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Miwa H, Sugimori K, Kaneko T, Ishii T, Iwase S, Irie K, Sanga K, Tozuka Y, Hirotani A, Komiyama S, Sato T, Tezuka S, Goda Y, Numata K, Maeda S. Clinical outcome of a highly flexible duodenal stent for gastric outlet obstruction: A multicenter prospective study. JGH OPEN 2020; 4:729-735. [PMID: 32782963 PMCID: PMC7411653 DOI: 10.1002/jgh3.12326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 03/05/2020] [Indexed: 12/17/2022]
Abstract
Background and Aim Endoscopic duodenal stenting for patients with malignant gastric outlet obstruction (GOO) has been widespread; however, clinical trials evaluating the structures of duodenal stents are lacking. Thus, we aimed to investigate the clinical outcomes of a highly flexible duodenal stent for GOO patients. Methods A prospective study of duodenal stenting for GOO patients from five hospitals between August 2017 and August 2018 was performed. WallFlex Duodenal Soft were used in all procedures. The primary endpoint was clinical success, defined as an improvement in the GOO scoring system. Results The study enrolled 31 patients (12 women, 19 men) with GOO, with a median age of 70 (range 52–90) years. Primary diseases were pancreatic cancer, gastric cancer, biliary tract cancer, and others in 14, 10, 3, and 4 patients, respectively. The technical success rate was 97%, and the clinical success rate was 87%. Simultaneous biliary drainage was performed in 19% of patients. Adverse events occurred in three patients. Chemotherapy was given in 41% of clinically successful cases, and the median overall survival time after stent placement was 82 days (range, 30–341 days), and. Stent dysfunction occurred in 30% of clinically successful cases (stent ingrowth in seven and stent overgrowth in one patient). The median time to stent dysfunction was 157 days (range, 11–183 days). Six patients were treated with additional stent placement after dysfunction. Conclusion Placement of a highly flexible duodenal stent is an effective and safe treatment for patients with GOO (UMIN‐CTR 000028783).
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Affiliation(s)
- Haruo Miwa
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Kazuya Sugimori
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Takashi Kaneko
- Department of Gastroenterology Yokohama Minami Kyousai Hospital Yokohama Japan
| | - Tomohiro Ishii
- Department of Gastroenterology Saiseikai Yokohamashi Nanbu Hospital Yokohama Japan
| | - Shigeru Iwase
- Department of Gastroenterology Fujisawa City Hospital Fujisawa Japan
| | - Kuniyasu Irie
- Department of Gastroenterology Yokohama City University Graduate School of Medicine Yokohama Japan
| | - Katsuyuki Sanga
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Yuichiro Tozuka
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Akane Hirotani
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Satoshi Komiyama
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Takeshi Sato
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Shun Tezuka
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Yoshihiro Goda
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Kazushi Numata
- Gastroenterological Center Yokohama City University Medical Center Yokohama Japan
| | - Shin Maeda
- Department of Gastroenterology Yokohama City University Graduate School of Medicine Yokohama Japan
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Tang T, Allison M, Dunkley I, Roberts P, Dickinson R. Enteral Stenting in 21 Patients with Malignant Gastroduodenal Obstruction. J R Soc Med 2017; 96:494-6. [PMID: 14519726 PMCID: PMC544629 DOI: 10.1177/014107680309601006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Placement of an enteral stent is emerging as an effective alternative to surgery for symptomatic relief in patients with malignant gastric outflow and duodenal obstruction. We report experience in a series of patients who had the Wallstent enteral prosthesis inserted. 21 consecutive patients with inoperable obstruction, median age 75 years, had twenty-three procedures for insertion of the Wallstent under fluoroscopic guidance. Stent implantation was successful in 18 patients (86%), all of whom gained relief from nausea and vomiting. There were no short-term complications. Median survival after the procedure was four months (longest ten months), and no deaths were related to insertion. The efficacy and lack of complications in this series support use of the endoscopically placed stent for palliative management of malignant upper gastrointestinal obstruction.
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Affiliation(s)
- Tjun Tang
- Vascular Unit, Addenbrooke's NHS Trust, Cambridge, UK.
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Min SH, Son SY, Jung DH, Lee CM, Ahn SH, Park DJ, Kim HH. Laparoscopic gastrojejunostomy versus duodenal stenting in unresectable gastric cancer with gastric outlet obstruction. Ann Surg Treat Res 2017; 93:130-136. [PMID: 28932728 PMCID: PMC5597536 DOI: 10.4174/astr.2017.93.3.130] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/05/2017] [Accepted: 03/16/2017] [Indexed: 01/25/2023] Open
Abstract
Purpose To compare the outcome between laparoscopic gastrojejunostomy (LapGJ) and duodenal stenting (DS) in terms of oral intake, nutritional status, patency duration, effect on chemotherapy and survival. Methods Medical records of 115 patients, who had LapGJ or duodenal stent placement between July 2005 and September 2015 in Seoul National University Bundang Hospital, have been reviewed retrospectively. Oral intake was measured with Gastric Outlet Obstruction Scoring System. Serum albumin and body weight was measured as indicators of nutritional status. The duration of patency was measured until the date of reintervention. Chemotherapy effect was calculated after the procedures. Survival period and oral intake was analyzed by propensity score matching age, sex, T-stage, comorbidities, and chemotherapy status. Results Forty-three LapGJ patients and 58 DS patients were enrolled. Improvement in oral intake was shown in LapGJ group versus DS group (88% vs. 59%, P = 0.011). Serum albumin showed slight but significant increase after LapGJ (+0.75 mg/dL vs. −0.15 mg/dL, P = 0.002); however, there was no difference in their body weight (+5.1 kg vs. −1.0 kg, P = 0.670). Patients tolerated chemotherapy longer without dosage reduction after LapGJ (243 days vs. 74 days, P = 0.006) and maintained the entire chemotherapy regimen after the procedure longer in LapGJ group (247 days vs. 137 days, P = 0.042). LapGJ showed significantly longer survival than DS (220 vs. 114 days, P = 0.004). Conclusion DS can provide faster symptom relief but LapGJ can provide improved oral intake, better compliance to chemotherapy, and longer survival. Therefore, LapGJ should be the first choice in gastric outlet obstruction patients for long-term and better quality of life.
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Affiliation(s)
- Sa-Hong Min
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Yong Son
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Do-Hyun Jung
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chang-Min Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Hoon Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Do Joong Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Ho Kim
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea.,Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Kim SH, Song HY, Park JH, Zhou WZ, Cho YC, Shin JH, Kim JH. Fluoroscopic-guided stent placement in failed tentative endoscopic approaches to malignant gastroduodenal obstructions. Acta Radiol 2017; 58:959-963. [PMID: 28084810 DOI: 10.1177/0284185116682379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Fluoroscopic or endoscopic placement of metallic stents is used as a safe, non-surgical, palliative treatment option for malignant gastroduodenal obstructions. However, endoscopic stent placement is not always feasible, due to the tight or tortuous stricture of the obstructed area and insufficient visualization of the stomach due to remnant food material. Purpose To assess the technical feasibility and clinical outcomes of fluoroscopic-guided stent placement in malignant gastroduodenal obstructions following the technical failure of endoscopic stent placement. Material and Methods In all, 19 patients (14 men, 5 women; age range, 36-85 years) were referred due to technical failures of tentative endoscopic stent placement. Indications were failure to pass the guide wire through the obstruction (n = 13), failure to reach the stricture lesion due to short endoscope (n = 5), and acute angulation of the stricture lesion (n = 1). Data were retrospectively collected regarding the technical and clinical success of the fluoroscopy, the dysphagia score before and after stent placement, and major complications and their management. Results Fluoroscopic stent placement was technically successful in 15/19 patients (79%). Failures were due to complete obstruction (n = 3) and acute angulation of the stricture lesion (n = 1). Clinical success was achieved in all 15 patients with successful stent placement. The dysphagia score significantly improved after stent placement ( P < 0.001). Complications occurred in 4/15 patients (27%), including tumor overgrowth (n = 2), stent collapse (n = 1), and jaundice (n = 1). Conclusion Fluoroscopic stent placement in malignant gastroduodenal obstructions following a technical failure of endoscopic stent placement is technically feasible and has an acceptable clinical outcome.
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Affiliation(s)
- Soo Hwan Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wei-Zhong Zhou
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Young Chul Cho
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Endoscopic Stenting With the Over-The-Scope Technique: Our Experience With 11 Consecutive Patients. Surg Laparosc Endosc Percutan Tech 2016; 26:e178-e181. [PMID: 27846161 DOI: 10.1097/sle.0000000000000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Endoscopic stenting is widely used to manage benign and malignant strictures, postoperative stenoses, or anastomotic leaks and fistulas. MATERIALS AND METHODS However, Over the Wire delivery systems are generally short and quite stiff, and therefore, cannot reach distal parts of the gastrointestinal tract or cross severely angulated strictures. In such cases, we used the Over-the-Scope stenting (OTSS) technique to deliver and deploy endoscopically large-bore fully covered stents. We present herein a series of 11 patients treated with the OTSS technique for a variety of indications. To our knowledge, this is the largest series of OTSS cases published. RESULTS The stents were correctly deployed in 10 cases. In one case, the stent was dislocated during scope withdrawal and Through the Scope stenting was performed with a smaller diameter uncovered stent instead. Predilation of the stricture was necessary in 5 patients. Clinical success was achieved in all patients. CONCLUSIONS Our results encourage the use of the OTSS technique in cases where standard Over the Wire delivery systems of large-bore stents cannot reach or cross distal or tortuous strictures. The technique can also be used to reinsert migrated stents or misplaced braided-suture release mechanism (Ultraflex) stents.
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Shim CS, Kim JH, Bok GH. Development of Biliary and Enteral Stents by the Korean Gastrointestinal Endoscopists. Clin Endosc 2016; 49:113-23. [PMID: 26956192 PMCID: PMC4821526 DOI: 10.5946/ce.2016.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 11/22/2022] Open
Abstract
Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.
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Affiliation(s)
- Chan Sup Shim
- Digestive Disease Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Gene Hyun Bok
- Department of Internal Medicine, Min Hospital, Seoul, Korea
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Lim SG, Kim JH, Lee KM, Shin SJ, Kim CG, Kim KH, Kim HG, Yang CH. Conformable covered versus uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction: a randomized prospective study. Dig Liver Dis 2014; 46:603-8. [PMID: 24675035 DOI: 10.1016/j.dld.2014.02.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 02/25/2014] [Accepted: 02/26/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND A conformable self-expandable metallic stent was developed to overcome the limitation of previous self-expandable metallic stents. The aim of this study was to evaluate outcomes after placement of conformable covered and uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction. METHODS A single-blind, randomized, parallel-group, prospective study were conducted in 4 medical centres between March 2009 and July 2012. 134 patients with unresectable malignant gastroduodenal obstruction were assigned to a covered double-layered (n=66) or uncovered unfixed-cell braided (n=68) stent placement group. Primary analysis was performed to compare re-intervention rates between two groups. RESULTS 120 patients were analysed (59 in the covered group and 61 in the uncovered group). Overall rates of re-intervention were not significantly different between the two groups: 13/59 (22.0%) in the covered group vs. 13/61 (21.3%) in the uncovered group, p=0.999. Stent migration was more frequent in the covered group than in the uncovered group (p=0.003). The tumour ingrowth rate was higher in the uncovered group than in the covered group (p=0.016). CONCLUSIONS The rates of re-intervention did not significantly differ between the two stents. Conformable covered double-layered and uncovered unfixed-cell braided stents were associated with different patterns of stent malfunction.
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Affiliation(s)
- Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea.
| | - Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sung Jae Shin
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chan Gyoo Kim
- Department of Gastroenterology, National Cancer Center, Goyang, Republic of Korea
| | - Kyung Ho Kim
- Department of Internal Medicine, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Chang Heon Yang
- Department of Internal Medicine, Dongguk University College of Medicine, Gyeongju, Republic of Korea
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Kim YW, Choi CW, Kang DH, Kim HW, Chung CU, Kim DU, Park SB, Park KT, Kim S, Jeung EJ, Bae YM. A double-layered (comvi) self-expandable metal stent for malignant gastroduodenal obstruction: a prospective multicenter study. Dig Dis Sci 2011; 56:2030-6. [PMID: 21264512 DOI: 10.1007/s10620-011-1566-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 01/05/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND A self-expandable metal stent (SEMS) has emerged as an effective palliative treatment for malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. Despite the stent's effectiveness, tumor ingrowth and stent migration remain complications requiring reintervention. The purpose of this study was to evaluate the efficacy and safety of a double-layered SEMS (Comvi). METHODS We performed a prospective multicenter study in two university hospitals and two referral hospitals. In fifty consecutive patients with malignant gastroduodenal obstructions, placement of double-layered SEMS, comprising an outer uncovered stent and an inner covered stent that overlap each other, was performed. Palliation, efficacy, and incidence of complications were evaluated. RESULTS Technical and clinical success was achieved in 100 and 88% of patients, respectively. There were no procedure-related complications. Five patients experienced stent migration (10%). For four of five patients' stent migration occurred within two weeks of stent placement. Stent collapse occurred in five patients after one month. Reintervention for stent migration, collapse, or tumor overgrowth was required for 14 (28%) patients. CONCLUSIONS Endoscopic placement of a double-layered stent is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, considering reintervention, this stent does not seem to add any clear advantage compared with preexisting uncovered stents. Migration, especially within the first two weeks, and stent collapse are still unresolved problems. The device should be fixed or the design modified to reduce these problems.
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Affiliation(s)
- Yong Wuk Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, South Korea
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Peroral placement of a self-expandable covered metallic stent using an overtube for malignant gastroduodenal obstructions. Surg Today 2011; 41:637-42. [PMID: 21533934 DOI: 10.1007/s00595-009-4332-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Accepted: 12/25/2009] [Indexed: 12/31/2022]
Abstract
PURPOSE To evaluate the technical feasibility and safety of overtube-guided covered metallic stent placement as palliative treatment for patients with inoperable malignant gastric outlet obstructions. METHODS To relieve the symptoms of severe nausea and recurrent vomiting in five patients with inoperable gastric cancer, we used an overtube (Long overtube; Sumitomo Bakelite, Tokyo, Japan) to place large-diameter, self-expandable, covered esophageal Ultraflex stents (inner diameter 22-28 mm, length 10 or 12 cm; Boston Scientific, Watertown, MA, USA). Success was defined both technically and clinically. RESULTS The stent placement was technically successful in all patients and resulted in improvement of symptoms in all five patients, four of whom were thereafter able to ingest solid food. The remaining patient, a 94-year-old man, was unable to ingest food because of dysmasesis. During the mean follow-up of 17 weeks, there was no stent reocclusion and no life-threatening complications developed. CONCLUSIONS The placement of a large diameter, self-expandable, covered esophageal stent using an overtube appears to be effective for the palliative treatment of malignant gastric outlet obstruction.
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Rudolph HU, Post S, Schlüter M, Seitz U, Soehendra N, Kähler G. Malignant gastroduodenal obstruction: retrospective comparison of endoscopic and surgical palliative therapy. Scand J Gastroenterol 2011; 46:583-90. [PMID: 21366507 DOI: 10.3109/00365521.2010.545831] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic stenting (ES) is a minimally invasive alternative to surgical gastroenterostomy (GE) for palliation of malignant gastroduodenal obstructions. This consecutive, retrospective analysis compares the clinical outcome of all patients undergoing ES or GE in the same period. METHODS ES was performed at the Endoscopy Department, University Hospital Mannheim or at the Interdisciplinary Endoscopy Department, University Hospital Hamburg-Eppendorf. GE was performed at the Surgical Department, University Hospital Mannheim. All palliative ES or GE on patients with malignant gastroduodenal obstruction without earlier gastric resections between January 2001 and April 2007 were evaluated. Main outcome measurements were ability of solid food intake (gastric outlet obstruction score), persistence of nausea and vomiting (gut function score), length of hospital stay, morbidity, mortality and re-interventions. RESULTS A total of 44 ES and 43 GE were performed. Nausea and vomiting--measured by means of the gut function score--persisted in significantly more patients in the GE group than in those who underwent stent placement (p = 0.0102). The gastric outlet obstruction score at discharge from the hospital revealed no significant difference in the ability of solid food intake between the groups. The hospital stay was significantly longer in the GE group (p = 0.0003). There was no significant difference in mortality and the rates of complications and re-interventions. CONCLUSION In this study, ES is a generally equivalent--and in several points superior--alternative to GE for palliation of malignant gastroduodenal obstruction. ES seems to be the less invasive alternative for symptomatic patients. GE has good results in patients with longer survival and can be practiced within abdominal explorations.
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Dolz C, Vilella À, González Carro P, González Huix F, Espinós JC, Santolaria S, Pérez Roldán F, Figa M, Loras C, Andreu H. Antral localization worsens the efficacy of enteral stents in malignant digestive tumors. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:63-8. [PMID: 21353341 DOI: 10.1016/j.gastrohep.2010.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Revised: 11/30/2010] [Accepted: 12/06/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Malignant gastric outlet obstruction can be treated by means of enteral stenting or surgical gastrojejunalanatomosis. We evaluated in a prospective and multicentre study the efficacy of the enteral stent on food intake, the quality of life impact, and the relationship between efficacy and determined clinical and technical parameters. PATIENTS AND METHODS Seventy one patients affected by symptoms arising from gastroduodenal obstruction due to malignant tumors, with criteria of irresecability, metastatic disease or very high surgical risk, were treated by means of self expanding metal stents. We used the GOOSS index to evaluate efficacy, and the Euro Qol-5D index to evaluate quality of life. RESULTS Before stenting patients with GOOSS 0 and 1 were 68 (98.5%). After stenting patients with GOOSS 2 and 3 (semisolid and solid food) were 58 (84,1%) (P<.0001). The Euro Qol-5D index measured before and a month after stenting were 10.17 and 10.04 respectively (P=.6). The median survival was 91 days (9-552). The enteral stents for localised tumors in the duodenum and the gastrojejunalanastomosis were effective in 26 patients (70.2%) and 13 patients respectively (86.6%), while the enteral stents of tumors in the antrum were effective in only 5 patients (29.4%). CONCLUSIONS The palliative treatment of malignant gastric outlet obstruction with a uncovered metal stent produces a significant improvement of oral food intake and maintains the overall quality of life index. The antral localization is associated with a lower efficacy of the procedure.
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Affiliation(s)
- Carlos Dolz
- Servicio de Aparato Digestivo, Hospital Son Llàtzer, Palma de Mallorca, Spain.
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Kim YW, Choi CW, Kang DH, Kim HW, Chung CU, Kim DU, Park SB, Park KT, Kim S, Jeung EJ, Bae YM. A double-layered (comvi) self-expandable metal stent for malignant gastroduodenal obstruction: a prospective multicenter study. Dig Dis Sci 2011. [PMID: 21264512 DOI: 10.1107/s10620-011-1566-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND A self-expandable metal stent (SEMS) has emerged as an effective palliative treatment for malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. Despite the stent's effectiveness, tumor ingrowth and stent migration remain complications requiring reintervention. The purpose of this study was to evaluate the efficacy and safety of a double-layered SEMS (Comvi). METHODS We performed a prospective multicenter study in two university hospitals and two referral hospitals. In fifty consecutive patients with malignant gastroduodenal obstructions, placement of double-layered SEMS, comprising an outer uncovered stent and an inner covered stent that overlap each other, was performed. Palliation, efficacy, and incidence of complications were evaluated. RESULTS Technical and clinical success was achieved in 100 and 88% of patients, respectively. There were no procedure-related complications. Five patients experienced stent migration (10%). For four of five patients' stent migration occurred within two weeks of stent placement. Stent collapse occurred in five patients after one month. Reintervention for stent migration, collapse, or tumor overgrowth was required for 14 (28%) patients. CONCLUSIONS Endoscopic placement of a double-layered stent is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, considering reintervention, this stent does not seem to add any clear advantage compared with preexisting uncovered stents. Migration, especially within the first two weeks, and stent collapse are still unresolved problems. The device should be fixed or the design modified to reduce these problems.
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Affiliation(s)
- Yong Wuk Kim
- Department of Internal Medicine, Pusan National University School of Medicine and Medical Research Institute, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, South Korea
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Abstract
AIM: To find out whether a newly designed big cup nitinol stent is suitable for treatment of patients with gastric outlet obstruction resulting from gastric cancer.
METHODS: The new stent is composed of a proximal big cup segment (20 mm in length and 48-55 mm in diameter), a middle part (60 mm in length and 20 mm in diameter) covered by a polyethylene membrane and a distal sphericity (20 mm in length and 28 mm in diameter). Half of the proximal big cup segment is also covered by a polyethlene membrane, which is adjacent to the middle part of the stent. The stent is preloaded in a 6.0-mm-diameter introducer system. Thirteen patients with gastric outlet obstruction resulting from gastric cancer received the new stents under endoscopic and fluoroscopic guidance.
RESULTS: Technical success was achieved in 12 of 13 (92.3%) patients. Among the 12 patients in whom endoscopic stent was placed successfully, the clinical success rate was 91.7% during a follow-up of average 6.5 mo. During the first month follow-up, the migration rate was 0%, recurrent obstruction 0% and gastric bleeding 8.3%. During the follow-up between 2-12 mo, no migration, recurrent obstruction and gastric bleeding occurred.
CONCLUSION: The proximal big cup segment seems to be effective and promising for technical efficacy, clinical outcome, and preventing migration and tumor ingrowth and increasing the emptying rate of sinus ventriculi.
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Lee KM, Choi SJ, Shin SJ, Hwang JC, Lim SG, Jung JY, Yoo BM, Cho SW, Kim JH. Palliative treatment of malignant gastroduodenal obstruction with metallic stent: prospective comparison of covered and uncovered stents. Scand J Gastroenterol 2010; 44:846-52. [PMID: 19462336 DOI: 10.1080/00365520902929849] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The placement of self-expandable metallic stents (SEMS) is known to be effective palliative treatment of malignant gastroduodenal obstruction. There are two types of SEMS--covered and uncovered--each with its own advantages and disadvantages. This study was conducted to compare between the clinical outcomes of covered and uncovered stents in patients with malignant gastroduodenal obstruction. PATIENTS AND METHODS The study was conducted prospectively from January 1998 to June 2007 and 154 patients were included. All had symptomatic gastroduodenal obstruction and were not candidates for curative operation. Seventy patients received covered SEMS, while the other 84 received uncovered SEMS. We compared technical and clinical success rates, tumour ingrowth rate, stent migration rate, stent patency time and patient survival in both SEMS groups. RESULTS The technical and clinical success rates of the covered and uncovered stent groups did not differ. Stent migration was more frequent in the covered stent group than in the uncovered group (17.1% versus 0%; p=0.0001). Tumour ingrowth was more frequent in the uncovered stent group than in the covered group (16.6% versus 2.9%; p=0.0066). Stent re-intervention rate, stent patency time and patient survival did not differ between groups. CONCLUSION Covered and uncovered stent insertions are technically feasible and effective palliative treatment of malignant gastroduodenal obstruction. Covered stents can reduce the risk of tumour ingrowth, whereas uncovered stents are effective in preventing stent migration. However, covered stents did not differ from uncovered stents in regard to other clinical outcomes.
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Affiliation(s)
- Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Efficacy and safety of the new WallFlex enteral stent in palliative treatment of malignant gastric outlet obstruction (DUOFLEX study): a prospective multicenter study. Gastrointest Endosc 2009; 69:1059-66. [PMID: 19152912 DOI: 10.1016/j.gie.2008.07.026] [Citation(s) in RCA: 142] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 07/08/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastric outlet obstruction (GOO) is most commonly a complication of advanced distal gastric, periampullary, or duodenal malignancy. Palliation of obstruction is the primary aim of treatment in most of these patients. Self-expandable metal stents have emerged as an effective treatment option. OBJECTIVE Our purpose was to investigate the efficacy and safety of a newly developed enteral metal stent (WallFlex). DESIGN Prospective multicenter cohort study. SETTING Three tertiary referral centers (2 academic). PATIENTS Fifty-one consecutive patients with symptomatic malignant GOO from January 2005 to February 2006. INTERVENTION Placement of a self-expandable metallic stent (WallFlex). MAIN OUTCOME MEASUREMENTS The primary end point was defined as improvement of the GOO scoring system for the remainder of the patients' lives. Secondary end points focused on efficacy and safety and global quality of life. RESULTS The Gastric Outlet Obstruction Scoring System score improved (P < .001), the body mass index decreased (P < .001), and the World Health Organization performance score improved (P = .002) when the score before stenting was compared with the mean score until death. Global quality of life did not improve. Technical and clinical success was achieved in 98% and 84% of the patients. Median survival was 62 days (75% alive at 35 days, 25% alive at 156 days). Median stent patency was 307 days (75% functional at 135 days, 25% functional at 470 days). Stent dysfunction was proved in 7 patients (14%), migration in 1 (2%), and tumor overgrowth or ingrowth in 6 (12%). LIMITATIONS Lack of a control group. CONCLUSION Placement of a WallFlex enteral stent in patients with nonresectable malignant GOO is safe and provides a statistically significant and clinically relevant relief of obstructive symptoms with a low need for reintervention.
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Malignant Gastroduodenal Obstruction: Treatment with Self-Expanding Uncovered Wallstent. Cardiovasc Intervent Radiol 2008; 32:97-105. [DOI: 10.1007/s00270-008-9445-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 08/20/2008] [Accepted: 09/03/2008] [Indexed: 01/15/2023]
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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.
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Affiliation(s)
- Eun H Seo
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, South Korea
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Jeurnink SM, Steyerberg EW, Hof GV', van Eijck CHJ, Kuipers EJ, Siersema PD. Gastrojejunostomy versus stent placement in patients with malignant gastric outlet obstruction: a comparison in 95 patients. J Surg Oncol 2007; 96:389-96. [PMID: 17474082 DOI: 10.1002/jso.20828] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM Gastrojejunostomy (GJJ) and duodenal stent placement are the most commonly used palliative treatment modalities for gastric outlet obstruction (GOO). In this retrospective study, we compared GJJ and stent placement with regard to medical effects. METHODS Medical records of 95 patients who had undergone palliative treatment between 1994 and 2006 in a Dutch university hospital, were reviewed. Study outcomes were improvement of food intake, complications, persistent and recurrent symptoms, re-interventions, hospital stay, and survival. RESULTS Fifty-three patients were referred for duodenal stent placement and 42 patients underwent GJJ. There were no differences in technical and clinical success and the incidence of minor and early major complications and survival. Food intake improved more rapidly after stent placement than GJJ (P = 0.01). The time to late major complications, recurrent obstructive symptoms and re-intervention was significantly shorter after stent placement than GJJ (P = 0.004, 0.002, and 0.004, respectively). Hospital stay was also shorter after stent placement than GJJ (P < 0.001). CONCLUSION These findings suggest that stent placement is associated with better short-term outcomes and GJJ with better long-term outcomes. A large randomized controlled trial is however needed to systematically compare stent placement with GJJ with regard to medical effects, quality of life and costs.
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Affiliation(s)
- S M Jeurnink
- Department of Gastroenterology and Hepatology, Erasmus MC/ University Medical Center Rotterdam, The Netherlands
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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.
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Affiliation(s)
- Néstor Chopita
- San Martin Hospital, La Plata and University of La Plata, calle 62 n 370, 1900 La Plata, Buenos Aires, Argentina
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20
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Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol 2007; 7:18. [PMID: 17559659 PMCID: PMC1904222 DOI: 10.1186/1471-230x-7-18] [Citation(s) in RCA: 279] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 06/08/2007] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gastrojejunostomy (GJJ) is the most commonly used palliative treatment modality for malignant gastric outlet obstruction. Recently, stent placement has been introduced as an alternative treatment. We reviewed the available literature on stent placement and GJJ for gastric outlet obstruction, with regard to medical effects and costs. METHODS A systematic review of the literature was performed by searching PubMed for the period January 1996 and January 2006. A total of 44 publications on GJJ and stents was identified and reported results on medical effects and costs were pooled and evaluated. Results from randomized and comparative studies were used for calculating odds ratios (OR) to compare differences between the two treatment modalities. RESULTS In 2 randomized trials, stent placement was compared with GJJ (with 27 and 18 patients in each trial). In 6 comparative studies, stent placement was compared with GJJ. Thirty-six series evaluated either stent placement or GJJ. A total of 1046 patients received a duodenal stent and 297 patients underwent GJJ. No differences between stent placement and gastrojejunostomy were found in technical success (96% vs. 100%), early and late major complications 7% vs. 6% and 18% vs. 17%, respectively) and persisting symptoms (8% vs. 9%). Initial clinical success was higher after stent placement (89% vs. 72%). Minor complications were less frequently seen after stent placement in the patient series (9% vs. 33%), however the pooled analysis showed no differences (OR: 0.75, p = 0.8). Recurrent obstructive symptoms were more common after stent placement (18% vs. 1%). Hospital stay was prolonged after GJJ compared to stent placement (13 days vs. 7 days). The mean survival was 105 days after stent placement and 164 days after GJJ. CONCLUSION These results suggest that stent placement may be associated with more favorable results in patients with a relatively short life expectancy, while GJJ is preferable in patients with a more prolonged prognosis. The paucity of evidence from large randomized trials may however have influenced the results and therefore a trial of sufficient size is needed to determine which palliative treatment modality is optimal in (sub)groups of patients with malignant gastric outlet obstruction.
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Sanders M, Papachristou GI, McGrath KM, Slivka A. Endoscopic palliation of pancreatic cancer. Gastroenterol Clin North Am 2007; 36:455-76, xi. [PMID: 17533090 DOI: 10.1016/j.gtc.2007.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic approaches have revolutionized the palliation of advanced pancreatic cancer. The ideal management consists of a multidisciplinary approach involving surgeons, endoscopists, radiologists, and oncologists. Concurrent advances in the fields of interventional radiology and laparoscopic surgical oncology should be readdressed and directly compared with endoscopic approaches in randomized controlled trials. Exciting novel endoscopic techniques are being developed and evaluated; however, these approaches require further validation with randomized clinical trials to determine the safety and efficacy when compared with more traditional approaches.
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Affiliation(s)
- Michael Sanders
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Mezzanine Level, C-Wing, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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22
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Song GA, Kang DH, Kim TO, Heo J, Kim GH, Cho M, Heo JH, Kim JY, Lee JS, Jeoung YJ, Jeon TY, Kim DH, Sim MS. Endoscopic stenting in patients with recurrent malignant obstruction after gastric surgery: uncovered versus simultaneously deployed uncovered and covered (double) self-expandable metal stents. Gastrointest Endosc 2007; 65:782-7. [PMID: 17324410 DOI: 10.1016/j.gie.2006.08.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Accepted: 08/22/2006] [Indexed: 01/19/2023]
Abstract
BACKGROUND Uncovered, rather than covered, metal stents are commonly used for palliation of malignant gastric outlet obstruction because of the low risk of stent migration, but tumor ingrowth risk is a major drawback. Few reports address malignant obstruction after gastric surgery. OBJECTIVE Our purpose was to compare the technical feasibility and clinical outcome of using an endoscopic uncovered self-expandable metal stent (SEMS) and simultaneous use of uncovered and covered SEMS (double SEMS) in patients with recurrent malignant obstruction after gastric surgery. DESIGN Retrospective study. SETTING Tertiary care, academic medical center, from August 2000 to June 2005. PATIENTS Twenty patients were included in the study. All patients had symptomatic obstruction with nausea, vomiting, and decreased oral intake. INTERVENTION Ten patients received uncovered SEMS; the other 10 received double SEMS. MAIN OUTCOME MEASUREMENTS To compare tumor ingrowth and stent patency between the uncovered and the double-SEMS groups. RESULTS Technical and clinical successes were 10 of 10 and 8 of 10, respectively, in the uncovered SEMS group and 10 of 10 and 10 of 10, respectively, in the double SEMS group. Six of 10 patients (60%) with uncovered SEMS had tumor ingrowth compared with 1 of 10 patients with double SEMS, P = .057. Five of 10 patients (50%) with uncovered SEMS had very early restenosis, but no patients had early restenosis in the double SEMS group, P = .033. Stent patency was a median of 21.5 days (range, 7-217 days) in the uncovered SEMS group and 150 days (range 29-263 days) in the double SEMS group, P = .037. Survival duration was 109.5 days (range 29-280 days) and 150 days (range 29-263 days), respectively. LIMITATIONS This was a small retrospective study. CONCLUSION Simultaneous double stent placement seems to be technically feasible and effective for palliative treatment of recurrent malignant obstruction after gastric surgery. Double stent placement is important in preventing tumor ingrowth, especially very early restenosis, and prolongs stent patency. We suggest that this procedure be considered rather than uncovered stent alone as the primary choice for palliation of obstruction in such patients.
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Affiliation(s)
- Geun Am Song
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Pusan National University College of Medicine, Busan, Korea
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Kim TO, Kang DH, Kim GH, Heo J, Song GA, Cho M, Kim DH, Sim MS. Self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction caused by stomach cancer. World J Gastroenterol 2007; 13:916-20. [PMID: 17352023 PMCID: PMC4065929 DOI: 10.3748/wjg.v13.i6.916] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To ascertain clinical outcome and complications of self-expandable metal stents for endoscopic palliation of patients with malignant obstruction of the gastrointestinal (GI) tract.
METHODS: A retrospective review was performed throughout August 2000 to June 2005 of 53 patients with gastric outlet obstruction caused by stomach cancer. All patients had symptomatic obstruction including nausea, vomiting, and decreased oral intake. All received self-expandable metallic stents.
RESULTS: Stent implantation was successful in all 53 (100%) patients. Relief of obstructive symptoms was achieved in 43 (81.1%) patients. No immediate stent-related complications were noted. Seventeen patients had recurrent obstruction (tumor ingrowth in 14 patients, tumor overgrowth in 1 patient, and partial distal stent migration in 2 patients). The mean survival was 145 d. Median stent patency time was 187 d.
CONCLUSION: Endoscopic placement of self-expandable metallic stents is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach cancer.
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Affiliation(s)
- Tae Oh Kim
- Department of Internal Medicine, Pusan National University College of Medicine, 1-10 Ami-dong, Soe-gu, Busan 602-739, Korea
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Espinel J, Sanz O, Vivas S, Jorquera F, Muñoz F, Olcoz JL, Pinedo E. Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation. Surg Endosc 2006; 20:1083-7. [PMID: 16703436 DOI: 10.1007/s00464-005-0354-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2005] [Accepted: 12/29/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND Malignant gastrointestinal obstruction is a secondary complication of cancers in an advanced state. Treatment has consisted of gastrojejunostomy. However, the endoscopic placement of metallic stents has provided positive results. This study aimed to compare the efficiency of both therapeutic options. METHODS A total of 41 patients with gastrointestinal obstruction caused by inoperable neoplasm were treated endoscopically with enteral stent (24 patients) or gastrojejunostomy (17 patients). RESULTS In the endoscopic group (EG) 24 patients (100%) achieved efficient gastric emptying, as compared with 82.3% in the surgical group (SG). The difference was not significant. The average time for initiating oral food tolerance was 2.4 days for the EG and 5 days for the SG (p < 0.001). The average inpatient time was 7.1 days for the EG and 11.5 days for the SG (p < 0.001). Mortality at 30 days was lower in the EG (16.6%) than in the SG (29.4%) (p < 0.05). The survival time was 20 weeks for the EG and 21.6 weeks for the SG. The difference was not significant. The rate of complications was 4% in the (EG) and 17.6% in the (SG), with the difference was not significant. CONCLUSION Endoscopic treatment of malignant gastrointestinal obstruction provides an adequate palliation of the symptoms. It is less invasive, avoids the morbidity associated with open gastrojejunostomy, and achieves a faster start to oral food and a shorter hospital stay, leading to a higher quality of life.
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Affiliation(s)
- J Espinel
- Department of Gastroenterology, Hospital de León, 24071, Leon, Spain.
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25
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26
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Lesurtel M, Dehni N, Tiret E, Parc R, Paye F. Palliative surgery for unresectable pancreatic and periampullary cancer: a reappraisal. J Gastrointest Surg 2006; 10:286-91. [PMID: 16455463 DOI: 10.1016/j.gassur.2005.05.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2005] [Accepted: 05/19/2005] [Indexed: 01/31/2023]
Abstract
This study aimed to reappraise short-term and long-term results of palliative biliary and gastric bypass surgery in patients with unresectable pancreatic head carcinoma found at explorative laparotomy. We retrospectively analyzed 83 consecutive patients whose pancreatic head carcinoma appeared unresectable at laparotomy (vascular involvement [57%], liver metastases [24%], distant metastatic lymph nodes [11%], peritoneal implants [8%]) and who underwent palliative surgical concomitant biliary and gastric bypass. Postoperative mortality and morbidity rates were 4.8% and 26.5%, respectively. Postoperative-delayed gastric emptying occurred in 9 patients (10%). Antecolic (46%) and retrocolic (54%) gastrojejunostomies did not differ for the duration of nasogastric suction, the delay of oral intake, and the incidence of delayed gastric emptying. Mean hospital stay was 16 +/- 8 days. Median survival was 9 months (range 1-44). Late cholangitis occurred in 2 patients (2.4%) treated medically. One recurrent jaundice required transhepatic stenting 9 months from surgery. Four late gastric outlet obstructions occurred (4.8%) with a mean delay of 8 months from surgery. These data demonstrate that, in patients with unresectable pancreatic head carcinoma at laparotomy, palliative concomitant biliary and gastric bypass in a single procedure is safe and long-term efficient. This strategy remains to be compared to endoscopic palliation in this setting.
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Affiliation(s)
- Mickael Lesurtel
- Department of Digestive Surgery, Saint Antoine University-Hospital, 184 Rue du Faubourg Saint Antoine, 75012 Paris, France
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Hayashi K, Okayama Y, Gotoh K, Ohara H, Sano H, Nakazawa T, Nakao H, Joh T, Itoh M. CLINICAL EVALUATION OF METALLIC STENTING FOR MALIGNANT DUODENAL OBSTRUCTION USING COVERED SELF-EXPANDABLE METALLIC STENT. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00509.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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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.
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Affiliation(s)
- Bertrand Bessoud
- Department of Medical and Interventional Imaging, Institut Gustave Roussy, Villejuif, France.
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29
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Bickston SJ, Foley E, Lawrence C, Rockoff T, Shaffer HA, Yeaton P. Terminal ileal stricture in Crohn's disease: treatment using a metallic enteral endoprosthesis. Dis Colon Rectum 2005; 48:1081-5. [PMID: 15785899 DOI: 10.1007/s10350-004-0865-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Enteral strictures are a frequent indication for surgery in Crohn's disease. Postoperative complications are increased in patients with poor preoperative nutritional status, which is common in this patient population. We present a 49-year-old female with longstanding Crohn's disease admitted to our Digestive Health Center with four weeks of increasing abdominal symptoms and radiographic evidence of small-bowel obstruction caused by ileal stricture. Given her poor nutritional status, our team elected to pursue metallic enteral stenting as a bridge to surgical resection. Two Wallstents were placed; luminal patency was subsequently confirmed by a fluoroscopic study. The patient tolerated regular diet and was discharged. When seen in follow-up, she remained asymptomatic and wished to defer surgical intervention indefinitely.
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Affiliation(s)
- S J Bickston
- Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, Virginia 22908-0708, USA.
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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.
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Affiliation(s)
- Andrew P Holt
- Liver Transplant and Hepato-biliary Unit, Queen Elizabeth Hospital, Birmingham, UK
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31
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Solt J, Grexa E. Treatment of recurrent malignant obstruction with a flexible covered metal stent after gastric surgery. Gastrointest Endosc 2004; 60:813-7. [PMID: 15557967 DOI: 10.1016/s0016-5107(04)02195-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The management of gastric outlet obstruction with expandable metallic stents is difficult and frequently is associated with late complications. A new, flexible, covered metal stent has been developed, which may be suitable for treatment of patients with recurrent malignant strictures after gastric surgery. METHODS The stainless-steel stent is covered by a polyethylene membrane. It has a proximal funnel attached to an expanded antimigratory segment 29 mm in diameter. The flexible covering membrane connects isolated distal segments that are 20 mm in diameter. The stent is preloaded in a 6.7-mm-diameter introducer system. The structural features and the increased flexibility of this new prosthesis are intended to reduce the risk of migration and the frequency of late complications, and to broaden the range of applications. RESULTS This stent was used to successfully treat two patients with recurrent tortuous malignant strictures after partial or complete gastrectomy. CONCLUSIONS This new flexible, polyethylene-covered stent potentially is a new alternative for the palliation of patients with recurrent, inoperable gastric malignant strictures.
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Affiliation(s)
- Jeno Solt
- Department of Medicine I, Baranya County Hospital, Pécs, Hungary
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Kazanjian KK, Reber HA, Hines OJ. Laparoscopic Gastrojejunostomy for Gastric Outlet Obstruction in Pancreatic Cancer. Am Surg 2004. [DOI: 10.1177/000313480407001018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Up to 20 per cent of patients with pancreatic cancer develop gastric outlet obstruction. Traditionally, these patients have been managed with an open gastrojejunostomy. Laparoscopic gastrojejunostomy may now be a preferable approach. We conducted a retrospective review of nine patients who underwent laparoscopic gastrojejunostomy in 2001–2004. All nine patients had unresectable pancreatic cancer. There were six men and three women. Median age was 66 years (range 36–87). Two patients had prior laparotomies for attempted resection. Four patients had previously placed duodenal stents that failed. Four others had undergone unsuccessful attempts of duodenal stenting. Median operating time was 116 minutes (range 75–300). There were no intraoperative complications or conversions to open procedure. Median time to postoperative oral intake was 4 days (range 3–6), and median postoperative length of stay was 7 days (range 5–18). Eight of our nine patients were palliated successfully using this technique. There were no complications or deaths related to the operation. All patients were discharged from the hospital. Six patients have since died, with a median postoperative survival of 2.5 months (range 1.5–8). Laparoscopic gastrojejunostomy provides safe and effective palliation of gastric outlet obstruction in patients with unresectable pancreatic cancer. This approach allows for rapid palliation in a group of patients with a very limited survival.
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Affiliation(s)
- Kevork K. Kazanjian
- From the Section of Gastrointestinal Surgery, UCLA Medical Center, Los Angeles, California
| | - Howard A. Reber
- From the Section of Gastrointestinal Surgery, UCLA Medical Center, Los Angeles, California
| | - Oscar J. Hines
- From the Section of Gastrointestinal Surgery, UCLA Medical Center, Los Angeles, California
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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.
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Affiliation(s)
- J O Lindsay
- Department of Gastroenterology, Imperial College Faculty of Medicine, Chelsea and Westminster NHS Trust, London, UK
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Abstract
BACKGROUND Patients with unresectable distal gastric cancer causing obstruction have classically undergone palliative gastrojejunostomy, but high mortality rates and delayed return of gastric emptying have been reported. The aim of the present study was to compare gastrojejunostomy and proximal gastric exclusion in patients with unresectable distal gastric cancer. METHODS Until 1996, patients with unresectable obstructing distal gastric cancer underwent antecolic gastrojejunostomy, but since 1997 we have performed proximal gastric exclusion for these patients. Mortality, morbidity, time taken to resume oral fluids and normal diet, length of palliation and survival were compared. RESULTS There was no mortality in either the gastrojejunostomy group (n = 4) or the exclusion group (n = 6). A single patient in the gastrojejunostomy group developed a sacral sore and another patient had recurrent vomiting following gastrojejunostomy. Exclusion resulted in a quicker return to diet and a slightly longer survival, although these were not statistically significant. CONCLUSION Proximal gastric exclusion offers a safe, quick and life-enduring palliation for unresectable malignant gastric outlet obstruction.
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Affiliation(s)
- Kevin Dolan
- Department of Surgery, The General Infirmary at Leeds, Leeds, United Kingdom.
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el-Shabrawi A, Cerwenka H, Bacher H, Schweiger J, Kornprat P, Mischinger HJ. Endoskopische Palliation der malignen Magenausgangsstenose durch selbstexpandierbare Metallstents. Wien Klin Wochenschr 2003; 115:840-5. [PMID: 14740348 DOI: 10.1007/bf03041045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Malignant gastric outlet stenosis is caused by tumour obstruction and restricts the oral intake of food, resulting in a seriously reduced quality of life. Endoscopic implantation of self expanding metal stents (SEMS) can clear stenosis in the GI-tract and reestablish and preserve the passage in the GI-tract. PATIENTS AND METHODS Between October 2001 and April 2003 seven patients with malignant gastric outlet stenosis have been treated by the implantation of SEMS. Four patients had malignant stenosis in the upper duodenum or gastric antrum, two patients had stenosis because of tumour recurrence in the efferent loop of the jejunum after gastric resection because of gastric carcinoma and one patient had an obstruction 20 cm distal of the oesophagus after gastrectomy because of gastric cancer. RESULTS In all patients obstruction was cleared by the implantation of SEMS, and oral intake of food was possible in all patients after two days. No serious complications occurred during or after stent implantation. CONCLUSION Stent implantation for the treatment of malignant gastric outlet stenosis is a cost effective procedure, associated with low risk and low stress for the patient, and provides excellent palliation of symptoms in patients with malignant gastric outlet stenosis.
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Affiliation(s)
- Azab el-Shabrawi
- Klinische Abteilung für Allgemeinchirurgie, Universitätsklinik für Chirurgie, Graz, Osterreich.
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Tang T, Allison M, Dunkley I, Roberts P, Dickinson R. Enteral stenting in 21 patients with malignant gastroduodenal obstruction. J R Soc Med 2003. [PMID: 14519726 DOI: 10.1258/jrsm.96.10.494] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Placement of an enteral stent is emerging as an effective alternative to surgery for symptomatic relief in patients with malignant gastric outflow and duodenal obstruction. We report experience in a series of patients who had the Wallstent enteral prosthesis inserted. 21 consecutive patients with inoperable obstruction, median age 75 years, had twenty-three procedures for insertion of the Wallstent under fluoroscopic guidance. Stent implantation was successful in 18 patients (86%), all of whom gained relief from nausea and vomiting. There were no short-term complications. Median survival after the procedure was four months (longest ten months), and no deaths were related to insertion. The efficacy and lack of complications in this series support use of the endoscopically placed stent for palliative management of malignant upper gastrointestinal obstruction.
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Affiliation(s)
- Tjun Tang
- Vascular Unit, Addenbrooke's NHS Trust, Cambridge, UK.
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Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Foundation, Rochester, Minnesota, USA
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Abstract
Metastatic pancreatic cancer is one of the leading causes of cancer-related deaths in North America and Europe. In the past, patients with metastatic pancreatic cancer have had few treatment options. However, recently, several effective palliative therapies and procedures have become available. The systemic administration of gemcitabine has been shown to result in clinical benefit and in a prolongation of median survival, and is now established as the standard first-line treatment for patients with metastatic pancreatic cancer. Clinical trials are exploring whether the use of gemcitabine-based chemotherapy combinations will result in further benefit. Several novel chemotherapeutic and biologic agents appear promising, and are likely to play a role in the treatment of patients with pancreatic cancer in the future. Palliative procedures, such as biliary or duodenal stenting and celiac plexus blockade, should be considered in conjunction with systemic therapy in patients with specific complications from pancreatic cancer.
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Affiliation(s)
- Matthew H Kulke
- Department of Adult Oncology, Dana-Farber Cancer Institute, 44 Binney Street, Boston, MA 02115, USA.
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Affiliation(s)
- Gary C Vitale
- Director of Interventional Endoscopy of the Center for Advanced Surgical Technologies, Norton Hospital Surgical Director, Digestive Disease Center, University of Louisville, Louisville, Kentucky, USA
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Abstract
Stents represent an exciting development in the field of gastroenterology. Their use to maintain luminal patency in the pancreatobiliary system has been well established. Stents have also found a place in maintaining the patency of the esophagus. Recent developments have led to an increasing role for their use to decompress both the small and large intestine. In the small intestine they are often placed to palliate proximal obstruction in the duodenum or the very proximal jejunum resulting from various malignancies. Self-expandable metal stents are an attractive alternative to surgery, especially in patients with compromised performance status, and can be done safely as outpatient procedures. However, one should be aware of the associated risks and complications. With a proper understanding of the principles involved in stent placement one can safely undertake this procedure.
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Affiliation(s)
- Sandeep Singh
- Division of Gastrointestinal Medicine and Nutrition, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 436, Houston, TX 77030, USA
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Sharma VK, Xie QY, Hassan HA, Howden CW. Placement of a covered metal stent via gastrostomy for management of malignant duodenocolic fistula with duodenal obstruction. Gastrointest Endosc 2002; 55:937-40. [PMID: 12024160 DOI: 10.1067/mge.2002.124211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Virender K Sharma
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Arkansas for Medical Sciences and Central Arkansas Veterans' Health Care System, Little Rock, Arkansas 85259, USA
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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.
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Affiliation(s)
- Jun Yong Jeong
- Department of Radiology, Seoul National University College of Medicine, 28 Yongon-dong, Chongno-gu, Seoul 110-744, Korea
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Jung GS, Song HY, Seo TS, Park SJ, Koo JY, Huh JD, Cho YD. Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stents. J Vasc Interv Radiol 2002; 13:275-83. [PMID: 11875087 DOI: 10.1016/s1051-0443(07)61720-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE To assess whether coaxial placement of uncovered and covered expandable nitinol stents overcomes the disadvantages of the increased migration rate seen with covered stents and the tumor ingrowth seen in uncovered stents in the treatment of malignant gastric outlet obstructions. MATERIALS AND METHODS Two types of expandable nitinol stent were designed: an uncovered stent and a covered stent. Under fluoroscopic guidance, the uncovered and covered stents were placed coaxially with complete overlap in 39 consecutive patients with malignant gastric outlet obstruction caused by stomach cancer. Food intake capacity was graded on a scale of 0-4. Stent patency rate was estimated by the Kaplan-Meier method. RESULTS Technical success rate was 97% (38 of 39 patients). After stent placement, food intake capacity improved at least one grade in 36 patients. Stent migration occurred in three patients (8%), that is, partial (n = 2) or complete (n = 1) upward migration of the inner covered stent into the stomach. Two of these patients were treated by placement of an additional covered stent. During the mean follow-up period of 134 days (range, 15-569 d), 10 patients developed recurrent symptoms of obstruction with tumor overgrowth being the most common cause. Nine underwent placement of an additional covered stent with good results. The median period of primary stent patency was 157 days (mean, 278 d). The 30-, 60-, and 180-day patency rates were 97%, 91%, and 39%, respectively. Four patients (10%) died within 1 month after the procedure. CONCLUSION Coaxial stent placement technique seems to contribute to decreasing the migration rate of the stent and decrease the rate of recurrent obstruction by preventing or delaying tumor ingrowth.
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Affiliation(s)
- Gyoo-Sik Jung
- Department of Diagnostic Radiology, College of Medicine, Kosin University, Pusan, Korea
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Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol 2002; 97:72-8. [PMID: 11808972 DOI: 10.1111/j.1572-0241.2002.05423.x] [Citation(s) in RCA: 358] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Malignant gastric outlet obstruction is seen in the setting of a variety of cancers, most commonly pancreatic. Self-expanding metal stents can be used to palliate these patients and restore the ability to eat. METHODS We reviewed the Mayo Clinic experience in the endoscopic treatment of malignant gastric outlet obstruction. Thirty-six patients (26 male, 10 female) were treated between October, 1998 and January, 2001. Data were collected from charts, endoscopy reports, x-rays, and telephone calls. A scoring system was created to grade the ability to eat. RESULTS All procedures were successful. Thirty-one of 36 patients (86%) required one stent at initial endoscopy, and 5/36 patients (14%) required two or more stents. Pretreatment, 19/36 patients (53%) were nil per os, 15/36 (42%) drank liquids, and 2/36 were able to eat soft solids. After stent placement, only 1/36 (3%) was still nil per os, 13/36 (36%) drank liquids, 13/36 (36%) ate soft solids, and 9/36 (25%) ate a full diet. The improvement in ability to eat using the scoring system was statistically significant (p < 0.0001). Nine of 36 patients (25%) required reintervention for recurrent symptoms. Sixteen of 36 patients (44%) had concomitant or subsequent development of biliary obstruction, of which 15 were successfully decompressed. CONCLUSIONS Self-expanding metal stents are a safe and efficacious method for palliating malignant gastric outlet obstruction. The majority of patients do not require reintervention, and those that do can usually be managed nonoperatively.
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Affiliation(s)
- Douglas G Adler
- Department of Medicine, Mayo Medical Center, Rochester, Minnesota, USA
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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.
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Maetani I, Ukita T, Inone H, Yoshida M, Igarashi Y, Sakai Y. Knitted nitinol stent insertion for various intestinal stenoses with a modified delivery system. Gastrointest Endosc 2001; 54:364-7. [PMID: 11522983 DOI: 10.1067/mge.2001.116882] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Insertion of metallic stents for esophageal stenoses is well established, but these stents are technically difficult to place elsewhere in the GI tract. Moreover, major complications have occurred when metal stents with sharp ends have been placed in these locations. The currently available flexible, blunt-ended, knitted nitinol stent is intended for use only in the esophagus. Because its short delivery system cannot reach segments of the gut distal to the esophagus, the delivery device was modified to facilitate intestinal access, and its performance was evaluated in the treatment of malignant intestinal obstructions. METHODS The Ultraflex delivery system was modified by connecting an additional plastic tube and a suture cord; the length was increased from 95 cm to 150 cm or more. Stents used were 18 to 23 mm in diameter, and 10 to 15 cm in length. A knitted metal stent was inserted by using the modified delivery system in 10 patients (7 men, 3 women, mean age 68 years); 8 with gastric outlet, 1 with jejunal, and 1 with proximal colonic obstruction. RESULTS Metal stent insertion was successful in all patients with significant relief of symptoms and restoration of the ability to eat. The patient with a jejunal stent required placement of a second stent because of bending of the initial stent. No major complications (migration or perforation) occurred. CONCLUSION This technique appears to facilitate placement of a metal stent with blunt ends in the duodenum, small intestine, and proximal colon. Manufacturers should offer blunt-ended stents with long delivery devices.
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Affiliation(s)
- I Maetani
- Third Department of Internal Medicine and Division of Digestive Endoscopy, Toho University School of Medicine, Ohashi Hospital, Tokyo, Japan
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Kawase A, Kakemura T, Maetani I, Igarashi Y, Sakai Y. Placement of additional stent for recanalizing procedure of occluded jejunal stent. Gastrointest Endosc 2001; 54:394-7. [PMID: 11522991 DOI: 10.1067/mge.2001.116625] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- A Kawase
- Third Department of Internal Medicine, Toho University School of Medicine, Ohashi Hospital, Tokyo, Japan
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Mao AW, Gao ZD, Xu JY, Yang RJ, Xiao XS, Jiang TH, Jiang WJ. Treatment of malignant digestive tract obstruction by combined intraluminal stent installation and intra-arterial drug infusion. World J Gastroenterol 2001; 7:587-92. [PMID: 11819837 PMCID: PMC4688681 DOI: 10.3748/wjg.v7.i4.587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the palliative treatment of malignant obstrution of digestive tract with placement of intraluminal stent combined with intra-arterial infusion of chemotherapeutic drugs.
METHODS: A total of 281 cases of digestive tract malignant obstruction were given per oral (esophagus, stomach, duodenum and jejunum), per anal (colon and rectum) and percutaneous transhepatic (biliary) installation of metallic stent. Among them, 203 cases received drug infusion by cannulation of tumor supplying artery with Seldinger’s technique.
RESULTS: Altogether 350 stents were installed in 281 cases, obstructive symptoms were relieved or ameliorated after installation. Occurrence of restenotic obstruction was 8-43 weeks among those with intra-arterial drug infusion, which was later than 4-26 weeks in the group with only stent installation. The average survival time of the former group was 43 (3-105) weeks, which was significantly longer than 13 (3-24) weeks of the latter group.
CONCLUSION: Intraluminal placement of stent combined with intra-arterial infusion chemotherapy is one of the effective palliative therapies for malignant obstruction of the digestive tract with symptomatic as well as etiological treatment.
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Affiliation(s)
- A W Mao
- Department of Interventional Radiology, Shanghai S.T, Luke's Hospital, 768 Yu Yuan Road, Shanghai 200050, China.
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