1
|
Shen Z, Yu J, Tang H, Lu B. Closed Loop Duodenal Obstruction Secondary to Pancreatic Carcinoma: A Case Report. Comb Chem High Throughput Screen 2019; 22:280-286. [PMID: 30973103 DOI: 10.2174/1386207322666190411112412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/30/2018] [Accepted: 12/11/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Patients with pancreatic adenocarcinoma may develop into duodenal obstruction during the course of their disease. The diagnosis of obstruction can be generally achieved by means of imaging technologies. Case and Outcome We reported a rare case of pancreatic tumor with duodenal obstruction accompanied by obstructive symptoms, which was finally confirmed by laparotomy. A 68-year-old man was admitted to our department with a 3-day medical history of upper abdominal pain, nausea and vomiting. The diagnosis of duodenal obstruction was established by means of various imagings including computed tomography (CT) scan, gastroscopy and upper gastrointestinal imaging. Upper gastrointestinal imaging and magnetic resonance imaging (MRI) showed extrinsic tumor mass was noted at the second and third portion of the duodenum accompanied by duodenal obstruction and dilatation, respectively. Laparotomy confirmed a tumor mass arising from the head and uncinate process of pancreas, which had invaded the second and third portions of the duodenum and caused closed loop obstruction. A pancreaticoduodenectomy (Whipple procedure) was performed followed by therapeutic trade-off according to intraoperative exploration. Postoperative histopathology revealed pancreatic tumor only infiltrated duodenal wall, while resection margins of pancreas, common bile duct and duodenum were all negative. The patient was cured and discharged home 12 days after surgery. CONCLUSION The present case indicated radical operation in our study appeared to be the first choice treatment for patients with malignant duodenal obstruction.
Collapse
Affiliation(s)
- Zhihong Shen
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| | - Jianhua Yu
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| | - Haijun Tang
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| | - Baochun Lu
- Department of Hepatobiliary Surgery, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing University, Shaoxing 312000, China
| |
Collapse
|
2
|
Manuel-Vázquez A, Latorre-Fragua R, Ramiro-Pérez C, López-Marcano A, De la Plaza-Llamas R, Ramia JM. Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature. World J Gastroenterol 2018; 24:1978-1988. [PMID: 29760541 PMCID: PMC5949711 DOI: 10.3748/wjg.v24.i18.1978] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 04/26/2018] [Accepted: 05/06/2018] [Indexed: 02/06/2023] Open
Abstract
The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.
Collapse
Affiliation(s)
- Alba Manuel-Vázquez
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Raquel Latorre-Fragua
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Carmen Ramiro-Pérez
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Aylhin López-Marcano
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - Roberto De la Plaza-Llamas
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| | - José Manuel Ramia
- Department of General and Digestive Surgery, University Hospital of Guadalajara, Guadalajara 19002, Spain
| |
Collapse
|
3
|
Abstract
PURPOSE OF REVIEW Malignant gastric outlet obstruction (GOO) is a debilitating complication of cancer associated with a poor prognosis. The primary aim in the management of malignant GOO is usually palliation starting with the reinstitution of luminal patency with either surgical bypass or enteral stenting. These traditional modalities, however, have important limitations. Endoscopic bypass is a novel approach to GOO and may be an ideal technique, in which a sustained bypass can be created through a minimally invasive approach. The goal of this review is to describe the technical aspects as well as the clinical data of endoscopic bypass. RECENT FINDINGS A review of this novel technique is timely given recent developments of several accessories and techniques that allow for safer and easier endoscopic bypass including the advent of the lumen apposing stent, a specialized double-balloon enteric tube, the EUS-assisted technique, and the natural orifice transluminal surgery approach. In addition, accumulating and promising data have emerged supporting the endoscopic approach to gastric bypass. SUMMARY Endoscopic bypass is a novel and developing field of therapeutic endoscopy with improving technique and promising clinical data. This review will help to shed light on the current status and future direction of this intricate endoscopic modality.
Collapse
|
4
|
Ryou M, Agoston AT, Thompson CC. Endoscopic intestinal bypass creation by using self-assembling magnets in a porcine model. Gastrointest Endosc 2016; 83:821-5. [PMID: 26522371 DOI: 10.1016/j.gie.2015.10.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 10/13/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A purely endoluminal method of GI bypass would be desirable for the treatment of obstruction, obesity, or metabolic syndrome. We have developed a technology based on miniature self-assembling magnets that create large-caliber anastomoses (Incisionless Anastomosis System [IAS]). The aim of this study was to evaluate procedural characteristics of IAS deployment and long-term anastomotic integrity and patency. METHODS We performed a 3-month survival study of Yorkshire pigs (5 interventions, 3 controls). Intervention pigs underwent simultaneous enteroscopy/colonoscopy performed with the animals under intravenous sedation. The IAS magnets were deployed and coupled with reciprocal magnets under fluoroscopy. Every 3 to 6 days pigs underwent endoscopy until jejunocolonic anastomosis (dual-path bypass) creation and magnet expulsion. Necropsies and histological evaluation were performed. The primary endpoints were technical success; secondary endpoints of anastomosis integrity, patency, and histological characteristics were weight trends. RESULTS Under intravenous sedation, endoscopic bypass creation by using IAS magnets was successfully performed in 5 of 5 pigs (100%). Given porcine anatomy, the easiest dual-path bypass to create was between the proximal jejunum and colon. The mean procedure time was 14.7 minutes. Patent, leak-free anastomoses formed by day 4. All IAS magnets were expelled by day 12. All anastomoses were fully patent at 3 months with a mean diameter of 3.5 cm. The mean 3-month weight was 45 kg in bypass pigs and 78 kg in controls (P = .01). At necropsy, adhesions were absent. Histology showed full re-epithelialization across the anastomosis without fibrosis or inflammation. CONCLUSION Large-caliber, leak-free, foreign body-free endoscopic intestinal bypass by using IAS magnets can be safely and rapidly performed in the porcine by model using only intravenous sedation.
Collapse
Affiliation(s)
- Marvin Ryou
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - A Tony Agoston
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
5
|
Miyazaki Y, Takiguchi S, Takahashi T, Kurokawa Y, Makino T, Yamasaki M, Nakajima K, Mori M, Doki Y. Treatment of gastric outlet obstruction that results from unresectable gastric cancer: Current evidence. World J Gastrointest Endosc 2016; 8:165-172. [PMID: 26862366 PMCID: PMC4734975 DOI: 10.4253/wjge.v8.i3.165] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 10/02/2015] [Accepted: 12/14/2015] [Indexed: 02/05/2023] Open
Abstract
Malignant gastric outlet obstruction (GOO) is a common condition that results from locally advanced malignancies in the upper gastrointestinal tract, such as pancreatic, gastric, and other carcinomas. Two types of procedures for malignant GOO, namely, gastrojejunostomy (GJ) with laparotomy or a laparoscopic approach and endoscopic stenting (ES), are currently available. Although numerous previous reports have clarified the benefits and drawbacks of each procedure, whether GJ or ES should be used in patients with GOO that results from gastric cancer who may have a longer life expectancy than patients with other malignancies has not been determined. In this review, which focuses on gastric cancer-induced GOO, we analyzed the two systematic reviews and a meta-analysis that compared GJ and ES and outlined the current status of GOO treatment. We also provide an updated review that includes laparoscopic GJ. Various data from 13 studies in one review and 6 studies in another review were analyzed. Although the main results of the present review indicated that both GJ and ES were efficacious treatments in patients with GOO that resulted from gastric cancer, current evidence suggests that GJ may be the preferable procedure given its good performance status and improved prognosis in gastric cancer patients.
Collapse
|
6
|
Endoscopic bilio-duodenal bypass: outcomes of primary and revision efficacy of combined metallic stents in malignant duodenal and biliary obstructions. Dig Dis Sci 2014; 59:2779-89. [PMID: 24821464 DOI: 10.1007/s10620-014-3199-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/30/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Self-expandable metal stents (SEMSs) can be used for palliation of combined malignant biliary and duodenal obstructions. However, the results of the concomitant stent placement for the duration of the patients' lives, as well as the need for and efficacy of endoscopic revision, are unclear. AIM This study evaluated the clinical effectiveness of SEMS placement for combined biliary and duodenal obstructions throughout the patients' lives and the need for endoscopic revision. METHODS This study is a retrospective multicenter study of 50 consecutive patients who underwent simultaneous or sequential SEMS placement for malignant biliary and duodenal obstructions. The data were collected to analyze the sustained relief of obstructive symptoms until the patients' death and the efficacy of endoscopic revision, as well as stent patency, adverse events, survival and prognostic factors for stent patency. RESULTS Technical and immediate clinical success was achieved in all of the patients. Duodenal stricture occurred before the papilla in 35 patients (70 %), involved the papilla in 11 patients (22 %) and was observed distal to the papilla in four patients (8 %). Initial biliary stenting was performed endoscopically in 42 patients (84 %) and percutaneously in eight patients. After combined stenting, 30 patients (60 %) required no additional intervention until the time of their death. The remaining 20 patients were successfully treated using endoscopic stent reinsertion: nine patients needed biliary revision, three patients needed duodenal restenting and eight patients needed both biliary and duodenal reinsertion. The median duodenal stent patency and median biliary stent patency were 34 and 27 weeks, respectively. The median survival after combined stent placement was 18 weeks. A Cox multivariate analysis showed that duodenal stent obstruction after combined stenting was a risk factor for biliary stent obstruction (hazard ratio 6.85; 95 % confidence interval 1.43-198.98; P = 0.025). CONCLUSIONS Endoscopic bilio-duodenal bypass is clinically effective, and the majority of the patients need no additional intervention until their death. Endoscopic revision is feasible and has a high success rate.
Collapse
|
7
|
Javaid MR, Yusuf AM. An instant rare complication: a fractured metallic pyloric stent. BMJ Case Rep 2013; 2013:bcr-2012-007695. [PMID: 23345482 DOI: 10.1136/bcr-2012-007695] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Metallic pyloric stenting (also termed as metallic enteral stenting) performed endoscopically, stands as first-line treatment for malignant gastric outlet obstruction. With reported evidence, these self-expandable metallic stents (SEMS) re-enable oral food intake, preventing patients having to face invasive techniques such as surgical gastroenterostomy. We report a patient having received a covered pyloric SEMS insertion following a tumour growth causing stenosis in the gastric antropyloric region. After 3 weeks, the patient presented with a fracture of the pyloric SEMS, a rare complication, resulting in a second pyloric SEMS insertion.
Collapse
|
8
|
Cha BH, Lee SH, Kim JE, Yoo JY, Park YS, Kim JW, Jeong SH, Kim N, Lee DH, Hwang JH. Endoscopic self-expandable metallic stent placement in malignant pyloric or duodenal obstruction: does chemotherapy affect stent patency? Asia Pac J Clin Oncol 2012; 9:162-8. [PMID: 23057590 DOI: 10.1111/j.1743-7563.2012.01590.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2012] [Indexed: 12/17/2022]
Abstract
AIM Self-expandable metallic stents (SEMS) have been used for palliation in patients with malignant gastroduodenal obstructions. We evaluated clinical outcomes after SEMS placement and identified prognostic factors of SEMS patency, including chemotherapy. METHODS A review of records of 85 patients with unresectable gastric or pancreatic cancer who underwent endoscopic SEMS insertion for gastroduodenal obstructions at Seoul National University Bundang Hospital. RESULTS From August 2003 to October 2009, 85 patients with gastroduodenal obstruction were managed with endoscopic SEMS placement. Technical success was achieved in 82 patients (96%) and clinical success in 68 patients (80%). Of 49 patients who had clinical success, 19 underwent chemotherapy (chemoTx group), and 30 patients did not (non-chemoTx group). Cumulative SEMS patency in the 49 patients who achieved clinical success were 84, 54 and 41% at 2, 3 and 6 months, respectively. By univariate and multivariate analysis, there was no statistical difference in the SEMS patency between the two groups (cumulative SEMS patency rate: 95 vs 73% at 2 months, 15 vs 63% at 3 months, 40 vs 42% at 6 months, respectively, P < 0.793). CONCLUSION Chemotherapy does not improve SEMS patency in patients with malignant gastroduodenal obstruction caused by unresectable gastric or pancreatic cancer.
Collapse
Affiliation(s)
- Byung Hyo Cha
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Role of the laparoscopic approach to biliary bypass for benign and malignant biliary diseases: a systematic review. Surg Endosc 2011; 25:2105-16. [PMID: 21298535 DOI: 10.1007/s00464-010-1544-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Accepted: 11/30/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND The laparoscopic approach for biliary bypass surgery is a contemporary management option. This article reviews the evidence available for its role and effectiveness. METHODS A computerised search was made of the MEDLINE, PubMed, and EMBASE databases for English language publications from the first report of laparoscopic biliary bypass in 1992 to January 2010. RESULTS Some 89 patients featured in 19 reports underwent 89 laparoscopic biliary bypass procedures for benign (n=17) and malignant (n=72) indications. Of those, 52 patients underwent biliary bypass alone, while 37 patients underwent biliary bypass combined with gastric bypass. The procedures included cholecystojejunostomy (n=64), hepaticojejunostomy (n=14), and choledochoduodenostomy (n=11). The overall success rate in achieving resolution of jaundice was 98.9%, with a morbidity rate of 12.3% and a mortality rate of 5.6%. More than one procedure was required in 1.1% of patients to achieve resolution of obstructive jaundice. During a reported median follow-up period of 13 months, obstructive jaundice recurred in none of the patients. CONCLUSION The laparoscopic approach to biliary bypass surgery is safe and has a high initial success rate, low reintervention rate, and low morbidity and mortality rates. Longer follow-up data and comparative studies with open surgery and endoscopic stenting are needed.
Collapse
|
10
|
Smart Self-Assembling MagnetS for ENdoscopy (SAMSEN) for transoral endoscopic creation of immediate gastrojejunostomy (with video). Gastrointest Endosc 2011; 73:353-9. [PMID: 21183179 DOI: 10.1016/j.gie.2010.10.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 10/13/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrojejunostomy is important for palliation of malignant gastric outlet obstruction and surgical obesity procedures. A less-invasive endoscopic technique for gastrojejunostomy creation is conceptually attractive. Our group has developed a compression anastomosis technology based on endoscopically delivered self-assembling magnets for endoscopy (SAMSEN) to create an instant, large-caliber gastrojejunostomy. OBJECTIVE To develop and evaluate an endoscopic means of gastrojejunostomy creation by using SAMSEN. SETTING Developmental laboratory and animal facility. DESIGN Animal study and human cadaveric study. SUBJECTS Yorkshire pigs (7 cadaver, 5 acute); human (1 cadaver). INTERVENTIONS A transoral procedure for SAMSEN delivery was developed in porcine and human cadaver models. Subsequently, gastrojejunostomy creation by using SAMSEN was performed in 5 acute pigs. The endoscope was advanced into the peritoneal cavity through the gastrotomy, and a segment of the small bowel was grasped and pulled closer to the stomach. An enterotomy was created, and a custom overtube was advanced into the small bowel for deployment of the first magnetic assembly. Next, a reciprocal magnetic assembly was deployed in the stomach. The 2 magnetic systems were mated under fluoroscopic and endoscopic guidance. Contrast studies assessed for gastrojejunostomy leak. Immediate necropsies were performed. MAIN OUTCOME MEASUREMENTS Technical feasibility and complications. RESULTS Gastrojejunostomy creation by using SAMSEN was successful in all 5 animals. Deep enteroscopy was performed through the stoma without difficulty. No leaks were identified on contrast evaluation. At necropsy, the magnets were properly deployed and robustly coupled together, resistant to vigorous tissue manipulation. LIMITATIONS Acute animal study. CONCLUSIONS Endoscopic creation of immediate gastrojejunostomy by using SAMSEN is technically feasible.
Collapse
|
11
|
Hamad MA, Mentges B, Schurr MO, El-shehry AH, Melzer A, Buess G. Laparoscopic intracorporeal bowel anastomosis by a new suturing device: A study in a laparoscopic simulator with integrated animal organs. MINIM INVASIV THER 2009. [DOI: 10.3109/13645709709153079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
12
|
A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc 2009; 24:290-7. [PMID: 19551436 DOI: 10.1007/s00464-009-0577-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Revised: 04/24/2009] [Accepted: 05/26/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome. METHOD A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO. RESULTS Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ. CONCLUSION This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid.
Collapse
|
13
|
Seo EH, Jung MK, Park MJ, Park KS, Jeon SW, Cho CM, Tak WY, Kweon YO, Kim SK, Choi YH. Covered expandable nitinol stents for malignant gastroduodenal obstructions. J Gastroenterol Hepatol 2008; 23:1056-62. [PMID: 18086117 DOI: 10.1111/j.1440-1746.2007.05260.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM The aim of the present study was to investigate the clinical effectiveness, safety, and outcome associated with the use of covered expandable Nitinol stents (Taewoong Medical, Seoul, Korea) for the treatment of malignant gastroduodenal obstructions. METHODS Between March 2001 and October 2004, covered expandable Nitinol stents were placed in 68 consecutive patients under endoscopic and fluoroscopic guidance for the following reasons: gastric carcinoma (n = 49), recurrent carcinoma after partial gastrectomy (n = 7), or another malignant neoplasm involving the duodenum (n = 12). RESULTS Technical success was achieved in 60 of the 68 patients (88.2%). After stent placement, mean dysphagia score improved from a mean of 3.5 to 1.2 (P < 0.001). The mean period of primary stent patency was 107.2 days. During follow up (mean 4.4 months; range, 1-15 months), major complications (migration [6], bleeding [3], perforation [1], ingrowth [1], overgrowth [7], fistula [1]) occurred in 19 patients (27.9%), and stent migration occurred in six (8.8%) (proximal migration into the stomach [n = 3], or distal migration [n = 3]). Recurrent dysphagia (mainly due to tumor ingrowth/overgrowth) occurred in eight patients (11.8%). CONCLUSION Covered expandable Nitinol stents appear to offer an effective and feasible palliative therapy in patients with a malignant gastroduodenal obstruction.
Collapse
Affiliation(s)
- Eun H Seo
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
| | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Kim JH, Song HY, Shin JH, Choi E, Kim TW, Jung HY, Lee GH, Lee SK, Kim MH, Ryu MH, Kang YK, Kim BS, Yook JH. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc 2007; 66:256-64. [PMID: 17643698 DOI: 10.1016/j.gie.2006.12.017] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2006] [Accepted: 12/04/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Metallic stents are a therapeutic option for patients with malignant GI obstruction. OBJECTIVE Our purpose was to evaluate the clinical effectiveness of a self-expandable metallic stent in 213 patients with malignant gastroduodenal obstruction and to identify prognostic factors associated with clinical outcomes. DESIGN Prospective cohort study. SETTING Single tertiary referral university hospital. PATIENTS Two hundred thirteen consecutive patients with symptomatic malignant gastric outlet or duodenal obstruction from 2001 to 2005. INTERVENTIONS Placement of a self-expandable metallic stent. MAIN OUTCOME MEASUREMENTS Prospective data collection focused on technical and clinical success, complications, and prognostic factors associated with stent patency. RESULTS Technical and clinical success were achieved in 94% and 94% of the patients, respectively, and the complication rate was 21%. The median and mean survival periods were 99 (95% CI, 78-121) and 159 days (95% CI, 116-203). The median and mean stent patency periods were 270 (95% CI, 234-413) and 324 days (95% CI, 128-412). With use of the multivariate Cox proportional hazard model, chemotherapy after stent placement (odds ratio, 0.19; 95% CI, 0.08-0.46; P < .001) was significantly associated with an increase in the maintenance of stent patency. LIMITATIONS Single-center experience and the lack of a control group. CONCLUSIONS Placement of a self-expandable metallic stent is clinically effective in patients with unresectable gastric outlet or duodenal obstruction. Chemotherapy after stent placement, albeit associated with increased migration rates, is associated with an increase in the maintenance of stent patency.
Collapse
Affiliation(s)
- Jin Hyoung Kim
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Chopita N, Landoni N, Ross A, Villaverde A. Malignant gastroenteric obstruction: therapeutic options. Gastrointest Endosc Clin N Am 2007; 17:533-44, vi-vii. [PMID: 17640581 DOI: 10.1016/j.giec.2007.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malignant gastric outlet obstruction is a complication of advanced pancreatic cancer, manifesting endoscopically or radiographically as a stricture of the proximal duodenum. Until recently, management consisted of surgical gastroenteric bypass with or without associated biliary bypass. Over the past decade, the endoscopic deployment of self-expanding metal stents (SEMS) emerged as a new option for restoration of enteric patency. Compared with surgical bypass, SEMS placement is less invasive with good clinical outcomes. Aside from SEMS placement and surgical bypass, recent reports of magnetic gastroenteric anastamosis have emerged. This article critically examines each of the different therapeutic options for malignant gastric outlet obstruction, defines their clinical utility, and provides the exact recommendations as to how they may be usefully employed.
Collapse
Affiliation(s)
- Néstor Chopita
- San Martin Hospital, La Plata and University of La Plata, calle 62 n 370, 1900 La Plata, Buenos Aires, Argentina
| | | | | | | |
Collapse
|
16
|
Lee KK, Chen D, Hughes SJ. Minimally invasive treatment of pancreatic disease. Gastroenterol Clin North Am 2007; 36:441-54, xi. [PMID: 17533089 DOI: 10.1016/j.gtc.2007.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Although open surgical procedures remain the standard for both benign and malignant diseases of the pancreas, in recent years a wide variety of surgical procedures performed on the pancreas have been completed laparoscopically. This article reviews the application of minimally invasive surgery to the management of both benign and malignant diseases of the pancreas.
Collapse
Affiliation(s)
- Kenneth K Lee
- Section of Gastrointestinal Surgery, Department of Surgery, University of Pittsburgh School of Medicine, 497 Scaife Hall, 3550 Lothrop Street, Pittsburgh, PA 15261, USA.
| | | | | |
Collapse
|
17
|
Lowe AS, Beckett CG, Jowett S, May J, Stephenson S, Scally A, Tam E, Kay CL. Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol 2007; 62:738-44. [PMID: 17604761 DOI: 10.1016/j.crad.2007.01.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Revised: 01/11/2007] [Accepted: 01/31/2007] [Indexed: 12/13/2022]
Abstract
AIM To assess the technical success rate, and evaluate the clinical outcome, length of hospital stay, and cost of palliative gastro-duodenal stenting in a single-centre. MATERIALS AND METHODS Eight-seven patients referred for insertion of a gastroduodenal stent between April 1999 and April 2004 were recruited to a non-randomized, before and after intervention study performed in a single centre. Demographic data, diagnosis and symptoms along with clinical and technical outcomes were recorded. RESULTS The technical success rate was 84/87 (96.6%), with inability to traverse the stricture in three patients. No immediate complications were demonstrated. There was marked improvement after stent placement with resolution of symptoms and commencement of dietary intake in 76 patients (87%). Stenting resulted in improved quality of life as reflected by an increase in Karnofsky score from 44/100, to 63/100 post-procedure. Late complications included perforation (n=1), migration (n=1) and stent occlusions due to tumour ingrowth/overgrowth (n=7; mean 165 days). Mean survival was 107 days (range 0-411 days). Median hospital stay post-stent placement was 5.5 days, (range 1-55 days) with a majority of patients (75%) discharged home. The mean cost of each treatment episode was 4146 pounds ($7132 $US, 6,028 EUROS). CONCLUSION The present series confirms that combined endoscopic and radiological gastroduodenal stenting is a highly favourable treatment for patients with inoperable malignant gastric outlet obstruction. The results suggest that this minimally invasive procedure has a very high technical success rate, whilst at the same time providing excellent palliation of symptoms with improved quality of life in the majority of patients.
Collapse
Affiliation(s)
- A S Lowe
- Department of Clinical Radiology, Bradford Royal Infirmary, Bradford, UK.
| | | | | | | | | | | | | | | |
Collapse
|
18
|
Hosono S, Ohtani H, Arimoto Y, Kanamiya Y. Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. J Gastroenterol 2007; 42:283-90. [PMID: 17464457 DOI: 10.1007/s00535-006-2003-y] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Accepted: 12/25/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND We attempted to elucidate the current status of endoscopic self-expanding metal stents for palliation of malignant gastroduodenal obstruction in comparison with surgical gastroenterostomy. METHODS Original articles and abstracts published from January 1990 to September 2006 were searched in Medline, EMBASE, and Cochrane Controlled Trials Register databases. Clinical appraisal and data extraction were independently conducted by two reviewers. Statistical analysis was performed by meta-analysis using a random effects model. Weighted mean differences with 95% confidence intervals (CI) were used to analyze continuous variables. Odds ratios with 95% CI were calculated for dichotomous variables. RESULTS The outcomes of 307 procedures from nine studies were analyzed. Endoscopic stenting was found to be associated with higher clinical success (P = 0.007), a shorter time from the procedure to starting oral intake (P < 0.001), less morbidity (P = 0.02), lower incidence of delayed gastric emptying (P = 0.002), and a shorter hospital stay (P < 0.001) than surgical gastroenterostomy. There was no significant difference between the two groups in the analysis of 30-day mortality. CONCLUSIONS Endoscopic stenting may be a feasible alternative to surgery for the palliation of inoperable malignant gastroduodenal obstruction, with a high clinical success and low morbidity rate. Additional well-designed randomized controlled trials with larger sample sizes are expected to further reinforce this conclusion.
Collapse
Affiliation(s)
- Shunsuke Hosono
- Department of Surgery, Osaka City Sumiyoshi Hospital, 1-2-16 Higashi-Kagaya, Osaka 559-0012, Japan
| | | | | | | |
Collapse
|
19
|
Sabharwal T, Irani FG, Adam A. Quality Assurance Guidelines for Placement of Gastroduodenal Stents. Cardiovasc Intervent Radiol 2006; 30:1-5. [PMID: 17103108 DOI: 10.1007/s00270-006-0110-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- T Sabharwal
- Guy's and St. Thomas' Foundation Hospital NHS Trust, London, UK.
| | | | | |
Collapse
|
20
|
Ghanem AM, Hamade AM, Sheen AJ, Owera A, Al-Bahrani AZ, Ammori BJ. Laparoscopic Gastric and Biliary Bypass: A Single-Center Cohort Prospective Study. J Laparoendosc Adv Surg Tech A 2006; 16:21-6. [PMID: 16494542 DOI: 10.1089/lap.2006.16.21] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.
Collapse
Affiliation(s)
- Ali M Ghanem
- Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, United Kingdom
| | | | | | | | | | | |
Collapse
|
21
|
Mehta S, Hindmarsh A, Cheong E, Cockburn J, Saada J, Tighe R, Lewis MPN, Rhodes M. Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction. Surg Endosc 2005; 20:239-42. [PMID: 16362479 DOI: 10.1007/s00464-005-0130-9] [Citation(s) in RCA: 177] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2005] [Accepted: 07/19/2005] [Indexed: 12/16/2022]
Abstract
BACKGROUND We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction. METHODS A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period. RESULTS Thirteen patients underwent successful LGJ and 10 had successful DS. Eight patients had complications after LGJ, but none had complications after DS. Patients who underwent LGJ had a significant increase in visual analog pain score at day 1 (p = 0.05), and also had a longer hospital stay compared to those who underwent DS (11.4 vs. 5.2 days, p = 0.02). After DS, patients experienced an improvement in physical health at 1 month as measured using the Short Form-36 (SF-36) questionnaire (p < 0.01). There was no change following LGJ. CONCLUSION Duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. It offers significant advantages for patients compared with minimal-access surgery.
Collapse
Affiliation(s)
- S Mehta
- Department of Upper Gastrointestinal Surgery, Norfolk and Norwich University Hospital, Colney Lane, Norwich, England, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Denley SM, Moug SJ, Carter CR, McKay CJ. The outcome of laparoscopic gastrojejunostomy in malignant gastric outlet obstruction. ACTA ACUST UNITED AC 2005; 35:165-9. [PMID: 16110117 DOI: 10.1385/ijgc:35:3:165] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS The development of gastric outlet obstruction (GOO) in patients with advanced pancreatic cancer is regarded by some as a terminal event. There are several interventional options available, one of which is laparoscopic gastrojejunostomy (LGJ). To date, there are little data on the effectiveness of this intervention. Using patient records we sought to analyze our own experience of LGJ in patients with terminal pancreatic cancer. METHODS A retrospective analysis of all patients with pancreatic or peri-ampullary cancer that underwent LGJ for GOO. All LGJ were performed by two consultant surgeons at Glasgow Royal Infirmary. Patient notes were assessed for survival time after LGJ; post-operative complications; resumption of oral intake; time to discharge and recurrence of GOO after surgery. RESULTS A total of 18 patients underwent LGJ for GOO between 2000 and 2004. Median age at time of procedure was 66.5 yr (range 40 to 79). Two patients were converted to an open procedure for technical reasons, both of whom died in the post-operative period. Of the remaining 16, 15 had successful relief of GOO. The remaining patient underwent revisional open surgery 15 d post-operatively due to persistent GOO. Two patients died in hospital but 14 were discharged with symptom relief. Median survival for these patients was 59 d (range 12 to 248). CONCLUSION The development of GOO in pancreatic and peri-ampullary cancer should not be regarded as a terminal event. LGJ should be considered as a treatment option in these patients.
Collapse
Affiliation(s)
- Simon M Denley
- University Department of Surgery, Glasgow Royal Infirmary, Alexandra Parade, Glasgow, G31 2ER, UK
| | | | | | | |
Collapse
|
23
|
Bessoud B, de Baere T, Denys A, Kuoch V, Ducreux M, Precetti S, Roche A, Menu Y. Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents. J Vasc Interv Radiol 2005; 16:247-53. [PMID: 15713926 DOI: 10.1097/01.rvi.0000145227.90754.76] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate the feasibility, efficacy, and tolerance of self-expanding metallic stent insertion under fluoroscopic guidance for palliation of symptoms related to malignant gastroduodenal obstruction. MATERIALS AND METHODS Seventy-two patients (38 men, 34 women) aged 25-98 years (mean, 62 years) with duodenal (n = 43), antropyloric (n = 13), surgical gastrojejunostomy (n = 10), or pyloroduodenal (n = 6) malignant obstruction were referred for insertion of self-expanding metallic stents over a 6-year period. Stent insertion was performed with use of a peroral or transgastric approach when necessary (n = 11). RESULTS Stents were successfully inserted in 70 of the 72 patients (97%) and provided symptom relief in 65 patients (90%). Inserted stents were mainly uncovered vascular (n = 55) or enteral (n = 10) Wallstents. One hundred eight stents were initially inserted: one, two, three, or four stents were indicated in 43, 17, nine, and one patient, respectively. Mean follow-up was 119 days (range, 4-513 days). Mean stent patency was 113 days (range, 4-513 days). Mean survival of patients was 120 days. During follow-up, stent obstruction occurred in seven patients as a result of tumoral overgrowth (n = 5) or ingrowth (n = 2). Complications occurred in 12 of the 72 patients (17%), including stent migration (n = 8), stent fracture (n = 1), duodenal perforation (n = 1), and death related to general anesthesia (n = 1). CONCLUSION Despite a significant complication rate, self-expanding metallic stent insertion under fluoroscopic guidance appears to be a feasible and useful technique in the palliative management of malignant gastroduodenal obstruction.
Collapse
Affiliation(s)
- Bertrand Bessoud
- Department of Medical and Interventional Imaging, Institut Gustave Roussy, Villejuif, France.
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004; 60:1010-7. [PMID: 15605026 DOI: 10.1016/s0016-5107(04)02276-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroduodenal obstruction is a common preterminal event for patients with gastric and pancreatic cancer who often undergo palliative surgical bypass. Endoscopic palliation with self-expanding metallic stents has emerged as a safe and an effective alternative to surgery, but experience with the technique remains limited. METHODS Twenty-eight patients hospitalized with GI obstruction because of incurable gastric or pancreatic cancer were recruited for a prospective study of palliation with self-expanding metallic stents. Complications and clinical outcomes were assessed. OBSERVATIONS Stent insertion was technically successful in 26 patients. Thereafter, 24 patients resumed an adequate liquid or semisolid diet. Stent insertion facilitated hospital discharge for 20 patients. Occlusion of the stent because of tumor ingrowth occurred in 3 patients, but there was no complication related to stent insertion or the stent itself. CONCLUSIONS Endoscopic placement of a self-expanding metallic stent is a simple, effective means of palliation for patients with malignant gastroduodenal obstruction.
Collapse
Affiliation(s)
- Andrew P Holt
- Liver Transplant and Hepato-biliary Unit, Queen Elizabeth Hospital, Birmingham, UK
| | | | | |
Collapse
|
25
|
Lopera JE, Brazzini A, Gonzales A, Castaneda-Zuniga WR. Gastroduodenal Stent Placement: Current Status. Radiographics 2004; 24:1561-73. [PMID: 15537965 DOI: 10.1148/rg.246045033] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Gastroduodenal obstruction is a preterminal event in patients with advanced malignancies of the stomach, pancreas, and duodenum. It severely limits the quality of life in affected patients due to constant emesis and associated malnutrition. Surgical gastrojejunostomy has been the traditional palliative treatment but is associated with a high complication rate, and delayed gastric emptying is a frequent problem. Gastroduodenal stent placement is a very safe and effective palliation method in patients with unresectable malignant tumors causing gastric outlet obstruction, with adequate palliation obtained in most cases. The procedure can be performed under fluoroscopic guidance or with a combination of fluoroscopic and endoscopic techniques. Advantages of gastroduodenal stent placement over surgical palliation include suitability as an outpatient procedure, more rapid gastric emptying, greater cost effectiveness, fewer complications, and improved quality of life. Covered duodenal stents are currently being evaluated and may play an increasingly important role in preventing recurrent obstruction secondary to tumor ingrowth. Moreover, simultaneous palliation of biliary and duodenal malignant strictures is possible with the use of metallic stents. Gastroduodenal stent placement is a promising new alternative for the palliation of malignant gastroduodenal obstruction.
Collapse
Affiliation(s)
- Jorge E Lopera
- Department of Radiology, Louisiana State University Health Science Center, 1542 Tulane Ave, New Orleans, LA 70112, USA.
| | | | | | | |
Collapse
|
26
|
Lindsay JO, Andreyev HJN, Vlavianos P, Westaby D. Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass. Aliment Pharmacol Ther 2004; 19:901-5. [PMID: 15080851 DOI: 10.1111/j.1365-2036.2004.01896.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND The primary therapeutic goals in patients with gastroduodenal obstruction secondary to advanced malignancy are the re-introduction of an enteral diet and early discharge. The endoscopic placement of expandable metal stents has been proposed as an alternative technique for palliation in patients not suitable for surgery. AIM To review our experience with gastroduodenal metal stent insertion for the palliation of malignant gastric and duodenal obstruction. METHODS A retrospective review was conducted of the notes of all patients who underwent gastroduodenal stent insertion in our unit. RESULTS Forty patients (mean age, 64.5 years; range, 34-93 years) underwent insertion of an enteral stent for malignant gastroduodenal obstruction. The primary tumour was gastric in 20 patients, pancreatico-biliary in 15 and metastatic in five. A stent was successfully placed in all cases. Thirty-two patients have subsequently died, the median (range) survival being 7 weeks (1 week to 10 months). Thirty-three patients (82.5%) were discharged from hospital. During follow-up, 12 patients (30%) returned to a solid diet, 20 (50%) required a soft diet, six (15%) tolerated liquids and two (5%) were unable to tolerate any enteral nutrition. CONCLUSION The use of enteral stents achieves good palliation, allowing discharge from hospital and re-introduction of an enteral diet.
Collapse
Affiliation(s)
- J O Lindsay
- Department of Gastroenterology, Imperial College Faculty of Medicine, Chelsea and Westminster NHS Trust, London, UK
| | | | | | | |
Collapse
|
27
|
Jeong JY, Kim YJ, Han JK, Lee JM, Lee KH, Choi BI, Yang HK, Lee KU. Palliation of anastomotic obstructions in recurrent gastric carcinoma with the use of covered metallic stents: clinical results in 25 patients. Surgery 2004; 135:171-7. [PMID: 14739852 DOI: 10.1016/s0039-6060(03)00346-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND The purpose of this study was to investigate the technical feasibility and the clinical effectiveness of the placement of covered self-expandable metallic stents for the treatment of anastomotic obstructions in recurrent gastric carcinoma. METHODS With fluoroscopic guidance, covered stents were placed in 25 patients with recurrent gastric carcinoma for the palliation of obstructions at anastomotic sites (14 gastrojejunostomy, 11 esophagojejunostomy). All patients had severe nausea and recurrent vomiting before the stent placement. RESULTS Stent placement was technically successful in 24 patients (96%). After stent placement, symptoms improved in all 24 patients. During the follow-up of 2 to 65 weeks (mean, 13.7 weeks), stent migration occurred in 1 patient 16 days after the procedure. He needed percutaneous catheter drainage because of an abscess, which was followed by esophagojejunostomy site rupture during a second stent trial. Stricture recurred in 4 patients because of tumor overgrowth 10 to 55 weeks after the procedure; all patients underwent coaxial placement of a second stent and had good oral intake. CONCLUSIONS The placement of covered expandable metallic stents seems to be both technically feasible and an effective means for the palliation of anastomotic obstructions in recurrent gastric carcinoma. This procedure can be considered to be the primary choice for the palliation in those patients.
Collapse
Affiliation(s)
- Jun Yong Jeong
- Department of Radiology, Seoul National University College of Medicine, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Conlon KC, McMahon RL. Minimally invasive surgery in the diagnosis and treatment of upper gastrointestinal tract malignancy. Ann Surg Oncol 2002; 9:725-37. [PMID: 12374655 DOI: 10.1007/bf02574494] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Kevin C Conlon
- Memorial Sloan-Kettering Cancer Center, Department of Surgery, Minimally Invasive Surgery Program, New York, New York 10021, USA.
| | | |
Collapse
|
29
|
Aviv RI, Shyamalan G, Khan FH, Watkinson AF, Tibballs J, Caplin M, Winslett M. Use of stents in the palliative treatment of malignant gastric outlet and duodenal obstruction. Clin Radiol 2002; 57:587-92. [PMID: 12096856 DOI: 10.1053/crad.2002.0934] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To evaluate the efficacy of stenting in the palliation of malignant duodenal and gastric outlet obstruction. MATERIALS AND METHODS We retrospectively reviewed our series of patients who underwent stenting for malignant upper gastrointestinal obstruction between March 1998 and December 1999. From January 2000 data have been acquired prospectively. Our series comprises 21 stents successfully deployed in 15 patients. RESULTS The technical and clinical success was 93% (14/15 patients). One patient required endoscopic negotiation of recurrent gastric carcinoma at the gastrojejunostomy site after failure to cross the lesion fluroscopically. Two patients required re-intervention 2 and 5 weeks after initial stent placement, for migration and ingrowth respectively. Eighteen stents were placed transorally, two stents transhepatically and one via a transgastric approach. Early complications (pain < 3 days) occurred in two patients (13%) and late complications (ingrowth, overgrowth and migration) occurred in three patients (20%). The median survival was 2.4 months (range 2-4 months). CONCLUSION Stenting provides a less invasive palliative option than surgery with the advantage of lower morbidity and complication rates. It has the advantage of high technical and clinical success rates facilitated by alternative routes of access into the upper gastrointestinal tract via transgastric and transhepatic routes in addition to the traditional peroral route.
Collapse
Affiliation(s)
- R I Aviv
- Department of Radiology, Royal Free Hospital, London, UK
| | | | | | | | | | | | | |
Collapse
|
30
|
Jeong JY, Han JK, Kim AY, Lee KH, Lee JY, Kang JW, Kim TJ, Shin SH, Choi BI. Fluoroscopically guided placement of a covered self-expandable metallic stent for malignant antroduodenal obstructions: preliminary results in 18 patients. AJR Am J Roentgenol 2002; 178:847-52. [PMID: 11906861 DOI: 10.2214/ajr.178.4.1780847] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The purpose of this study was to investigate the technical feasibility and the clinical effectiveness of fluoroscopically guided placement of covered self-expandable metallic stents in the treatment of malignant antroduodenal obstructions. SUBJECTS AND METHODS With fluoroscopic guidance, covered self-expandable metallic stents were placed in 18 consecutive patients with inoperable malignant antroduodenal obstructions. All patients were treated for severe nausea and recurrent vomiting. RESULTS Stent placement was technically successful in all patients with or without gastrostomy (n = 2) and balloon dilatation (n = 3). After stent placement, symptoms improved in all but one patient, who had another stenosis in the proximal jejunum. During the follow-up of 2-73 weeks (mean, 12 weeks), stent migration occurred in three patients (16.7%) from 1 to 41 days after the procedure. These patients were treated successfully by means of placing a second covered metallic stent. Two patients, who were followed up for longer than 30 weeks, showed a recurrence of strictures because of mechanical failure of the stents; one of the patients was treated with coaxial placement of a second covered metallic stent, which had a positive clinical outcome. CONCLUSION Fluoroscopically guided placement of covered self-expandable metallic stents is technically feasible and effective for the palliative treatment of inoperable malignant antroduodenal obstructions. The rate of stent migration in our study was lower than those in previous reports.
Collapse
Affiliation(s)
- Jun Yong Jeong
- Department of Radiology, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Palliation of malignant gastric outlet obstruction caused by gastric cancer with self-expandable metal stents. Surg Laparosc Endosc Percutan Tech 2001. [PMID: 11444744 DOI: 10.1097/00129689-200106000-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Gastric carcinoma is among the most common cancers worldwide. Surgery remains the mainstay of potentially curative treatments. Unfortunately, most patients have an advanced form of the disease. We evaluated our experience in palliating malignant gastric outlet obstruction caused by gastric cancer with expandable metal stents (Wallstent Enteral; Boston Scientific, Singapore). Six patients with a median age of 68 years (range, 45-88) underwent the procedure. Three had metastatic gastric cancer; two recurrent gastric cancer; and one locally advanced gastric cancer with poor comorbid status. After the procedure, five of the six patients were able to resume an oral feeding within 24 hours. One patient with gastric dysmotility caused by linitus plastica required nasogastric tube feeding. Three patients died during a median follow-up period of 4 weeks (range, 2-8). The other three patients were still well at a median follow-up period of 10 weeks (range, 5-12). There was no procedure-related mortality or morbidity, nor was there any stent migration or blockage in any of these patients. In conclusion, palliation of malignant gastric outlet strictures caused by gastric cancer with expandable metal stents is an effective and safe alternative to surgery, particularly in patients with postgastrectomy anastomotic recurrence and in those who are poor candidates for surgery. Patients who are not expected to survive beyond 1 month and those with linitus plastica and associated gastric dysmotility may not be appropriate candidates for such a procedure.
Collapse
|
32
|
Lopera JE, Alvarez O, Castaño R, Castañeda-Zuñiga W. Initial experience with Song's covered duodenal stent in the treatment of malignant gastroduodenal obstruction. J Vasc Interv Radiol 2001; 12:1297-303. [PMID: 11698629 DOI: 10.1016/s1051-0443(07)61555-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Initial experience with use of Song's covered duodenal stent in the treatment of malignant gastroduodenal obstruction is reported. MATERIALS AND METHODS Sixteen consecutive patients with malignant gastroduodenal obstruction were treated with peroral placement of Song's covered duodenal stent. The mean age was 58 years (range, 28-90 y). Gastroduodenal obstruction was caused by gastric (n = 8), metastatic (n = 2), gallbladder (n = 3), pancreatic (n = 2), or ampullary (n = 1) cancer. The disease was considered inoperable in all patients. With use of a flexible 20-F introducing system, seven fully covered, three uncovered, and 10 partially covered duodenal stents were placed under fluoroscopic guidance. RESULTS The technical success rate was 94% (15 of 16) with no major complications. Symptoms of gastroduodenal obstruction improved in 14 patients. Stent migration was observed in three of seven fully covered stents. Patients with migrated stents required endoscopic stent removal and placement of uncovered duodenal stents. Tumor ingrowth was observed in two thirds of uncovered stents. In the 10 procedures with partially covered duodenal stents, no migration or tumor ingrowth was observed. All patients died 1-48 weeks (mean, 12 weeks) after stent placement. CONCLUSION Peroral placement of Song's covered duodenal stent is a feasible and effective method of palliation in the majority of patients with malignant gastroduodenal obstruction. Migration of fully covered stents and tumor ingrowth of uncovered stents are important limitations that can be overcome with the use of a partially covered duodenal stent.
Collapse
Affiliation(s)
- J E Lopera
- Department of Radiology, Louisiana State University Health Science Center, New Orleans, Louisiana 70112, USA.
| | | | | | | |
Collapse
|
33
|
Park KB, Do YS, Kang WK, Choo SW, Han YH, Suh SW, Lee SJ, Park KS, Choo IW. Malignant obstruction of gastric outlet and duodenum: palliation with flexible covered metallic stents. Radiology 2001; 219:679-83. [PMID: 11376254 DOI: 10.1148/radiology.219.3.r01jn21679] [Citation(s) in RCA: 120] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE To assess the usefulness of flexible covered metallic stents in the palliation of malignant obstruction of the gastric outlet and duodenum. MATERIALS AND METHODS Twenty-four consecutive patients with malignant obstruction of the gastric outlet (n = 22) or duodenum (n = 2) underwent palliative treatment with self-expandable flexible covered metallic stents. Fourteen patients had advanced gastric carcinoma at the antrum and/or pylorus, and eight had obstruction at the anastomosis site of previous gastrojejunostomy. Complications and clinical status were investigated during the study period. RESULTS The technical success rate was 75% (18 of 24 patients). Twenty-one stents were placed in 18 patients by using an introducer 6 (n = 7) or 8 mm (n = 14) in diameter. The mean follow-up period was 3.4 months (range, 1 week to 9 months). Symptoms improved in 12 (67%) patients after the procedure. There was no change in symptoms in five and a decrease in one. Twelve patients died during the follow-up period (mean survival, 4.3 months). The complication rate was 25% (six of 24 patients), including stent migration (n = 5) and fracture (n = 3). CONCLUSION Flexible covered metallic stent placement can be useful for palliation in patients with malignant obstruction of the gastric outlet or duodenum.
Collapse
Affiliation(s)
- K B Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50, Ilwon-Dong, Kangnam-Ku, Seoul, 135-710, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
|
35
|
Morgan R, Adam A. Use of metallic stents and balloons in the esophagus and gastrointestinal tract. J Vasc Interv Radiol 2001; 12:283-97. [PMID: 11287504 DOI: 10.1016/s1051-0443(07)61906-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The majority of malignant and benign strictures in the esophagus and GI tract can be treated with use of minimally invasive alternatives to surgery such as balloon dilation or metallic stents. Virtually any obstructing lesion in the esophagus, stomach, duodenum, colon, and rectum can be treated with these methods with use of interventional radiologic or endoscopic techniques. In general, metallic stents are reserved for malignant strictures and balloon dilation is indicated for benign lesions. Patients with malignant esophageal fistulas and perforations can be palliated effectively and promptly by sealing the fistula or leak by deployment of a covered stent. Patients with malignant disease may benefit from a treatment regime that includes metallic stent placement, chemotherapy, radiation therapy and/or brachytherapy, although the efficacy of such combined therapies has yet to be defined. Further refinements to stent design are required. The ideal stent would be resistant to tumor ingrowth and migration. Placing a coating material on uncovered stents to prevent tumor ingrowth may achieve these aims. Finally, a biodegradable stent that dissolves before the development of intimal hyperplasia might enable stents to be used to treat benign strictures.
Collapse
Affiliation(s)
- R Morgan
- Department of Radiology, St. George's Hospital, London, UK.
| | | |
Collapse
|
36
|
Reardon PR, Schwartz MR, Fagan SP, Reardon MJ, Brunicardi FC. Completely laparoscopic resection of a rare pyloric tumor with laparoscopically sutured gastroduodenostomy. J Laparoendosc Adv Surg Tech A 1999; 9:147-54. [PMID: 10235352 DOI: 10.1089/lap.1999.9.147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
We report the case of a 31-year-old woman who presented with epigastric pain and weight loss. Esophagogastroduodenoscopy revealed a submucosal mass in the distal antrum and pylorus. Endoscopic biopsy of the mass was nondiagnostic. A CT scan confirmed a 3.0-cm mass in the posterior wall of the distal antrum. She underwent laparoscopic resection of the distal antrum and pylorus with end-to-end gastroduodenostomy. Pathologic examination showed an adenomyoma of the antrum and pylorus. Her postoperative course was uncomplicated, and she continues to do well 38 months postoperatively. Gastric adenomyoma is a rare, benign intramural tumor of the antrum and pylorus. Fewer than 40 cases have been described in the literature. The lesions are generally within 4 cm of the pylorus. Histologically, they are characterized by ductal structures lined by cuboidal to columnar epithelium surrounded by smooth muscle bundles and, occasionally, Brunner's-type glands and heterotopic pancreas. Treatment is by resection, and recurrence has not been reported. Laparoscopic resection of portions of the stomach has been reported. Side-to-side gastrojejunostomies (Billroth II) performed laparoscopically have been reported. This is the first report in the English-language literature of a completely laparoscopically performed sutured gastroduodenostomy. Technical details of the procedure and adenomyomas are discussed.
Collapse
Affiliation(s)
- P R Reardon
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | | | | | | |
Collapse
|
37
|
Abstract
Treatment of gallstones by laparoscopic cholecystectomy has become standard therapy over the past decade and has received wide patient acceptance. Problems are infrequent but those such as biliary injury may be serious and continue to be a cause of concern. Biliary injury is more likely when surgery is performed in the presence of acute inflammation. Laparoscopic bile duct exploration is becoming standardized and the results are good. The role of other laparoscopic biliary procedures such as biliary bypass is still uncertain.
Collapse
Affiliation(s)
- S M Strasberg
- Section of Hepatobiliary-Pancreatic Surgery, Washington University, St. Louis, Missouri, USA
| |
Collapse
|
38
|
Laparoscopic gastrojejunostomy in the palliation of pancreatic cancer: reflections on the preliminary results. ACTA ACUST UNITED AC 1999. [PMID: 9799138 DOI: 10.1097/00019509-199810000-00001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aim of this study was to assess the feasibility of laparoscopic gastroenteric and cholecystenteric bypass procedures for palliation of inoperable cancer of the pancreas. Between July 1994 and January 1996, five patients underwent laparoscopic gastroenterostomy for duodenal obstruction due to pancreatic cancer. There were four men and one woman, ranging in age from 53 to 72 years (median 63). Four patients already had endoscopic biliary decompression. One patient underwent laparoscopic cholecystojejunostomy for biliary obstruction at the time of the laparoscopic gastroenterostomy. The procedure was completed laparoscopically in all patients. There was no perioperative mortality, and the morbidity was low. The median post-operative stay was 4 days (range, 4-6). Laparoscopic gastroenterostomy associated with cholecystojejunostomy in selected cases offers a less invasive alternative than open surgery, with a shorter hospital stay and more rapid return to normal activity.
Collapse
|
39
|
Milsom JW, Marchesa P, Vignali A. Minimally invasive surgery in surgical oncology. Cancer Treat Res 1997; 90:309-29. [PMID: 9367090 DOI: 10.1007/978-1-4615-6165-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- J W Milsom
- Cleveland Cl. Foundation, OH 44195-5044, USA
| | | | | |
Collapse
|