Metal stents for the palliation of inoperable upper gastrointestinal stenoses

Enteral Stenting in 21 Patients with Malignant Gastroduodenal Obstruction

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.

Efficacy and safety of a new fully covered self-expandable non-foreshortening metal esophageal stent

BACKGROUND

Fully covered esophageal self-expandable metal stents (SEMSs) are potentially removable but can be associated with high migration rates. For precise positioning, non-foreshortening SEMSs are preferred. Recently, a new fully covered non-foreshortening SEMS with anti-migration features was introduced.

OBJECTIVE

To evaluate the efficacy and safety of this new esophageal SEMS.

DESIGN

Retrospective study.

SETTING

Single, tertiary-care center.

PATIENTS

Consecutive patients with malignant and benign strictures with dysphagia grade of ≥3 and patients with fistulas/leaks were studied.

INTERVENTIONS

Stent placement and removal.

MAIN OUTCOME MEASUREMENTS

Technical success in stent deployment/removal, efficacy in relieving dysphagia and sealing fistulas/leaks, and adverse events.

RESULTS

Forty-three stents were placed in 35 patients (mean [± standard deviation] age 65 ± 11 years; 31 male), 24 for malignant and 11 for benign (5 strictures, 6 leaks) indications. Technical success in precise SEMS placement was 100%. The after-stent dysphagia grade improved significantly (at 1 week: 1.5 ± 0.7; at 4 weeks: 1.2 ± 0.4; baseline: 3.8 ± 0.4; P < .0001). Twenty stents were removed for clinical indications, with technical success of 100%. All leaks sealed after SEMS placement and did not recur after stent removal. All benign strictures recurred after stent removal. Adverse events included migration (14%), chest pain (11%), and dysphagia from tissue hyperplasia (6%). There was no stent-related mortality.

LIMITATIONS

Nonrandomized, single-center study.

CONCLUSION

The new esophageal SEMS was effective in relieving malignant dysphagia, allowed for precise placement, and was easily removable. It was effective in treating benign esophageal fistulas and leaks. Stent-related adverse events were acceptable.

Conformable covered versus uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction: a randomized prospective study

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.

Endoscopic self-expandable metallic stent placement in malignant pyloric or duodenal obstruction: does chemotherapy affect stent patency?

AIM

Self-expandable metallic stents (SEMS) have been used for palliation in patients with malignant gastroduodenal obstructions. We evaluated clinical outcomes after SEMS placement and identified prognostic factors of SEMS patency, including chemotherapy.

METHODS

A review of records of 85 patients with unresectable gastric or pancreatic cancer who underwent endoscopic SEMS insertion for gastroduodenal obstructions at Seoul National University Bundang Hospital.

RESULTS

From August 2003 to October 2009, 85 patients with gastroduodenal obstruction were managed with endoscopic SEMS placement. Technical success was achieved in 82 patients (96%) and clinical success in 68 patients (80%). Of 49 patients who had clinical success, 19 underwent chemotherapy (chemoTx group), and 30 patients did not (non-chemoTx group). Cumulative SEMS patency in the 49 patients who achieved clinical success were 84, 54 and 41% at 2, 3 and 6 months, respectively. By univariate and multivariate analysis, there was no statistical difference in the SEMS patency between the two groups (cumulative SEMS patency rate: 95 vs 73% at 2 months, 15 vs 63% at 3 months, 40 vs 42% at 6 months, respectively, P < 0.793).

CONCLUSION

Chemotherapy does not improve SEMS patency in patients with malignant gastroduodenal obstruction caused by unresectable gastric or pancreatic cancer.

Malignant gastroduodenal obstruction: retrospective comparison of endoscopic and surgical palliative therapy

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.

Treatment of malignant gastric outlet obstruction by endoscopically implanting pyloric stents without fluoroscopic guidance: an analysis of 36 cases

AIM: To evaluate the feasibility, efficacy, and complications of endoscopic placement of pyloric stents without fluoroscopic guidance in patients with malignant gastric outlet obstruction.

METHODS: The clinical data for 36 patients with malignant gastric outlet obstruction who underwent endoscopic placement of pyloric stents between January 2007 and December 2009 were analyzed retrospectively.

RESULTS: Thirty-six patients received a total of 39 stents, one stent each in 33 patients and two stents each in three patients. In seven patients with high-grade stenosis, endoscopic balloon dilatation was performed before stent insertion. Successful stent implantation was achieved in all patients. The gastric outlet obstruction score system (GOOSS) score was significantly increased within 1 and 4 weeks after stent placement (P = 0.000). The mean duration was increased 101.3 days (7-380 days). The mean survival time was 123.3 days (10-380 days). Device-related adverse events included stent migration (n = 2, day 20 and day 65), stent occlusion caused by tumor infiltration (n = 2), and acute cholangitis (n = 1, day 7). No hemorrhage or perforation occurred.

CONCLUSION: Endoscopic implantation of pyloric stents without fluoroscopic guidance is a simple, safe and effective method for malignant gastric outlet obstruction.

Malignant gastric outlet obstructions: treatment with self-expandable metallic stents

Unresectable malignant gastric outlet obstruction (GOO) severely affects the quality of life, with complications that include nausea, vomiting, aspiration, pain, and malnutrition. Although palliative surgical procedures have been traditionally performed, they are associated with high morbidity and mortality rates. Placing self-expandable metallic stents is associated with higher clinical success rates, lower morbidity, shorter time from the procedure to starting oral intake, lower incidence of delayed gastric emptying, and a shorter hospital stay than palliative surgery. Fluoroscopic or endoscopic placement of either bare or covered self-expandable metallic stents is a safe, nonsurgical, palliative treatment option for unresectable malignant GOOs, with a high clinical success rate and a low rate of serious complications. Stent obstruction and migration are the most common complications, but most can be managed by interventional treatments. Although there have been substantial developments in stent design over the past decade, large prospective, randomized studies are required to determine the ideal stent for malignant GOOs.

Palliative treatment of malignant gastroduodenal obstruction with metallic stent: prospective comparison of covered and uncovered stents

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.

Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents

Malignant gastroduodenal obstruction can occur in up to 20% of patients with primary pancreatic, gastric or duodenal carcinomas. Presenting symptoms include nausea, vomiting, abdominal distention, pain and decreased oral intake which can lead to dehydration, malnutrition, and poor quality of life. Endoscopic stent placement has become the primary therapeutic modality because it is safe, minimally invasive, and a cost-effective option for palliation. Stents can be successfully deployed in the majority of patients. Stent placement appears to lead to a shorter time to symptomatic improvement, shorter time to resumption of an oral diet, and shorter hospital stays as compared with surgical options. Recurrence of the obstructive symptoms resulting from stent occlusion, due to tumor ingrowth or overgrowth, can be successfully treated with repeat endoscopic stent placement in the majority of the cases. Both endoscopic stenting and surgical bypass are considered palliative treatments and, to date, no improvement in survival with either modality has been demonstrated. A tailored therapeutic approach, taking into consideration patient preferences and involving a multidisciplinary team including the therapeutic endoscopist, surgeon, medical oncologist, radiation therapist, and interventional radiologist, should be considered in all cases.

Covered expandable nitinol stents for malignant gastroduodenal obstructions

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.

Endoscopic stenting-Where are we now and where can we go?

Self expanding metal stents (SEMS) play an important role in the management of malignant obstructing lesions in the gastrointestinal tract. Traditionally, they have been used for palliation in malignant gastric outlet and colonic obstruction and esophageal malignancy. The development of the polyflex stent, which is a removable self expanding plastic stent, allows temporary stent insertion for benign esophageal disease and possibly for patients undergoing neoadjuvant chemotherapy prior to esophagectomy. Potential complications of SEMS insertion include perforation, tumour overgrowth or ingrowth, and stent migration. Newer stents are being developed with the aim of increasing technical and clinical success rates, while reducing complication rates. Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease. It is hoped that, in the future, newer stents will improve our management of these difficult conditions and, possibly, provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.

Use of a colonoscope for distal duodenal stent placement in patients with malignant obstruction

BACKGROUND

Stent placement in the distal duodenum or proximal jejunum with a therapeutic gastroscope can be difficult, because of the reach of the endoscope, loop formation in the stomach, and flexibility of the gastroscope. The use of a colonoscope may overcome these problems.

OBJECTIVE

To report our experience with distal duodenal stent placement in 16 patients using a colonoscope.

METHODS

Multicenter, retrospective series of patients with a malignant obstruction at the level of the distal duodenum and proximal jejunum and treated by stent placement using a colonoscope. Main outcome measurements are technical success, ability to eat, complications, and survival.

RESULTS

Stent placement was technically feasible in 93% (15/16) of patients. Food intake improved from a median gastric outlet obstruction scoring system (GOOSS) score of 1 (no oral intake) to 3 (soft solids) (p = 0.001). Severe complications were not observed. One patient had persistent obstructive symptoms presumably due to motility problems. Recurrent obstructive symptoms were caused by tissue/tumor ingrowth through the stent mesh [n = 6 (38%)] and stent occlusion by debris [n = 1 (6%)]. Reinterventions included additional stent placement [n = 5 (31%)], gastrojejunostomy [n = 2 (12%)], and endoscopic stent cleansing [n = 1 (6%)]. Median survival was 153 days.

CONCLUSION

Duodenal stent placement can effectively and safely be performed using a colonoscope in patients with an obstruction at the level of the distal duodenum or proximal jejunum. A colonoscope has the advantage that it is long enough and offers good endoscopic stiffness, which avoids looping in the stomach.

Malignant gastroenteric obstruction: therapeutic options

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.

Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review

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.

Endoscopic stenting in patients with recurrent malignant obstruction after gastric surgery: uncovered versus simultaneously deployed uncovered and covered (double) self-expandable metal stents

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.

Self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction caused by stomach cancer

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.

Surgical bypass versus endoscopic stenting for malignant gastroduodenal obstruction: a decision analysis

The treatment options for palliating malignant gastroduodenal obstruction include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ), and endoscopic stenting (ES). The aim of this study was to compare the clinical outcomes and costs among ES, OGJ, and LGJ in patients who present with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. We designed a model for patients with malignant gastroduodenal obstruction. We analyzed success rates, complication rates and costs of the three treatment modalities: ES, OGJ, and LGJ. Baseline outcomes and costs were based on published reports. Success was defined as no major procedure-related and long-term complications over a 1-month period. Failure of therapy was defined as recurrent symptoms or death due to a procedural complication. Sensitivity analyses and cost-effectiveness analyses for the various strategies were performed. ES resulted in the lowest mortality rate and the lowest cost of the three treatment options analyzed. Mortality in the OGJ group was 2.1 times that in the ES cohort and 1.8 times that in the LGJ cohort. Sensitivity analyses confirmed ES as the dominant strategy. In conclusion, ES is the preferred treatment for palliation of duodenal obstruction due to advanced upper gastrointestinal tract cancer.

One-stage laparoscopic colorectal resection after placement of self-expanding metallic stents for colorectal obstruction: a prospective study

The aim of this study was to assess the clinical outcomes of self-expandable metallic stents placing followed by laparoscopic resection and primary anastomosis for the treatment of acute colonic obstruction. From January 2003 to December 2004, 14 patients diagnosed with acute and complete colonic obstruction were treated with endoscopic colonic stenting as a bridge to an elective 1-stage laparoscopic resection. Three patients who underwent a successful stent insertion but had an inoperable tumor were excluded from the analyzed data. Ninety-three percent technical and clinical success was achieved. The stent insertion related perforation rate was 7% (1/14). The mean duration of stent insertion was approximately 1 hour and the mean time between the stent insertion and surgery was 6.2 days. Mean operating time was 132 +/- 38 minutes. No cases required conversion to laparotomy and there were no intraoperative complications. One case of anastomotic leakage was observed and treated by laparoscopic drainage and protective ileostomy. Ambulation time after operation was 1.8 +/- 0.6 days and total hospital stay length was 16.4 +/- 5.0 days. During a period of 11 +/- 7 months of follow-up, neither recurrences nor port-site metastases were observed. The management of acute colonic obstruction using endoscopic stent decompression, followed by laparoscopic resection, had good results and can be considered feasible and safe. Larger comparative studies may help to establish this approach.

Endoscopic gastrojejunostomy with survival in a porcine model

BACKGROUND

We have previously reported the feasibility and the safety of an endoscopic transgastric approach to the peritoneal cavity in a porcine model. We now report successful performance of endoscopic gastrojejunostomy with survival.

METHODS

All procedures were performed on 50-kg pigs, with the pigs under general anesthesia, in aseptic conditions with sterilized endoscopes and accessories. The stomach was irrigated with antibiotic solution, and a gastric incision was performed with a needle-knife and a sphincterotome. A standard upper endoscope was advanced through a sterile overtube into the peritoneal cavity. A loop of jejunum was identified, was retracted into the stomach, and was secured with sutures while using a prototype endoscopic suturing device. An incision was made into the jejunal loop with a needle-knife, and the filet-opened ends of the jejunal wall were secured to the gastric wall with a second line of sutures, completing the gastrojejunostomy.

OBSERVATIONS

Two pigs survived for 2 weeks. Endoscopy and a radiographic contrast study performed after gastrojejunostomy revealed a patent anastomosis with normal-appearing gastric and jejunal mucosa. Postmortem examination demonstrated a well-healed anastomosis without infection or adhesions.

CONCLUSIONS

The endoscopic transgastric approach to create a gastrojejunostomy is technically feasible and can be performed, with survival, in a porcine model.

A dual expandable nitinol stent: experience in 102 patients with malignant gastroduodenal strictures

PURPOSE

To investigate the technical feasibility and clinical effectiveness of a dual expandable nitinol stent in the palliative treatment of malignant gastroduodenal strictures.

MATERIALS AND METHODS

The dual stent consisted of two stents, an outer partially covered stent and an inner bare nitinol stent. The outer diameter of the stent delivery system was 3.8 mm. With fluoroscopic guidance, the outer stent was placed into the stricture, followed by coaxial placement of the inner stent. The stent placement was attempted in 102 consecutive patients with malignant gastroduodenal strictures. The underlying causes of malignant strictures were gastric cancer (n = 55), pancreatic cancer (n = 24), gallbladder cancer (n = 7), cholangiocarcinoma (n = 5), duodenal cancer (n = 5), and metastatic cancer (n = 6). All patients presented with symptoms of gastric outlet obstruction.

RESULTS

Stent placement was technically successful and well tolerated in 101 of 102 patients (99%). After stent placement, 85 of the 101 patients (84%) with technical success experienced improvement of their symptoms. Tumor overgrowth occurred in five patients, stent migration in two, mucosal hyperplasia in one, bleeding in one, and jaundice in two. Seventy one of the 101 patients died 5 to 340 days (mean, 71 days) after stent placement from progression of their disease, myocardial infarction, bleeding, or sepsis. The remaining 30 patients are still alive 6 to 227 days (mean, 39 days) after stent placement. The 30-day, 60-day, 90-day, and 180-day survival rates were 78%, 58%, 39%, and 8%, respectively.

CONCLUSION

The dual stent with a 3.8-mm stent delivery system is easy to insert, safe, and reasonably effective for the palliative treatment of malignant gastroduodenal strictures.

Gastroduodenal Stent Placement: Current Status

Gastroduodenal obstruction is a preterminal event in patients with advanced malignancies of the stomach, pancreas, and duodenum. It severely limits the quality of life in affected patients due to constant emesis and associated malnutrition. Surgical gastrojejunostomy has been the traditional palliative treatment but is associated with a high complication rate, and delayed gastric emptying is a frequent problem. Gastroduodenal stent placement is a very safe and effective palliation method in patients with unresectable malignant tumors causing gastric outlet obstruction, with adequate palliation obtained in most cases. The procedure can be performed under fluoroscopic guidance or with a combination of fluoroscopic and endoscopic techniques. Advantages of gastroduodenal stent placement over surgical palliation include suitability as an outpatient procedure, more rapid gastric emptying, greater cost effectiveness, fewer complications, and improved quality of life. Covered duodenal stents are currently being evaluated and may play an increasingly important role in preventing recurrent obstruction secondary to tumor ingrowth. Moreover, simultaneous palliation of biliary and duodenal malignant strictures is possible with the use of metallic stents. Gastroduodenal stent placement is a promising new alternative for the palliation of malignant gastroduodenal obstruction.

Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass

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.

Endoskopische Palliation der malignen Magenausgangsstenose durch selbstexpandierbare Metallstents

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.

Enteral stenting in 21 patients with malignant gastroduodenal obstruction

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.

Stents in the small intestine

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.

Fluoroscopically guided placement of a covered self-expandable metallic stent for malignant antroduodenal obstructions: preliminary results in 18 patients

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.

Malignant gastric outlet obstructions: treatment by means of coaxial placement of uncovered and covered expandable nitinol stents

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.

Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction

BACKGROUND

The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction.

METHODS

Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy.

RESULTS

Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value < 0.005).

CONCLUSION

Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative.

Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience

PURPOSE

To investigate the technical feasibility and clinical effectiveness of a polyurethane-covered expandable nitinol stent in the treatment of malignant gastroduodenal obstructions.

MATERIALS AND METHODS

The stent was constructed in-house by weaving a single thread of 0.2-mm nitinol wire in a tubular configuration and was covered with polyurethane solution by means of a dipping method. With fluoroscopic guidance, the stent was placed in 19 consecutive patients with malignant gastric outlet obstruction (n = 15) or duodenal obstruction (n = 4). All patients had severe nausea and recurrent vomiting, and their obstructions were inoperable.

RESULTS

Stent placement was technically successful in all but one patient. After stent placement, symptoms improved in all but one patient, who had another stenosis at the proximal jejunum. One patient with stent placement in the second portion of the duodenum became jaundiced. During the mean follow-up of 11 weeks, stent migration occurred in five patients 1-4 days after the procedure. All patients with stent migration were treated by means of placing a second, uncovered nitinol stent. Two of these five patients showed recurrence of stricture because of tumor ingrowth; they underwent coaxial placement of a third, covered nitinol stent with good results.

CONCLUSION

Placement of a polyurethane-covered expandable nitinol stent seems to be technically feasible and effective for palliative treatment of inoperable malignant gastroduodenal obstructions. Stent migration, however, is problematic and requires further investigation.