carcinoembryonic antigen (CEA) levels were correlated with a reduction in stent patency [P = 0.006; adjusted hazard ratio (aHR) = 2.92, 95%CI: 1.36-6.25]. Palliative chemotherapy was statistically associated with an increase in stent patency (P = 0.009; aHR = 0.27, 95%CI: 0.10-0.72).
CONCLUSION: CEA levels can easily be measured at the time of stent placement and may help clinicians to predict stent patency and determine the appropriate stent procedure.
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Hori Y, Naitoh I, Ban T, Narita K, Nakazawa T, Hayashi K, Miyabe K, Shimizu S, Kondo H, Nishi Y, Yoshida M, Umemura S, Kato A, Yamada T, Ando T, Joh T. Stent under-expansion on the procedure day, a predictive factor for poor oral intake after metallic stenting for gastric outlet obstruction. J Gastroenterol Hepatol 2015; 30:1246-51. [PMID: 25708096 DOI: 10.1111/jgh.12933] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2015] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Self-expandable metallic stents (SEMS) have been widely accepted as palliation therapy for malignant gastric outlet obstruction (GOO). However, the factors predictive of poor oral intake after SEMS placement have not been elucidated sufficiently. We aimed to clarify both the patient and stent-related predictive factors. METHODS We retrospectively reviewed 126 consecutive patients who underwent uncovered SEMS placement for malignant GOO between April 2010 and March 2013 at a university hospital and two tertiary care referral centers. RESULTS Technical success of SEMS placement was achieved in all 126 (100%) patients. Improved oral intake was observed in 111 (88.1%) patients. A Karnofsky performance status ≤ 40 (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.02-1.28; P = 0.041), peritoneal dissemination (OR, 1.20; 95% CI, 1.01-1.26; P = 0.038), and under-expansion of the SEMS on the procedure day (OR, 1.55; 95% CI, 1.26-1.62; P < 0.001) were independent predictive factors for poor improvement on the GOO scoring system, according to multivariate analysis. CONCLUSIONS SEMS under-expansion was a stent related, while poor performance status and peritoneal dissemination were patient related, predictive factors for poor oral intake after SEMS placement for malignant GOO.
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Affiliation(s)
- Yasuki Hori
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Itaru Naitoh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tesshin Ban
- Department of Gastroenterology, Nagoya Daini Red cross Hospital, Nagoya, Japan
| | - Kei Narita
- Department of Gastroenterology, Gamagori City Hospital, Gamagori, Japan
| | - Takahiro Nakazawa
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Kazuki Hayashi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Katsuyuki Miyabe
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shuya Shimizu
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Hiromu Kondo
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yuji Nishi
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Michihiro Yoshida
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shuichiro Umemura
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akihisa Kato
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Tomonori Yamada
- Department of Gastroenterology, Nagoya Daini Red cross Hospital, Nagoya, Japan
| | - Tomoaki Ando
- Department of Gastroenterology, Gamagori City Hospital, Gamagori, Japan
| | - Takashi Joh
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Palliation of malignant gastric outlet obstruction with simultaneous endoscopic insertion of afferent and efferent jejunal limb enteral stents in patients with recurrent malignancy. Surg Endosc 2015; 30:521-525. [PMID: 26091983 DOI: 10.1007/s00464-015-4234-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 05/10/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with prior pancreaticobiliary or distal gastric cancer treated surgically may have local anastomotic recurrence with obstruction of the afferent and efferent jejunal limbs. This report describes the efficacy and safety of simultaneous endoscopic insertion of self-expanding metal stents into the afferent and efferent jejunal limbs in patients with gastric outlet obstruction (GOO) of post-surgical anatomy for palliation of recurrent malignancy. METHODS Patients were identified from an endoscopic database at a specialized cancer center between September 2007 and March 2014. Technical success was defined as single-session insertion of afferent and efferent jejunal limb enteral stents. Clinical success was defined as immediate symptom relief and ability to advance diet. A durable response was defined as symptom relief of at least 60 days or until hospice placement or death. RESULTS Twenty-three patients were identified who underwent insertion of two 22-mm-diameter uncovered duodenal stents. Stent length varied from 60 to 120 mm. Stents were placed under endoscopic and fluoroscopic guidance. Three patients required balloon dilation to facilitate stent insertion. Average procedure time was 58.8 min (range 28-120). Technical success was achieved in 23/24 (96%) patients. Clinical success was achieved in 19/23 (83%) patients. Following initial stent insertion and prior to subsequent re-intervention, 11/19 (58%) patients had a durable response with a median duration of 70 days (range 4-315). Eight (42%) patients underwent subsequent re-intervention at a median of 22 days (range 11-315). Five patients had stent revision and were able to tolerate oral intake. Two patients had percutaneous endoscopic gastrostomy/jejunostomy insertion. One patient required surgical diversion for persistent obstruction. Complications included stent migration and post-stent insertion bacteremia due to food bolus obstruction. CONCLUSIONS Recurrent malignant GOO in patients with post-surgical anatomy treated with simultaneous endoscopic enteral stenting of afferent and efferent jejunal limbs has a high rate of technical and clinical success and low rate of complications and provides effective palliation.
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Abstract
Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kang HW, Kim SG. Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders. Clin Endosc 2015; 48:187-93. [PMID: 26064817 PMCID: PMC4461661 DOI: 10.5946/ce.2015.48.3.187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/22/2015] [Indexed: 02/06/2023] Open
Abstract
Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Chok AY, Koh YX, Lee J, Wong ASY. Secondary stent-in-stent self-expanding metallic stent placement for early stent occlusion due to mucosal oedema in the gastrojejunal anastomosis after palliative subtotal gastrectomy for locally advanced gastric cancer. Singapore Med J 2015; 54:e240-3. [PMID: 24356763 DOI: 10.11622/smedj.2013249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Herein, we report a case of early in-stent occlusion due to the ingrowth of soft oedematous mucosal tissue through the lattices of an uncovered stent, which was used for palliation of a postoperative gastrojejunal anastomotic stricture. The in-stent occulsion was treated with the deployment of a second stent, which was covered, within the first stent. This led to successful resolution of the occlusion.
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Affiliation(s)
- Aik-Yong Chok
- Department of General Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
| | - Ye-Xin Koh
- Department of General Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
| | - June Lee
- Department of General Surgery, Changi General Hospital, 2 Simei Street 3, Singapore 529889.
| | - Andrew Siang-Yih Wong
- Herein, we report a case of early in-stent occlusion due to the ingrowth of soft oedematous mucosal tissue through the lattices of an uncovered stent, which was used for palliation of a postoperative gastrojejunal anastomotic stricture. The in-stent occulsion was treated with the deployment of a second stent, which was covered, within the first stent. This led to successful resolution of the occlusion
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Park CH, Park JC, Kim EH, Chung H, An JY, Kim HI, Shin SK, Lee SK, Cheong JH, Hyung WJ, Lee YC, Noh SH, Kim CB. Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy. Gastrointest Endosc 2015; 81:321-32. [PMID: 25085332 DOI: 10.1016/j.gie.2014.06.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expandable metal stent (SEMS) placement and palliative gastrojejunostomy (GJJ) are palliative treatment options for malignant gastric outlet obstruction. OBJECTIVE To compare clinical outcomes of palliative treatments for gastric outlet obstruction caused by unresectable gastric cancer. DESIGN Retrospective study. SETTING University-affiliated tertiary-care hospital in the Republic of Korea. PATIENTS Two hundred fifty-six patients with gastric outlet obstruction caused by unresectable gastric cancer. INTERVENTION SEMS placement and palliative GJJ. MAIN OUTCOME MEASUREMENTS Patency duration and overall survival duration. RESULTS In total, 217 and 39 patients underwent SEMS placement and palliative GJJ, respectively, as an initial palliative treatment. Treatment modality affected reobstruction after clinical success (hazard ratio [HR] [95% confidence interval {CI}], 0.5 [0.3-0.8] of palliative GJJ). In addition, carcinomatosis with ascites was an independent associated factor of clinical success and reobstruction (HR [95% CI], 0.3 [0.1-0.7] and 1.4 [1.0-2.0], respectively). In a subgroup of patients with good performance who had neither carcinomatosis nor ascites, patency duration and overall survival duration did not differ between the 2 groups (P = .079 and P = .290, respectively). In patients with good performance who had carcinomatosis without ascites, patency duration was longer in the palliative GJJ group than in the SEMS placement group (P = .016). Overall survival, however, did not differ between the 2 groups (P = .062). In a subgroup of patients with good performance who had carcinomatosis with ascites, both patency duration and overall survival were longer in the palliative GJJ group than in the SEMS placement group (P = .007 and P = .012, respectively). LIMITATIONS Nonrandomized, retrospective study. CONCLUSION Long-term clinical outcomes of the palliative treatment modality for gastric outlet obstruction caused by unresectable gastric cancer were affected by carcinomatosis and ascites status.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeong An
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyoung-Il Kim
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Ho Cheong
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Chan Lee
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Noh
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Choong Bae Kim
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Godzhello EA, Khrustaleva MV, Sharipzhanova RD, Dekhtyar MA. [The results of endoscopic gastroduodenal, enteral and colorectal stenting for blastomatous stenosis: 8-year experience]. Khirurgiia (Mosk) 2015:51-55. [PMID: 26978764 DOI: 10.17116/hirurgia20151251-55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Gastroduodenal, enteral and colorectal stenting of blastomatous stenosis is a reasonable alternative to operative treatment of unresectable tumors. Moreover in some cases it allows to gain time and to prepare the patient for radical surgery. MATERIAL AND METHODS For the period from 2007 to 2015 in endoscopic department of acad. B.V. Petrovskiy Russian Research Center for Surgery 76 patients with piloroduodenal, enteral and colic stenoses successfully underwent self-expanding metal stents installation. There were 21 patients with malignant stenosis of the stomach and pilorobulbar area, 17 with secondary duodenal stenosis, 17 after gastrectomy and distal gastric resection; 2 with stenosing colorectal cancer, 4 patients with rectal cancer involving rectosigmoid junction, 7 with rectosigmoid junction cancer and 8 with sigmoid cancer. RESULTS Ambulatory and hospital interventions were performed in 35.5% and 64.5% of cases respectively. Hospital-stay did not exceed 2 days. The total complication rate was 11.8% (9/76), 3 of 9 patients required surgical intervention. The attention is given to important technical aspects of intervention as well as to those clinical situations when stenting is inappropriate because of absence of favourable functional outcome. CONCLUSION Stenting should be more actively implemented in clinical practice, especially in emergency surgical hospitals. However it requires adequate technical support of hospitals with different endoprostheses, because it provides simultaneous diagnostic survey and remedial procedure.
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Affiliation(s)
- E A Godzhello
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
| | - M V Khrustaleva
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
| | | | - M A Dekhtyar
- Acad. B.V. Petrovsky Russian Research Center of Surgery, Moscow
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Sasaki T, Isayama H, Nakai Y, Takahara N, Hamada T, Mizuno S, Mohri D, Yagioka H, Kogure H, Arizumi T, Togawa O, Matsubara S, Ito Y, Yamamoto N, Sasahira N, Hirano K, Toda N, Tada M, Koike K. Clinical outcomes of secondary gastroduodenal self-expandable metallic stent placement by stent-in-stent technique for malignant gastric outlet obstruction. Dig Endosc 2015; 27:37-43. [PMID: 24995858 DOI: 10.1111/den.12321] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 06/10/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM To evaluate the efficacy and safety of secondary gastroduodenal stent placement after first stent dysfunction for malignant gastric outlet obstruction. METHODS We conducted a retrospective analysis to investigate the efficacy and safety of secondary stent-in-stent gastroduodenal stent placement. RESULTS Among 260 patients who had been treated with first gastroduodenal stent placement for malignant gastric outlet obstruction, 29 patients (11.2%) were treated with secondary gastroduodenal stent placement because of first stent dysfunction. Pancreatic cancer was the major primary cancer (55.2%). A WallFlex duodenal stent was the most frequently inserted stent both as a first stent (75.9%) and as a secondary stent (62.1%). There were 22 patients (75.9%) that received gastroduodenal stents at the bending site (supraduodenal angle or infraduodenal angle). Technical and clinical success rates were 100% and 86.2%, respectively. Median eating period was 3.0 months, and median survival time was 3.5 months. As for related complications, gastrointestinal perforation, insufficient stent expansion, tumor ingrowth, tumor overgrowth, and cholangitis were experienced in 13.8% (four cases), 6.9% (two cases), 6.9% (two cases), 3.4% (one case), and 3.4% (one case), respectively. CONCLUSION Secondary gastroduodenal stent placement might be effective for managing first stent dysfunction in malignant gastric outlet obstruction. However, gastrointestinal perforation was the major complication.
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Affiliation(s)
- Takashi Sasaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Sato T, Hara K, Mizuno N, Hijioka S, Imaoka H, Niwa Y, Tajika M, Tanaka T, Ishihara M, Shimizu Y, Bhatia V, Kobayashi N, Endo I, Maeda S, Nakajima A, Kubota K, Yamao K. Gastroduodenal stenting with Niti-S stent: long-term benefits and additional stent intervention. Dig Endosc 2015; 27:121-9. [PMID: 24754262 DOI: 10.1111/den.12300] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 03/07/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Self-expandable metallic stents have mainly been used for the palliation of malignant gastric outlet obstruction (GOO). However, their use in long-term survivors and the feasibility, safety and benefit of additional intervention for stent dysfunction remain controversial. The present study examined the long-term benefits of endoscopic gastroduodenal stenting. METHODS We reviewed 61 patients treated with Niti-S stents at several hospitals and estimated the efficacy of stent intervention, stent patency, eating period and factors related to poor effectiveness. RESULTS All 61 first stent interventions and 14 additional stent interventions (11 second interventions and 3 third interventions) were successfully carried out. Clinical success rates were 83.6% and 85.7%, and median stent patency was 214 days and 146 days (P = 0.47), respectively. Fifty patients could be treated with a first stent only, and 11 patients received additional stents. At the time of study termination or death, 70.0% of the former group and 63.6% of the latter group maintained oral intake (P = 0.71), and each 86% and 100% among the group could maintain oral intake for a period exceeding half of their remaining lives after first stent intervention. Karnofsky performance status ≤50 (P = 0.03), ascites (P = 0.009), and peritoneal dissemination (P = 0.001) appeared to be factors related to poor effectiveness. CONCLUSIONS Despite the presence of factors related to poor effectiveness, endoscopic gastroduodenal stenting would be the first treatment of choice for GOO and provide long-term benefits. If stent dysfunction occurs, additional stent intervention enables continued oral intake safely.
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Affiliation(s)
- Takamitsu Sato
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan; Division of Gastroenterology, Yokohama City University School of Medicine, Yokohama, Japan
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Laval G, Marcelin-Benazech B, Guirimand F, Chauvenet L, Copel L, Durand A, Francois E, Gabolde M, Mariani P, Rebischung C, Servois V, Terrebonne E, Arvieux C. Recommendations for bowel obstruction with peritoneal carcinomatosis. J Pain Symptom Manage 2014; 48:75-91. [PMID: 24798105 DOI: 10.1016/j.jpainsymman.2013.08.022] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 06/25/2013] [Accepted: 08/28/2013] [Indexed: 02/08/2023]
Abstract
This article reports on the clinical practice guidelines developed by a multidisciplinary group working on the indications and uses of the various available treatment options for relieving intestinal obstruction or its symptoms in patients with peritoneal carcinomatosis. These guidelines are based on a literature review and expert opinion. The recommended strategy involves a clinical and radiological evaluation, of which CT of the abdomen is a crucial component. The results, together with an analysis of the prognostic criteria, are used to determine whether surgery or stenting is the best option. In most patients, however, neither option is feasible, and the main emphasis, therefore, is on the role and administration of various symptomatic medications such as glucocorticoids, antiemetic agents, analgesics, and antisecretory agents (anticholinergic drugs, somatostatin analogues, and proton-pump inhibitors). Nasogastric tube feeding is no longer used routinely and should instead be discussed on a case-by-case basis. Recent studies have confirmed the efficacy of somatostatin analogues in relieving obstruction-related symptoms such as nausea, vomiting, and pain. However, the absence of a marketing license and the high cost of these drugs limit their use as the first-line treatment, except in highly selected patients (early recurrence). When these medications fail to alleviate the symptoms of obstruction, venting gastrostomy should be considered promptly. Rehydration is needed for virtually every patient. Parenteral nutrition and pain management should be adjusted according to the patient needs and guidelines.
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Affiliation(s)
- Guillemette Laval
- Palliative and Supportive Care Mobile Unit, University Hospital Center, Grenoble, France.
| | | | | | - Laure Chauvenet
- Department of Medical Oncology, Hospital Hôtel Dieu, APHP, Paris, France
| | - Laure Copel
- Department of Medical Oncology, Institute Curie, Paris, France
| | - Aurélie Durand
- Department of Hepato-Gastroenterology, University Hospital Center, Grenoble, France
| | | | - Martine Gabolde
- Palliative Care Unit, Hospital Paul Brousse, APHP, Villejuif, France
| | - Pascale Mariani
- Department of Digestive Surgery, Institute Curie, Paris, France
| | | | | | - Eric Terrebonne
- Department of Hepato-Gastroenterology, Hospital du haut Levêque, Pessac, France
| | - Catherine Arvieux
- Department of Digestive Surgery, University Hospital Center, Grenoble, France
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Lee KC, Hsieh YC, Perng CL, Chao Y, Li CP, Hou MC, Lin HC. Outcome for self-expandable metal stents in patients with malignant gastroduodenal obstruction: A single center experience. ADVANCES IN DIGESTIVE MEDICINE 2014. [DOI: 10.1016/j.aidm.2014.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Jeon HH, Park CH, Park JC, Shim CN, Kim S, Lee HJ, Lee H, Shin SK, Lee SK, Lee YC. Carcinomatosis matters: clinical outcomes and prognostic factors for clinical success of stent placement in malignant gastric outlet obstruction. Surg Endosc 2014; 28:988-95. [PMID: 24185750 DOI: 10.1007/s00464-013-3268-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 10/06/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although carcinomatosis is not a contraindication to stenting in selected patients with malignant gastric outlet obstruction (GOO), associate factors for clinical success rate of self-expandable metallic stent (SEMS) placement in GOO patients with carcinomatosis have not been fully characterized. METHODS We analyzed a total 228 patients who were scheduled for SEMS placement for malignant GOO in tertiary-care academic medical center. All patients were treated with an uncovered or covered SEMS by using the over-the-wire placement procedure. We retrospectively evaluated clinical outcomes of SEMS placement. RESULTS Technical success was achieved in all patients. Patients were categorized into two groups according to the presence of carcinomatosis. Clinical success rates of patients without carcinomatosis group and with carcinomatosis group were 93.9 % (92 of 98) and 80.8 % (105 of 130), respectively (P = 0.004). In subgroup analysis of patients with carcinomatosis, the clinical success rate was lower in patients with ascites (64.8 %) than in those without ascites (92.1 %, P < 0.001). Multivariate logistic regression model revealed that carcinomatosis without ascites did not decrease clinical success rate compared with absence of carcinomatosis; meanwhile, carcinomatosis with ascites showed lower clinical success rates compared with absence of carcinomatosis (adjusted odds ratio 0.163, 95 % confidence interval 0.058-0.461). In addition, poor performance status [Eastern Cooperative Oncology Group (ECOG) status ≥ 3, adjusted odds ratio 0.178, 95 % confidence interval 0.078-0.409] was also an independent poor predictive factor for clinical success of SEMS placement. CONCLUSIONS In palliation for malignant GOO, the status of carcinomatosis with ascites and poor performance status (ECOG status ≥ 3) are significant predictive factors for poor clinical success of SEMS placement.
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Affiliation(s)
- Han Ho Jeon
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Tringali A, Didden P, Repici A, Spaander M, Bourke MJ, Williams SJ, Spicak J, Drastich P, Mutignani M, Perri V, Roy A, Johnston K, Costamagna G. Endoscopic treatment of malignant gastric and duodenal strictures: a prospective, multicenter study. Gastrointest Endosc 2014; 79:66-75. [PMID: 23932009 DOI: 10.1016/j.gie.2013.06.032] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 06/19/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Malignant gastric outlet obstruction is often treated by stent placement. OBJECTIVE To investigate the outcomes of stent placement in the palliative treatment of malignant neoplasms. DESIGN Prospective, observational, multicenter registry. SETTING Six tertiary care centers in 5 countries. PATIENTS A total of 108 adult patients with malignant gastric outlet obstruction. INTERVENTIONS Placement of an uncovered, self-expandable, metal duodenal stent. MAIN OUTCOME MEASUREMENTS The primary endpoint was stent patency at 14 days after stent implantation. Secondary endpoints included stent patency at 1, 2, 3, and 6 months, gastric outlet obstruction scoring system (GOOSS) scores at 14 days and 1, 2, 3, and 6 months after stent deployment, technical success, adverse events, and patient survival (ie, confirmed duration of the implant). RESULTS Technical success was achieved in 99.1% of stent placements. Stent patency at 14 days was 94.6%. Kaplan-Meier estimates of stent patency were 92.9% at 1 month, 86.2% at 2 months, 81.9% at 3 months, and 63.4% at 6 months. At 14 days, GOOSS scores increased by a median of 1 point. The overall GI adverse event rate was 32.4%; however, the stent-related adverse event rate was 19.4%. The median implant duration was 47 days (range 0-195 days). LIMITATIONS Observational study, no control group. CONCLUSIONS Duodenal stent placement resulted in prompt relief of malignant gastric outlet obstruction and improved GOOSS scores. ( CLINICAL TRIAL REGISTRATION NUMBER NCT00991614.).
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Affiliation(s)
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Alessandro Repici
- Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Manon Spaander
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Julius Spicak
- Department of Hepatogastroenterology, IKEM, Prague, Czech Republic
| | - Pavel Drastich
- Department of Hepatogastroenterology, IKEM, Prague, Czech Republic
| | | | - Vincenzo Perri
- Digestive Endoscopy Unit, Catholic University, Rome, Italy
| | - André Roy
- Endoscopy Unit, Centre Hospitalier de l'Université de Montreal (CHUM), Hôpital Saint-Luc, Montréal Québec, Canada
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Goldberg EM. Palliative treatment of gastric outlet obstruction in terminal patients: SEMS. Stent every malignant stricture! Gastrointest Endosc 2014; 79:76-8. [PMID: 24342588 DOI: 10.1016/j.gie.2013.07.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 07/30/2013] [Indexed: 01/22/2023]
Affiliation(s)
- Eric Mathew Goldberg
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Tominaga K, Maetani I, Shigoka H, Omuta S, Sato K, Ito S, Saigusa Y, Gomi T, Kohda E. Factors associated with delayed gastric emptying in patients with stent placement for malignant gastric outlet obstruction. Endosc Int Open 2013; 1:17-23. [PMID: 26135508 PMCID: PMC4440376 DOI: 10.1055/s-0033-1359266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 12/05/2013] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Delayed gastric emptying (DGE) is an important factor in determining the clinical outcome in patients with stent placement for malignant gastric outlet obstruction but the factors associated with DGE remain unclear. The aim of this study was to investigate whether clinicopathologic data could be used to identify the factors for DGE in such patients. PATIENTS AND METHODS A prospective, single-arm, observational clinical study was performed in a referral hospital in Japan. A total of 54 patients with stent placement for malignant gastric outlet obstruction were enrolled. A gastric emptying scintigraphy test was performed 1 week after stent placement. The relationship between DGE and clinicopathologic factors was investigated, and also the relationship between DGE and stent patency time, eating period (when the patient was able to maintain oral intake), and survival time. RESULTS A total of 38.9 % (21 /54) of patients had DGE. The following were identified as independent predictive factors of DGE: opioid use (odds ratio, 5.32; 95 % confidence interval [95 %CI], 1.07 - 26.41; p = 0.04), chemotherapy before stent placement (odds ratio, 8.03; 95 %CI, 1.85 - 34.95; p = 0.006), and smaller stent diameter (odds ratio, 13.59; 95 %CI, 1.72 - 107.41; p = 0.01). No relationship was found between DGE and the level of oral intake, stent patency time, eating period, and survival time. CONCLUSIONS The factors associated with DGE after stent placement include those associated with the patient's tumor as well as factors relating to their treatment, including stenting. The clinical and functional results after stent placement appear to be unrelated to the gastric emptying findings.
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Affiliation(s)
- Kenji Tominaga
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan,Corresponding author: Iruru Maetani, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine,Toho University Ohashi Medical Center,2-17-6 Ohashi, Meguro-ku, Tokyo 153-8515,Japan
| | - Hiroaki Shigoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Shigefumi Omuta
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Koichiro Sato
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Sayo Ito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yoshinori Saigusa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tatsuya Gomi
- Department of Radiology, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Ehiichi Kohda
- Department of Radiology, Toho University Ohashi Medical Center, Tokyo, Japan
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Abstract
Because of significant advances in endoscopic techniques and the development of high-quality stents, endoscopic enteral stent placement is increasingly being performed for the management of malignant GI obstruction. Palliative stenting is now routinely performed for malignant esophageal, gastric, duodenal, and colon obstruction. In addition to palliative indications, preoperative stenting in the colon may be performed as a bridge to surgery to achieve immediate decompression and convert an emergent surgery into an elective, 1-stage procedure.The realm of enteral stenting has recently expanded to include management of benign conditions such as leaks, fistulas, and benign strictures in the GI tract. Further research is required to study the use of enteral stents in benign conditions and to adequately compare endoscopic stent placement with surgical intervention. Promising new technologies such as biodegradable stents and drug-eluting stents also require further investigation. With continued innovation in endoscopic techniques and stenting devices, the field of enteral stenting is likely to expand further, with an increase in indications and improvement in outcomes.
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Affiliation(s)
- Rajan Kochar
- Clinical Instructor, Advanced Endoscopy, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nimeesh Shah
- Associate Chief, Division of Gastroenterology, Santa Clara Valley Medical Center, San Jose, California, USA; Clinical Instructor of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Palo Alto, California, USA
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Khashab M, Alawad AS, Shin EJ, Kim K, Bourdel N, Singh VK, Lennon AM, Hutfless S, Sharaiha RZ, Amateau S, Okolo PI, Makary MA, Wolfgang C, Canto MI, Kalloo AN. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc 2013; 27:2068-75. [PMID: 23299137 DOI: 10.1007/s00464-012-2712-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/06/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Endoscopic placement of enteral self-expandable metallic stents is an alternative to surgical gastrojejunostomy (GJ) for palliation of malignant gastric outlet obstruction (GOO). Factors associated with clinical outcomes are not known. The aims of this study are to compare the overall complication rate and effectiveness (duration of oral intake) between endoscopic stenting (ES) and GJ in patients with GOO and identify predictors of clinical outcomes. PATIENTS AND METHODS This was a retrospective cohort study at a single tertiary academic center. Patients who underwent ES or GJ for treatment of GOO between 1/2001 and 12/2010 were identified using an institutional claims database. The electronic medical records for each patient were reviewed. Univariate and multivariate logistic regression analyses were performed to study the association of treatment outcomes with patient factors and cancer therapy. RESULTS 120 patients had ES while 227 had GJ. Technical success was higher for GJ (99 vs. 96 %, p = 0.004). Complication rates were higher in the GJ group (22.10 vs. 11.66 %, p = 0.02). Reintervention was more common with ES [adjusted odds ratio (OR) 9.18, p < 0.0001]. Mean length of hospital stay (LOHS) was shorter (adjusted p = 0.005) in the ES compared with the GJ group. However, mean hospital charges, including reinterventions, were greater in the ES group (US $34,250 vs. US $27,599, p = 0.03). ES and GJ had comparable reintervention-free time in patients who had reintervention (88 vs. 106 days, respectively, p = 0.79). Chemotherapy [adjusted hazard ratio (HR) 3 > 0.57, p = 0.04] and radiation therapy (adjusted HR 0.35, p = 0.03) were associated with significantly longer duration of oral intake after ES or GJ. CONCLUSION ES is associated with fewer complications, shorter LOHS, but higher reintervention rates and overall charges.
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Affiliation(s)
- Mouen Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1830 E. Monument Street, Room 424, Baltimore, MD 21205, USA.
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Sasaki T, Isayama H, Maetani I, Nakai Y, Kogure H, Kawakubo K, Mizuno S, Yagioka H, Matsubara S, Ito Y, Yamamoto N, Sasahira N, Hirano K, Tsujino T, Toda N, Tada M, Koike K. Japanese multicenter estimation of WallFlex duodenal stent for unresectable malignant gastric outlet obstruction. Dig Endosc 2013; 25:1-6. [PMID: 23286249 DOI: 10.1111/j.1443-1661.2012.01319.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 03/12/2012] [Indexed: 01/16/2023]
Abstract
AIM This retrospective study estimated the efficacy and safety of the WallFlex duodenal stent for malignant gastric outlet obstruction (GOO) in Japan. METHODS Forty-two consecutive patients with symptomatic malignant GOO were treated using WallFlex duodenal stents between January 2010 and October 2010. RESULTS The technical and clinical success rates were 100% and 83.3%, respectively.The median gastric outlet obstruction scoring system increased significantly, from 0 to 2, after stent placement (P < 0.01).The median survival time was 3.3 months (95% confidence interval (CI), 1.8-6.0 months), and the median eating period was 3.0 months (95% CI, 1.1-4.3 months). Re-intervention was required in 11 patients (26.2%). The complication rate was 26.2%. The major complication was stent occlusion (23.8%) by tumor ingrowth, which occurred in nine (21.4%) patients, and tumor overgrowth, which occurred in one (2.4%) patient. Stentmigration, perforation, and food impaction without stent occlusion were not observed.The median survival time of the patients with stent occlusion was 11.7 months (95% CI, 2.2 months - not reached), and the median stent patency of these patients was 4.0 months (95% CI, 0.8-4.7 months).These patients were successfully treated with additional stent insertion using a stent-in-stent procedure. CONCLUSION Duodenal stent placement using a WallFlex duodenal stent was safe and effective for managing malignant GOO.This stent is an uncovered metallic stent, and the major problem was stent occlusion due to tumor ingrowth. However, the occluded stent could be corrected by inserting an additional duodenal stent.
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Affiliation(s)
- Takashi Sasaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Nakai Y, Ishigami H, Isayama H, Sasaki T, Kawakubo K, Kogure H, Emoto S, Yamaguchi H, Kitayama J, Yamamoto N, Sasahira N, Hirano K, Tada M, Koike K. Role of intervention for biliary and gastric/intestinal obstruction in gastric cancer with peritoneal metastasis. J Gastroenterol Hepatol 2012; 27:1796-800. [PMID: 22849855 DOI: 10.1111/j.1440-1746.2012.07241.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2012] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIM Gastrointestinal (GI) luminal obstruction or malignant biliary obstruction (MBO) is not a rare condition in gastric cancer patients with peritoneal metastasis. The role of endoscopic or percutaneous interventions is not fully elucidated in this setting. METHODS A total of 123 patients with unresectable or recurrent gastric adenocarcinoma with peritoneal metastasis receiving intravenous and intraperitoneal paclitaxel combined with S-1 were retrospectively studied. Safety and efficacy of interventions for GI luminal obstruction and MBO were evaluated. RESULTS A total of 27 patients (22%) underwent GI luminal and/or biliary interventions; GI luminal alone in 10, biliary alone in 10 and both in seven, with a technical success rate of 100%. Clinical success rate was 65% in self-expandable metallic stents (SEMS) placement for GI luminal obstruction. Eastern Cooperative Oncology Group (ECOG) performance status (PS) was prognostic of clinical success in GI luminal stenting (100% in PS of 1 vs 14% in PS of 2-3, P < 0.001). Biliary drainage (endoscopic SEMS placement in four and percutaneous transhepatic biliary drainage in 12) relieved obstructive jaundice in 94%. Six complications were observed: four after GI luminal stenting (two occlusion and one aspiration pneumonia) and two after biliary stenting (one cholangitis and one cholecystitis). Median survival after the initial intervention was 5.7 months. PS at interventions was prognostic of survival after interventions (12.3 months in PS of 1 vs 2.2 months in PS of 2 or 3, P < 0.001). CONCLUSION Endoscopic or percutaneous interventions for GI luminal obstruction or MBO were feasible and effective in gastric cancer patients with peritoneal dissemination receiving combination chemotherapy.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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Placement of a Covered Expandable Metallic Stent to Treat Nonanastomotic Malignant Jejunal Obstructions After Total Gastrectomy With Esophagojejunostomy. AJR Am J Roentgenol 2012; 198:1203-7. [DOI: 10.2214/ajr.11.7419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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