Endoscopic management of unresectable malignant gastroduodenal obstruction with a nitinol uncovered metal stent: A prospective Japanese multicenter study

Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis

Background and study aims  Malignant disease accounts for up to 80 % of gastric outlet obstruction (GOO) cases, which may be treated with duodenal self-expanding metal stents (SEMS), surgical gastrojejunostomy (GJ), and more recently endoscopic-ultrasound-guided gastroenterostomy (EUS-GE). These three treatments have not been compared head-to-head in a randomized trial. Methods  We searched the Embase and MEDLINE databases for studies published January 2015-February 2021 assessing treatment of malignant GOO using duodenal SEMS, endoscopic (EUS-GE) or surgical (laparoscopic or open) GJ. Efficacy outcomes assessed included technical and clinical success rates, GOO recurrence and reintervention. Safety outcomes included procedure-related bleeding or perforation, and stent-related events for the duodenal SEMS and EUS-GE arms. Results  EUS-GE had a lower rate of technical success (95.3%) than duodenal SEMS (99.4 %) or surgical GJ (99.9%) ( P  = 0.0048). For duodenal SEMS vs. EUS-GE vs. surgical GJ, rates of clinical success (88.9 % vs. 89.0 % vs. 92.3 % respectively, P  = 0.49) were similar. EUS-GE had a lower rate of GOO recurrence based on limited data ( P  = 0.0036), while duodenal SEMS had a higher rate of reintervention ( P  = 0.041). Overall procedural complications were similar (duodenal SEMS 18.7 % vs. EUS-GE 21.9 % vs. surgical GJ 23.8 %, P  = 0.32), but estimated bleeding rate was lowest ( P  = 0.0048) and stent occlusion rate was highest ( P  = 0.0002) for duodenal SEMS. Conclusions  Duodenal SEMS, EUS-GE, and surgical GJ showed similar clinical efficacy for the treatment of malignant GOO. Duodenal SEMS had a lower procedure-related bleeding rate but higher rate of reintervention.

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.

Malignant Gastric Outlet Obstruction Caused by Duodenal Cervix Metastasis in a Young Woman: Rendezvous Technique

Background: Malignant gastric outlet obstruction (MGOD) is an extremely rare expression of advanced extra-gastrointestinal cancer, such as squamous cell carcinoma (SCC) of the cervix, and only sixcases are described in the literature.Because of the short life expectancyand the high surgical risk involving these patients, less invasive approaches have been developed over time, such asthe use of an enteral stent or less invasive surgical techniques (i.e., laparoscopic gastrojejunostomy). However, MGOD could make it difficult to perform an endoscopic retrograde cholangio-pancreatography (ERCP) for standard endoscopic drainage, so in this case a combined endoscopic-percutaneous technique may be performed. This article, therefore, aims to highlight the presence in the doctor’s armamentarium of the “rendezvous technique”, few case reports of whichare described in the literature, and, moreover, this article aims to underline the technique’sfeasibility. Case Presentation: The case is that of a 38-year-old woman who presented with MGOD three years after the diagnosis of SCC of the cervix, who successfully underwent the rendezvous technique with the resolution of duodenal obstruction. Endoscopic enteral stenting treatment with the placement of a metal stent (SEMSs) represents the mainstay of MGOD treatment compared withsurgery due to its lower morbidity, mortality, shorter hospitalization and earlier symptom relief. However, in patients with both duodenal and biliary obstruction, a combined endoscopic–percutaneous approach may be necessary because of the difficulty in passing the duodenal stricture or in accessing the papilla through the mesh of the duodenal SEMS. Conclusion: The rendezvous procedure is a technicallyfeasible and minimally invasive approach to the double stenting of biliary and duodenal strictures. It achieves the desired therapeutic result while avoiding the need to perform more invasive procedures that could have a negative impact on the patient’sprognosis.

Percutaneous Enteral Stent Placement Using a Transhepatic Access for Palliation of Malignant Bowel Obstruction after Surgery

Objective

To assess the safety and clinical efficacy of percutaneous transhepatic enteral stent placement for recurrent malignant obstruction in patients with surgically altered bowel anatomy.

Materials and Methods

Between July 2009 and May 2019, 36 patients (27 men and 9 women; mean age, 62.7 ± 12.0 years) underwent percutaneous transhepatic stent placement for recurrent malignant bowel obstruction after surgery. In all patients, conventional endoscopic peroral stent placement failed due to altered bowel anatomy. The stent was placed with a transhepatic approach for an afferent loop obstruction (n = 27) with a combined transhepatic and peroral approach for simultaneous stent placement in afferent and efferent loop obstruction (n = 9). Technical and clinical success, complications, stent patency, and patient survival were retrospectively evaluated.

Results

The stent placement was technically successful in all patients. Clinical success was achieved in 30 patients (83.3%). Three patients required re-intervention (balloon dilatation [n = 1] and additional stent placement [n = 2] for insufficient stent expansion). Major complications included transhepatic access-related perihepatic biloma (n = 2), hepatic artery bleeding (n = 2), bowel perforation (n = 1), and sepsis (n = 1). The 3- and 12-months stent patency and patient survival rates were 91.2%, 66.5% and 78.9%, 47.9%, respectively.

Conclusion

Percutaneous enteral stent placement using transhepatic access for recurrent malignant obstruction in patients with surgically altered bowel anatomy is safe and clinically efficacious. Transhepatic access is a good alternative route for afferent loop obstruction and can be combined with a peroral approach for simultaneous afferent and efferent loop obstruction.

Efficacy and Adverse Effects of Self-Expandable Metal Stent Placement for Malignant Duodenal Obstruction: The Papilla of Vater as a Landmark

Purpose

Self-expandable metal stents are used for malignant duodenal obstruction. Outcomes between stents placed above and below the papilla of Vater differ, and no study has investigated these differences. We evaluated the efficacy and adverse events of stent placement in these two locations and reported our experience with self-expandable metal stent placement in patients.

Patients and Methods

We retrospectively analyzed the data of patients with unresectable metastatic cancers (n = 101), who underwent successful duodenal self-expandable metal stent placement between 2008 and 2018. Patients were divided into above and below the papilla of Vater groups. Patient demographics, technical and clinical outcomes, post-procedural morbidity, and stent patency were analyzed.

Results

Overall, 71 and 30 patients had intestinal obstruction above (including the papilla itself) and below the papilla of Vater and underwent successful stenting. Common bile duct obstruction was more common in the above-papilla group. Procedure time was similar between the groups, if an appropriate endoscope could facilitate stent placement in the below-papilla group. Both groups achieved symptomatic relief. Median stent patency duration was not significantly different between the groups; three patients had severe gastrointestinal bleeding due to postoperative vascular-enteric fistula.

Conclusion

Self-expandable metal stents can effectively relieve symptoms of duodenal obstructions located above and below the papilla of Vater. Duodenoscopes could facilitate stent placement if the obstruction is located below the papilla of Vater; if gastrointestinal bleeding occurs postoperatively, the possibility of vascular-enteric fistula formation should be considered.

Clinical outcome of a highly flexible duodenal stent for gastric outlet obstruction: A multicenter prospective study

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).

Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction

INTRODUCTION AND OBJECTIVES

Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement.

MATERIAL AND METHODS

A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction.

RESULTS

The study included 43 patients, technical success was 97.7% (n=42), and clinical success was 88.3% (n=38). SEMS dysfunction presented in 30.2% (n=13) of the patients, occurring in<6 months after placement in 53.8% (n=7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p=0.02) and the use of uncovered SEMS (p=0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months).

CONCLUSIONS

SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors.

Outcomes of duodenal stenting: Experience in a French tertiary center with 220 cases

INTRODUCTION

Endoscopic stenting for malignant gastroduodenal outlet obstruction (MGOO) is described as ineffective and not long-lasting despite a few favorable studies. This study aimed to evaluate the clinical outcomes of a large series of patients in a tertiary center.

METHODS

A single-center retrospective study was performed using data collected from all patients who received palliative duodenal self-expandable metal stents between January 2011 and December 2016. The primary endpoints were patient diet after the first duodenal procedure (Gastric Outlet Obstruction Scoring System, GOOSS) and clinical success. The secondary endpoints were the median patency duration (calculated according to the Kaplan-Meier method) and the cumulative incidence of reintervention.

RESULTS

Two-hundred twenty patients were included. The increase in the GOOSS score was significant (p < 0.001), and the clinical success rate was 86.3%. The median estimated patency duration was 9.0 months [6.5-29.1]. Patients with pancreatic adenocarcinoma had significantly longer patency durations (p = 0.02). The estimated cumulative probability of a second duodenal procedure after 4 months was 13%.

CONCLUSIONS

In this large series of patients who underwent duodenal stenting for MGOO, we observed significant changes in GOOSS scores, a relatively long patency duration compared to findings in previous series, and a low probability of subsequent duodenal procedures, primarily due to a low median overall survival time (4 months).

Big End Double-Layer Stents for the Treatment of Gastric Outlet Obstruction Caused by Stomach Cancer

Objectives

This study is aimed at evaluating the efficacy and safety of the big end double-layer uncovered self-expanding metal stents (SEMS) for the treatment of gastric outlet obstruction (GOO) caused by distal stomach cancer.

Methods

Seventy three patients receiving big end double-layer uncovered SEMS for the treatment of GOO caused by distal gastric cancer will be included in this multicenter prospective clinical trial. The main outcome measures included the functional outcome, the complications, the reinterventional rates, the average treatment charges, and the mean survival time. Monthly telephone calls were needed to assess the food intake until the patients died.

Results

The technical and the clinical success rates were 98.6%. The stent obstruction caused by tumor ingrowth was observed in one patient (1.4%). The incidence of food impaction was 2.9% (2/70) and the reinterventional rate was 4.3% (3/70). However, stent migration and obstruction caused by overgrowth were not observed. No perforation and severe bleeding were observed. The median cost of endoscopic stenting and total hospitalization (including reinterventions) for the big end double-layer uncovered SEMS in this study was $2945 and $3408, respectively. The mean survival time was 212.5 days.

Conclusions

The placement of big end double-layer uncovered SEMS is a safe and effective modality and has the potential to be one of the options for the treatment of GOO caused by the distal gastric cancer.

Palliative therapy in pancreatic cancer-palliative surgery

Pancreatic cancer is a highly lethal disease with a dismal prognosis. It will probably become the second leading cause of cancer-related death within the next decade in Western countries. Over 80% of patients undergo palliative treatment for unresectable pancreatic cancer due to locally advanced disease or metastases. Those patients often develop gastric outlet obstruction (GOO), obstructive jaundice and pain during the course of their disease. Symptoms such as vomiting, anorexia, pruritus and jaundice will impact the quality of life (QOL) and could delay the administration of the chemotherapy. Palliative therapy in pancreatic cancer aims to relieve the symptoms durably and to improve the QOL. Palliative surgery was traditionally considered as a gold standard with the "double by-pass" including biliary-digestive and gastro-jejunal anastomosis. However, since the development of endoscopic stenting and minimally invasive surgery, the choice of the best modalities remains debated. While there is still a place for surgical gastrojejunostomy (GJ) in case of duodenal or GOO, endoscopic biliary stenting during endoscopic retrograde cholangiopancreatography (ERCP) is now accepted as the gold standard in case of obstructive jaundice. In pain management, endoscopic ultrasound guided or percutaneous celiac plexus neurolysis is recommended. The selection of the best technique should consider the effectiveness and the morbidity of the treatment, the performance status of the patient and the disease stage. While endoscopic stenting is associated with earlier recovery and shorter length of stay, recurrence of symptoms and reintervention are less frequent after palliative surgery. Finally, controversy exists on whether to perform prophylactic palliative surgery in the absence of symptoms when unresectable disease is discovered during surgical exploration.

Palliation of malignant gastroduodenal obstruction with self-expandable metal stent using side- and forward-viewing endoscope: Feasibility and outcome

Background

The endoscopic placement of a self‐expandable metal stent (SEMS), an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction (GOO), is commonly performed using a forward‐viewing endoscope with a wide therapeutic channel; however, due to limited availability, most Indian centers use a side‐viewing duodenoscope. We studied the feasibility and outcome of SEMS placement using side‐ and forward‐viewing endoscopes.

Method

Data of patients undergoing SEMS placement using side‐ and forward‐viewing endoscopes with a therapeutic channel for the palliation of malignant GOO presenting during a 5‐year period were analyzed retrospectively. Follow‐up data were obtained from records and telephonic interviews, and technical and clinical success, complications, and survival were evaluated.

Results

Of 114 patients (age 56.5 ± 11.6 years, 59 [52%] female), 90 (79%) and 24 (21%) underwent SEMS placement using side‐ and forward‐viewing endoscopes, respectively. Technical (89, 98.9% vs. 24, 100%, P = ns) and clinical success (84, 93.3% vs. 23, 95.8%, P = ns) and complication rate (3, 3.3% vs. 0, P = ns) between side‐ and forward‐viewing endoscopes were comparable. However, SEMS could be placed in a shorter time using a forward‐ rather than side‐viewing endoscope (21 min [inter‐quartile range 19.5–35] vs. 34 min [25–45], P = < 0.001). SEMS could be deployed successfully with a forward‐viewing endoscope in two patients in whom an initial attempt using side‐viewing endoscope failed. Gastric outlet obstruction scoring system (GOOSS) improved following stent placement (median 0, range 0–2 vs. 2, 0–3, P = 0.0001). The survival of patients undergoing SEMS placement using side‐ and forward‐viewing endoscopes was comparable.

Conclusion

Although side‐ and forward‐viewing endoscopes are equally effective for antroduodenal SEMS placement, the procedure can be performed faster using the latter.

Comparison of big funnel and individualized stents for management of stomach cancer with gastric outlet obstruction

BACKGROUND

Previous studies reported a similar rate of complications, including stent migration and obstruction, between individualized stents and the standard uncovered stents in gastric outlet obstruction (GOO) caused by distal stomach cancer. The objective of this study was to evaluate the efficacy and safety of funnel stents for management of GOO caused by distal stomach cancer.

METHODS

This study was designed as a multicenter, controlled, prospective, and randomized clinical trial involving 4 hospitals. The individualized stent group (44 cases) received cup and funnel covered stents, and the funnel group (44 cases) received only funnel covered stents for management of GOO caused by distal gastric cancer.

RESULTS

All patients with GOO were treated with cup and funnel stents according to their assigned groups. The rate of GOO resolution was 100% in the funnel group and 97.7% in the individualized stent group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group, and proximal partial stent migration was observed in 1 patient in each group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group. There was no statistical difference in stent migration, obstruction, and survival between groups.

CONCLUSION

Big funnel stents and individualized stents resulted in similar shaping effect and prevention of stent migration and obstruction, suggesting that funnel shaped stents can be used to treat cup or funnel shaped GOO caused by distal stomach cancer.

Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer

BACKGROUND

Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment.

AIMS

To compare the efficacy and safety of GJJ and DS for GOO with APC.

METHODS

Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis.

RESULTS

GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS.

CONCLUSIONS

There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.

Recent advancements in stent therapy in patients with malignant gastroduodenal outlet obstruction

Gastric outlet obstruction (GOO) is one of severe comorbidities caused by many kinds of malignant diseases and is associated with not only degradation of patients' quality of life but also mortality. Although surgical bypass is one of the main therapies for malignant GOO, it is often difficult to perform in end-stage patients. The deployment of self-expandable metallic stents (SEMSs) has recently become a viable alternative to surgical bypass for malignant GOO. This technique is less invasive and more effective, particularly in patients with poor prognoses. Many reports have referred to the feasibility, effectiveness, and safety of the placement of SEMSs for malignant GOO. According to these reports, the rates of technical and clinical success were reported to be relatively high and the rate of adverse events to be acceptable. However, precautions against severe adverse events such as massive bleeding and perforation are necessary. Several reports have described the differences in clinical results among different kinds of SEMSs. The presence of a covered design for SEMSs may affect the patency of SEMSs and the rate of stent dysfunction. Selection of the SEMS according to axial force may affect successful achievement of long patency of SEMSs and avoidance of gastroduodenal perforation at the bending site of the duodenum. Compared with high technical success rates nearing 100%, clinical success rates were usually lower than technical success. Therefore, determination of predictive factors for failure of clinical success is important. Several papers reported that low performance status could be associated with failure of clinical success. However, the association of clinical success with other factors such as carcinomatosa and ascites remains controversial, which is a problem to be solved. Reintervention with SEMS using the stent-in-stent method after stent dysfunction can be performed effectively as well as placement of the first SEMS.