Gastroduodenal stenting

Practical guide to duodenal stenting for gastric outlet obstruction: Clinical outcomes, selection criteria, placement techniques, and management strategies

Duodenal stenting is a widely used palliative treatment for gastric outlet obstruction (GOO) caused by unresectable malignancies. Compared to surgical gastrojejunostomy, duodenal stenting allows for earlier oral intake, shorter hospitalization, and earlier chemotherapy initiation. However, its long-term efficacy is limited by stent occlusion, which typically occurs 2-4 months post-procedure, due to tumor ingrowth, overgrowth, or food impaction. Covered stents can reduce tumor ingrowth but increase the migration risk, particularly in patients receiving chemotherapy. This review provides a comprehensive comparison of duodenal stenting, surgical gastrojejunostomy, and endoscopic ultrasound-guided gastroenterostomy, by discussing their clinical outcomes, advantages, and limitations. We further explore stent selection based on stricture characteristics, optimal placement techniques, post-procedural management, and for handling complications including occlusion, migration, bleeding, and perforation. Additionally, we address technical challenges and troubleshooting strategies, including management of guidewire-induced perforation, incomplete stent expansion, and bile duct obstruction for overlapping biliary and duodenal stricture cases. Despite its widespread clinical use, no prior review has comprehensively covered both the technical and clinical aspects of duodenal stenting so extensively. By providing a clinically oriented, practical guide, this review serves as a valuable resource for endoscopists and gastroenterologists, facilitating optimized decision-making and improved outcomes for patients with GOO in real-world practice.

Percutaneous Transgastric Duodenal Stenting and Gastrostomy Repair Using a Vascular Closure Device: Proof of Concept in a Porcine Model

Introduction. Gastroduodenal stenting is efficacious and safe in both benign and malignant foregut diseases. Transgastric duodenal stenting has been described and however requires a gastrostomy tube to remain in situ for 4 to 6 weeks post-procedure which can lead to complications. We present a technique for immediate gastric repair using a suture-mediated vascular closure device, without the need for a gastrostomy tube in porcine models. Methods. Percutaneous access into the stomach was achieved using fluoroscopy. Two or 3 Perclose Proglide devices were pre-deployed. The tract was dilated and a wire advanced into the distal duodenum. A 15.5 cm covered enteric stent was delivered through the gastrostomy, deployed and position confirmed. The gastrostomy was closed using Perclose Proglide sutures. Necropsy leak pressure measurement was performed to assess integrity of gastrostomy closure in the porcine models. Results. Two (n = 8) or 3 (n = 2) Perclose Proglide devices were deployed in ten porcine models, with 1 misfire (4.5%). Percutaneous transgastric access and stent delivery was successful in all porcine models. Mean leak pressure in the animals with adequately deployed devices was 219 mmHg (range 172 mmHg-270 mmHg). Conclusion. This study demonstrates percutaneous transgastric duodenal stenting with immediate gastric repair using suture-mediated vascular closure devices is a feasible procedure.

When to Discharge a Patient After Endoscopy: A Narrative Review

Video endoscopy is an important modality for the diagnosis and treatment of various gastrointestinal diseases. Most endoscopic procedures are performed as outpatient basis, sometimes requiring sedation and deeper levels of anesthesia. Moreover, advances in endoscopic techniques have allowed invasion into the third space and the performance of technically difficult procedures that require the utmost precision. Hence, formulating strategies for the discharge of patients requiring endoscopy is clinically and legally challenging. In this review, we have discussed the various criteria and scores for the discharge of patients who have undergone endoscopic procedures with and without anesthesia.

Fluoroscopic-guided stent placement in failed tentative endoscopic approaches to malignant gastroduodenal obstructions

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.