Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents

Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

BACKGROUND

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

METHODS

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

RESULTS

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p = ns) and 100 and 96.6% (p > 0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p = 0.274) and 13.7 and 16.7% (p = 0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p = 0.761) and 25.9, 15, and 0% (p = 0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

CONCLUSIONS

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.

Gastrointestinal and biliary stents

Advances in stent design have led to a substantial increase in the use of stents for a variety of malignant and benign strictures in the gastrointestinal tract and biliary system. Whereas early stents were mostly composed of plastic, the majority of contemporary stents are self-expanding metal stents that are composed of either nitinol or stainless steel. These stents are able to exert an adequate expansile force and, at the same time, are highly flexible and biocompatible. Covered stents have been introduced to minimize tumor ingrowth through the metal mesh but are associated with higher rates for spontaneous migration. This has led to the development of covered stents with uncovered ends and stents with both covered and uncovered layers. Drug-eluting and biodegradable stents are also likely to become available in the near future. Although stents appear to be the preferred form of palliation for some patients with advanced cancer, many patients will benefit from a multidisciplinary approach that usually includes surgeons and oncologists.

[Comparison of effects of preoperative stenting for obstructing colorectal cancers according to the location of the obstructing lesion]

BACKGROUND/AIMS

With the development of self-expanding metallic stents, colonic obstruction can be relieved without the need for surgery. The results of preoperative placement of stents for malignant colorectal obstruction might be different according to the obstructing lesion. The objective of this study was to compare clinical improvement rates and operative results after preoperative placement of stents for malignant colorectal obstruction according to the location of the obstructing lesion.

METHODS

This is a retrospective study including 57 patients who underwent self-expanding metallic stent insertion for obstructing resectable colorectal cancers. Patients were classified into three groups according to the location of the lesion as follows: proximal to the sigmoid colon (Group A), sigmoid colon (Group B), and rectum (Group C).

RESULTS

The number of patients in A, B, and C groups was 13, 22, and 22, respectively. No significant differences in age, gender, stent type, and accompanying diseases among the three groups were observed. There were no significant differences in stent-related complications, clinical improvement rates, and one-stage resection rates among the three groups. The postoperative complications, the requirement rate of ICU care, the period of ICU stay, postoperative hospital stay, and hospital mortality did not significantly differ among the three groups.

CONCLUSIONS

Clinical improvement rates and operative results after successful placement of stents for obstructing resectable colorectal cancers are not different according to the location of the obstructing lesion, suggesting that preoperative stenting for one-stage curative resection is useful, irrespective of the location of lesion.

Enteral stents for malignancy: a report of 46 consecutive cases over 10 years, with critical review of complications

BACKGROUND

Current management of malignant gastric outlet obstruction (GOO) includes surgical diversion or enteral stent placement for unresectable cancer. We analyzed the long-term results, predictive factors of outcomes, and complications associated with enteral stents with focus on their management.

METHODS

Between 1997 and 2007, 46 patients with malignant GOO underwent placement of self-expandable metal stents (SEMS) for palliation. Patients were captured prospectively after 2001 and followed until complication or death. Patency, management of complications, and long-term survival were analyzed.

RESULTS

Forty-six patients had a mean survival of 152 +/- 235 days and a mean SEMS patency rate of 111 +/- 220 days. SEMS patency rates of 98%, 74%, and 57% at 1, 3, and 6 months were seen. Thirteen patients presented with obstruction and included two SEMS migration, two early occlusion, one fracture, four malignant ingrowth, and four with delayed clinical failure. Interventions included seven endoscopic revisions with three SEMS replacements. Six had percutaneous endoscopic gastrostomy with jejunal arm placed. Two patients eventually underwent surgical bypass. Two patients required surgery for complications including delayed duodenal perforation and aortoenteric fistula.

CONCLUSIONS

SEMS effectively palliate gastric outlet obstructions that result from upper gastrointestinal malignancies. Their benefits offset potential complications or malfunctions, when a pluridisciplinary approach is adopted.

Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts in the treatment of acute malignant colorectal obstruction

PURPOSE

To evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided placement of self-expandable metallic stents and stent-grafts for acute malignant colorectal obstruction.

MATERIALS AND METHODS

Radiologic images and clinical reports of 42 patients (22 men, 20 women; age range, 28-93 years; median age, 65.5 years) who underwent fluoroscopically guided colorectal stent insertion without endoscopic assistance for acute malignant obstruction were reviewed retrospectively. Eighteen patients received bare stents as a bridge to surgery. Twenty-four patients received 27 insertions of either a bare stent (n = 15) or a stent-graft (n = 12) for palliation. The obstruction was located in the rectum (n = 8), sigmoid (n = 17), descending colon (n = 8), splenic flexure (n = 3), and transverse colon (n = 6).

RESULTS

Clinical success, defined as more than 50% dilatation of the stent with subsequent symptomatic improvement, was achieved in 41 of the 42 patients (98%). No major procedure-related complications occurred. Minor complications occurred in eight of the 45 procedures (18%). No perioperative mortalities occurred within 1 month after surgery. In the palliative group, the median stent patency was 62 days (range, 0-1,014 days). There was no statistically significant difference in stent patency between the bare stents (range, 0-855 days; median, 68 days) and stent-grafts (range, 1-1,014 days; median, 81 days).

CONCLUSIONS

Fluoroscopically guided placement of self-expandable metallic stents and stent-grafts for the relief of acute malignant colorectal obstruction was technically feasible without endoscopic assistance-even in lesions proximal to the splenic flexure and transverse colon-and clinically effective in both bridge to surgery and palliative management.

Metallic stent placement in patients with recurrent cancer after gastrojejunostomy

PURPOSE

To assess the technical feasibility and clinical effectiveness of placement of expandable metallic stents in patients with recurrent cancer after a gastrojejunostomy.

MATERIALS AND METHODS

Data from 39 consecutive patients who had undergone metallic stent placement for recurrent malignant obstruction after a gastrojejunostomy were retrospectively analyzed. Thirty patients underwent a distal gastrectomy with a gastrojejunostomy with (n=10) or without (n=20) jejunojejunostomy, two patients underwent distal gastrectomy with a Roux-en-Y gastrojejunostomy, and seven patients underwent a palliative gastrojejunostomy with (n=5) or without (n=2) jejunojejunostomy. A total of 57 metallic stents were used in this study: four bare stents, 29 partially covered stents, and 24 fully covered stents. Types of obstruction were classified into 12 patterns and types of stent placement were classified into 16 patterns.

RESULTS

Stent placement was technically successful in all patients. After stent placement, 35 of the 39 patients (90%) experienced improvement of their symptoms, two showed no change, and the remaining two showed aggravation of symptoms as a result of faulty stent placement. Two patients treated with stent placement only in the afferent loop died of aspiration pneumonia. In one of two patients who underwent stent placement according to pattern 6, afferent loop syndrome occurred 10 days after stent placement and was treated by percutaneous pigtail catheter drainage. Stent migration occurred in four of 24 fully covered stents, but in none of the bare or partially covered stents. Tumor ingrowth occurred in one of four bare stents, tumor overgrowth in one of 29 partially covered stents, and mucosal prolapse in one of 24 fully covered stents; all were treated with a second stent placement.

CONCLUSIONS

Placement of expandable metallic stents in patients with recurrent cancer after a gastrojejunostomy seems to be feasible and effective, but accurate knowledge of the type of surgical procedure performed and determination of the pattern of tumor recurrence are important for successful stent placement.

Ultraflex precision colonic stent placement as a bridge to surgery in patients with malignant colon obstruction

BACKGROUND

Emergency surgery for malignant colon obstruction entails relatively high morbidity and mortality rates and typically necessitates a 2-step resection. These problems might be potentially mitigated by placement of a self-expanding metal stent (SEMS) as a bridge to surgery. A nitinol colorectal SEMS may offer several advantages, but available evidence on the utility of this SEMS type remains highly limited.

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety as a bridge to surgery of a nitinol SEMS designed for colorectal use.

DESIGN

Prospective and retrospective multicenter clinical study.

SETTING

Sixteen European study centers.

PATIENTS

Thirty-six patients with malignant colonic obstruction.

INTERVENTIONS

Nitinol colorectal SEMS placement.

MAIN OUTCOME MEASURES

Technical success in accurate SEMS placement with coverage of the entire stricture length, clinical success in alleviating colonic obstructive symptoms, and bridging to elective surgery.

RESULTS

Technical success was achieved in 97% of patients with a 95% CI of 85% to 100% and clinical success in 81% (95% CI, 64%-92%). Elective surgery was performed in 94% (95% CI, 81%-99%) of patients at a median of 11 days (95% CI, 7-15 days) after SEMS placement. SEMS-related perforation occurred in 3 patients.

LIMITATIONS

No control group was included in this nonrandomized cohort study.

CONCLUSIONS

In this first comparatively large clinical study of a nitinol colorectal SEMS as a bridge to surgery, a high proportion of patients successfully proceeded to elective surgery after prior decompression by SEMS placement.

Palliative nonvascular interventions

Interventional radiologists are often called on to help with quality of life issues in end-stage cancer patients. Many times, the discomfort can be directly associated to the tumor mass itself, but in other instances, tumors can cause secondary obstruction of normal structures that can lead to patient distress. As with most palliative care patients, their medical conditions are not conducive to major surgery; therefore minimally invasive techniques are ideal for the treatment of these conditions. The following discussion addresses the various nonvascular interventions available to these patients, including the indications and limitations of these procedures.

Management of obstructive colorectal cancer with endoscopic stenting followed by single-stage surgery: open or laparoscopic resection?

BACKGROUND

About one-third of patients with colorectal carcinoma present with acute colonic obstruction requiring emergency surgery. Current surgical options are intraoperative lavage and resection of the colonic segment involved with primary anastomosis, subtotal colectomy with primary anastomosis, colostomy followed by resection, and resection of the colonic segment involved with end colostomy (Hartmann's procedure) requiring a second operation to reconstruct the colon. These procedures present risks and a poor quality of life. Endoscopic colonic stent insertion can effectively decompress the obstructed colon, allowing bowel preparation and elective resection.

METHODS

The authors present their experience managing 31 patients with obstructing colorectal cancer who underwent endoscopic colonic decompression with self-expanding metallic stents. A total of 16 patients were treated with open resection, and 6 underwent a laparoscopic resection. The remaining 9 patients were managed with endoscopic palliation and adjuvant therapy. Of the 31 patients, 17 were treated with postoperative chemotherapy.

RESULTS

The mean interval between stenting and surgery was 11 days (range, 1-21 days). There was no intraoperative morbidity. The incidence of postoperative morbidity was 20% for open surgery and 0% for laparoscopic surgery. The mean postoperative hospital stay was 13 days for the open surgery group, and 7 days for the laparoscopic group (p = 0.003). The hospital mortality rate was 3.2%. Follow-up evaluation was completed for 96% of the patients. The minimum follow-up period was 15 months. All the patients in the palliative group died of disease, with a median survival of 3 months. Of the 22 surgically treated patients, 17 (77%) are alive at this writing.

CONCLUSION

This initial experience shows that after successful endoscopic stenting of malignant colorectal obstruction, elective surgical resection can be performed safely. The presence of the endoluminal stent does not prevent a laparoscopic approach. The combined endoscopic and laparoscopic procedures are a less invasive alternative to the multistage open operations and offer a faster recovery.

Stenting of the proximal colon in patients with malignant large bowel obstruction: techniques and outcomes

BACKGROUND

Self-expandable metal stents are used throughout the GI tract to relieve malignant obstructions.

OBJECTIVE

Our purpose was to determine the outcome after colonic stent placement into the proximal colon.

DESIGN

Medical records of patients from 3 institutions who underwent attempts at placement of self-expandable metal stents for malignant obstructions of the proximal colon were retrospectively reviewed. Extracted data included patient characteristics, obstruction location, and goal of procedure (palliation vs bridge to surgery).

SETTING

Academic medial centers.

PATIENTS

Those with right-sided malignant colonic obstruction.

INTERVENTIONS

Placement of colonic stent.

MAIN OUTCOME MEASUREMENTS

Initial technical success, relief of obstruction, and early and long-term complications.

RESULTS

Twenty-one patients (15 men, 6 women; mean age 67 years) were included. Tumor type was colonic adenocarcinoma in 19 patients. Obstruction was complete in 8 patients and subtotal in 13 patients. Stenting was attempted as a bridge to surgery in 8 patients and as palliation in 13 patients. Initial technical success was achieved in 20 of 21 patients (95%). Complete relief of obstruction was achieved in 17 of 20 patients who had technical success (85%), unachieved in 2 patients (No. 14 and 17), and unknown in 1 patient (No. 6). There were no procedure-related complications (bleeding, perforation, etc). The only long-term complication was stent reocclusion from tumor ingrowth.

LIMITATIONS

Retrospective, single-arm analysis.

CONCLUSIONS

Self-expandable metal stents appear to be safe and effective in the treatment of malignant obstruction of the proximal colon. Technical and clinical success rates are comparable to those seen with distal colonic stenting.

Colorectal stenting: an effective therapy for preoperative and palliative treatment

PURPOSE

To demonstrate the effectiveness of preoperative and palliative colorectal stent placement in acute colonic obstruction.

METHODS

Sixty-seven consecutive patients (mean age 67.3 years, range 25-93 years) with clinical and radiological signs of colonic obstruction were treated: 45 (67%) preoperatively and 22 (33%) with a palliative intent. In 59 patients (88%) the obstruction was malignant, while in 8 (12%) it was benign. A total of 73 enteric Wallstents were implanted under combined fluoroscopic/endoscopic guidance.

RESULTS

Forty-five patients were treated preoperatively with a technical success rate of 84%, a clinical success rate of 83%, and a complication rate of 16%. Of the 38 patients who were successfully stented preoperatively, 36 (95%) underwent surgery 2-22 days (mean 7.2 days) after stent insertion. The improved general condition and adequate bowel cleansing allowed single-stage tumor resection and primary end-to-end anastomosis without complications in 31 cases (86% of all operations), while only 5 patients had colostomies. Stent placement was used as the final palliative treatment in 22 patients. The technical success rate was 95%, the clinical success rate 72%, and the complication rate relatively high at 67%, caused by reocclusion in most cases. After noninvasive secondary interventions (e.g., tube placement, second stenting, balloon dilatation) the secondary patency of stents was 71% and mean reported survival time after stent insertion was 92 days (range 10-285 days).

CONCLUSION

Preoperative stent placement in acute colonic obstruction is minimally invasive and allows an elective one-stage surgery in most cases. Stent placement also proved a valuable alternative to avoid colostomy in palliation.

Treatment of gastric outlet and duodenal obstructions with uncovered expandable metal stents

AIM: To investigate and evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided peroral uncovered expandable metal stent placement to treat gastric outlet and duodenal obstructions.

METHODS: Fifteen consecutive patients underwent peroral placement of Wallstent^TM Enteral Endoprosthesis to treat gastric outlet and duodenal obstructions (14 malignant, 1 benign). All procedures were completed under fluoroscopic guidance without endoscopic assistance. Follow-up was completed until the patients died or were lost, and the clinical outcomes were analyzed.

RESULTS: The technique success rate was 100%, and the oral intake was maintained in 12 of 14 patients varying from 7 d to 270 d. Two patients remained unable to resume oral intake, although their stents were proven to be patent with the barium study. One patient with acute necrotizing pancreatitis underwent enteral stenting to treat intestinal obstruction, and nausea and vomiting disappeared. Ten patients died during the follow-up period, and their mean oral intake time was 50 d. No procedure-related complications occurred. Stent migration to the gastric antrum occurred in one patient 1 year after the procedure, a tumor grew at the proximal end of the stent in another patient 38 d post-stent insertion.

CONCLUSION: Fluoroscopically guided peroral metal stent implantation is a safe and effective method to treat malignant gastrointestinal obstructions, and complications can be ignored based on our short-term study. Indications for this procedure should be discreetly considered because a few patients may not benefit from gastrointestinal insertion, but some benign gastrointestinal obstructions can be treated using this procedure.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

OBJECTIVE

To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature.

SUMMARY BACKGROUND DATA

Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers.

METHODS

A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review.

RESULTS

Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates.

CONCLUSIONS

Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.

Self-expanding metallic stents for relieving malignant colorectal obstruction: a systematic review

OBJECTIVE

To assess the safety and efficacy of self-expanding metallic stents (SEMS) placement for the relief of malignant colorectal obstruction in comparison to surgical procedures through a systematic review of the literature.

SUMMARY BACKGROUND DATA

Conventional therapies for relieving colorectal obstructions caused by cancer have high rates of morbidity and mortality, particularly when performed under emergency conditions, and palliative procedures resulting in colostomy creation can be a burden for patients and caregivers.

METHODS

A systematic search strategy was used to retrieve relevant studies. Inclusion of papers was established through application of a predetermined protocol, independent assessment by 2 reviewers, and a final consensus decision. Eighty-eight articles, 15 of which were comparative, formed the evidence base for this review.

RESULTS

Little high-level evidence was available. However, the data suggested that SEMS placement was safe and effective in overcoming left-sided malignant colorectal obstructions, regardless of the indication for stent placement or the etiology of the obstruction. Additionally, SEMS placement had positive outcomes when compared with surgery, including overall shorter hospital stays, and a lower rate of serious adverse events. Postoperative mortality appeared comparable between the 2 interventions. Combining SEMS placement with elective surgery also appeared safer and more effective than emergency surgery, with higher rates of primary anastomosis, lower rates of colostomy, shorter hospital stays, and lower overall complication rates.

CONCLUSIONS

Stenting appears to be a safe and effective addition to the armamentarium of treatment options for colorectal obstructions. However, the small sample sizes of the included studies limited the validity of the findings of this review. The results of additional comparative studies currently being undertaken will add to the certainty of the conclusions that can be drawn.

Stent collapse as a delayed complication of placement of a covered gastroduodenal stent

OBJECTIVE

The purpose of this study was retrospective evaluation of the incidence, predictive factors, and interventional management of stent collapse after placement of a covered metallic stent in patients with obstruction of the gastric outlet or duodenum due to malignant disease.

MATERIALS AND METHODS

Among 259 patients with symptomatic malignant gastroduodenal obstruction successfully treated with stent placement, stent collapse occurred in 12 (4.6%) of the patients 34-270 days (mean, 101.8 days) after stent placement. Multivariate analysis was performed to evaluate factors predictive of stent collapse. Interventional management of stent collapse also was evaluated.

RESULTS

Multivariate analysis showed that presence of the stent in the peripyloric region (odds ratio, 27.745; p = 0.036), longer survival time (odds ratio, 1.016; p < 0.001), and absence of chemotherapy after stent placement (odds ratio, 31.661; p = 0.048) were independent predictors of stent collapse. Eleven patients with stent collapse were successfully treated with placement of a second bare stent. The twelfth patient refused further treatment.

CONCLUSION

Stent collapse is an uncommon delayed complication of placement of covered metallic stents in patients with malignant gastroduodenal obstruction. Collapse occurs most commonly in the peripyloric region, in patients with longer survival times, and in patients who do not undergo chemotherapy after stent placement. Stent collapse can be managed by coaxial placement of a second bare stent into the collapsed stent.

Palliation of Malignant Biliary and Duodenal Obstruction with Combined Metallic Stenting

PURPOSE

The purpose of this study is to evaluate the efficacy of palliation of malignant biliary and duodenal obstruction with combined metallic stenting under fluoroscopy guidance.

MATERIALS AND METHODS

A retrospective analysis of 9 patients (6 men and 3 women) who underwent biliary and duodenal stenting was performed. The mean age of patients was 61 years (range: 42-80 years). The causes of obstruction were pancreatic carcinoma in 7 patients, cholangiocellular carcinoma in one, and duodenal carcinoma in the other. Biliary and duodenal stents were placed simultaneously in 4 patients. In other 5 patients dudodenal stents were placed after biliary stenting when the duodenal obstruction symptoms have developed. In two patients duodenal stents were advanced via transgastric approach.

RESULTS

Technical success rate was 100 %. After percutaneous biliary drainage and stenting bilirubin levels decreased to normal levels in 6 patients and in remaining 3 patients mean reduction of 71% in bilirubin levels was achieved. Tumoral ingrowth occurred in one patient and percutaneous biliary restenting was performed 90 days after the initial procedure. Of the 9 patients, 6 patients were able to tolerate solid diet, whereas 2 patients could tolerate liquid diet and one patient did not show any improvement. Mean survival periods were 111 and 73 days after biliary and duodenal stenting, respectively.

CONCLUSION

Combined biliary and duodenal stent placement which can be performed under fluoroscopic guidance without assistance of endoscopy is feasible and an effective method of palliation of malignant biliary and duodenal obstructions. If transoral and endoscopic approaches fail, percutaneous gastrostomy route allows duodenal stenting.

Complications of colonic stenting: a pictorial review

Surgical resection of colorectal carcinoma is the only curative treatment currently available. In the elective setting peri-operative mortality is low and refinements in surgical technique and peri-operative care have resulted in high primary anastamosis rates and progressively reduced postoperative morbidity. In those presenting with large bowel obstruction the mortality and morbidity remains high. Many of those undergoing surgery will have incurable disease and a short life expectancy. Increasingly self-expanding metal stents are being deployed as either a 'bridge to surgery' or for palliation. This review covers the imaging appearances, detection and management of complications of colonic stenting.

Acute colonic obstruction: endoscopic stenting and laparoscopic resection

INTRODUCTION

Acute colonic obstruction is a frequent emergency condition in a general surgical setting. The use of an endoscopic self-expanding stent can relieve obstruction and eventually prepare the patient for elective laparoscopic or open surgery.

MATERIALS AND METHODS

From September 2001 to March 2006 we treated 25 patients with acute left or transverse colonic obstruction. In 23 patients stents were positioned planning an elective procedure to be performed. In two patients with multiple liver metastases and malignant ascites only a palliation was intended (2 of 25 patients).

RESULTS

Mean age was 66.6 years. The 23 patients who underwent resection, 14 females and nine males, had a mean age of 65.5 years. Obstructions were located in the rectum (five), in the sigmoid (16) and in the transverse colon (two). In one patient stricture was due to radiotherapy, in twenty four cases it was due to primary cancer. Stents were successfully placed in 24 patients. In one of them two stents had to be placed due to the slippage of the first one beyond the stricture. Excellent resumption of colonic transit was achieved in all the patients. No complications were observed. In 23 patients resection was performed (19 laparoscopy; four open). Complications occurred in one patient in open group (pancreatic fistula after splenectomy) and was treated conservatively. Mean postoperative stay was 18.5 (range 9-35) days for the open group and 12 (range 9-20) for the laparoscopic group. Mean follow-up was 36 months.

CONCLUSIONS

Use of self expanding endoscopic colonic stents can provide excellent palliation in acute obstruction, aiming both to prepare the colon to elective surgery after adequate preparation or to palliate the stricture in case of unresectable advanced tumors.

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.

Operative colonoscopy in cancer patients

Gastrointestinal endoscopy has experienced tremendous developments in technology and equipment over the past decades. It is not only a diagnostic tool, but it also allows some interventional treatments in benign and malignant digestive diseases. Operative colonoscopy has been used to perform curative treatment of various kinds of polyps, flat and carpet-like adenomas and early colorectal carcinomas. Endoscopic palliative treatment strategies, such as the placement of self-expandable metal stents (SEMS), laser ablation, photodynamic therapy (PDT), argon plasma coagulation (APC), electrocoagulation, and injection therapy, have been proved to effectively alleviate advanced colorectal cancer (CRC) associated symptoms and maintain or improve the quality of the patient's remaining life.

Acute colonic obstruction

Acute colonic obstruction is a medical emergency because of the potential for bowel ischemia, perforation, and sepsis with peritonitis if not rapidly and appropriately treated. There are numerous causes of acute colonic obstruction, which must be differentiated from colonic pseudo-obstruction, which also is considered a medical emergency. Management options include medical therapy, surgical therapy, endoscopic therapy, and interventional radiologic therapy. Self-expandable metal stents (SEMS) have gained acceptance for alleviating acute malignant colonic obstruction and in some situations for preoperative relief of acute benign colonic obstruction. This article reviews the approach to the patient who has acute colonic obstruction.

Endoscopic Stenting for Malignant Gastric Outlet Obstruction

BACKGROUND AND AIMS

Obstruction often gives rise to disabling symptoms in non curable malignant upper gastrointestinal disease. Surgical relief is associated with high morbidity and mortality. We report outcomes of 24 patients palliated with endoscopic inserted stents. PATIENTS STUDIED: Thirteen females and 11 males, median age 66 years (range 24 to 88) suffered from gastroduodenal obstruction because of non curable malignant disease. All patients had nausea, repeated vomiting, and weight loss. The obstruction was localized in the stomach (n=5), gastrojejunostomy (n=3), or the duodenum (n=16). Self-expanding metal stents were delivered endoscopically under fluoroscopic control.

RESULTS

All patients got an improved quality of life and could eat at least semisolid food. All the patients were followed until they died. The median survival time after the procedure was 6.4 (range 0.5 to 23) months. In 1 patient stenting was complicated by perforation leading to death 2 weeks later. In another patient the stent migrated during the initial placement, but a secondary stent could be placed during the same procedure. Due to a long duodenal stenosis 2 patients got 2 stents under the primary procedure. During the follow-up period, 6 patients had supplementary gastroduodenal stents placed. Nine patients had biliary stents placed before the placement of the gastroduodenal stents, 2 after.

CONCLUSIONS

Our data suggest that endoscopic stenting for disabling symptoms due to gastroduodenal obstruction from non curable malignant disease, gives good symptomatic improvement with only few complications.

Comparison between two techniques of endoscopic metal stent placement on relieving gastric outlet obstruction

AIM: To compare two techniques of endoscopic metal stent placement in the treatment of gastric outlet obstruction (GOO) and evaluate their clinical efficacies.

METHODS: A total of 28 GOO patients were randomly allocated into 2 groups for endoscopic metal stent placement. Metal stents were placed under endoscope in 18 cases (group A), and they were placed into 10 cases (group B) through large aperture for biopsy. The clinical efficacy, complications and followed-up results were compared between the two groups.

RESULTS: The success rates of stent placement were 88.9% and 100%, respectively, in the two groups, and the overall success rate was as high as 94.4%. The effective rates for abdominal distention and vomiting were 81.3% and 87.5%, respectively. No obvious complications occurred in short term in all the patients except for 1 case of cardiac arrhythmia in group A. After following-up for 1 to 42 months, GOO reoccurred in 5 cases, and the average time for the reoccurrence was 110 days. The mean survival time was 140 days. Most patients mainly died of tumor progression.

CONCLUSION: Both techniques of endoscopic metal stent placement are safe and effective in the treatment of GOO, while metal stent placement via large aperture for biopsy is superior to the other.

Palliative stenting for late malignant gastric outlet obstruction

Malignant gastric outlet obstruction (MGO) is a late complication of pancreatobiliary and gastric cancers. Although surgical gastrojejunostomy provides good palliation, many of these patients may be nonoperative candidates or underwent previous extensive resection such as a Whipple procedure. Recently, endoscopically placed self-expanding metallic stents (SEMS) have been used to palliate MGO. The aim of this study was to evaluate the efficacy of SEMS for palliation of late MGO. Medical records of patients with endoscopic placement of SEMS for palliation of MGO were reviewed. Results showed that 30 patients with MGO had SEMS placed for late gastroduodenal (n = 20) or jejunal (n = 10) obstruction. Twenty-one patients (70%) had previous surgery. Return to oral feeding was observed in 90% of patients who presented with recurrent obstruction after prior bypass surgery and in 88% of nonoperative patients in whom SEMS were placed as the primary therapy for obstruction. No major complications were observed, and median survival after SEMS was 4.1 months (0.1 to 10.5 months). SEMS also did not interfere with biliary drainage. In conclusion, endoscopically placed SEMS are safe and provide good palliation for late malignant gastroduodenal and jejunal strictures and are an excellent complement to recurrent obstruction after surgical gastrojejunostomy.

Anterograde colonic stent placement via a cecostomy tube site

Colonic stents have been used as a method of relieving colonic obstruction since 1991. They are classically inserted in a retrograde fashion via the rectum and are deployed under a combination of endoscopic and fluoroscopic guidance. A unique case is presented where the colonic stent was passed in an anterograde fashion through a recently created cecostomy tube site as a method of palliation to relieve an obstructing hepatic flexure tumour.

Self-Expanding Metal Stents in Gastrointestinal Interventional Radiology: Technical Problems

Aims and background

To analyze the procedural difficulties in the placement of metal stents in stenoses of the digestive tract and optimize the technique.

Methods

Twenty-nine patients with digestive tract stenoses were treated from January 1999 to December 2004. In 14 cases the stricture was anastomotic (9 colorectal, 3 esophageal, 1 gastroesophageal and 1 gastrojejunal), in 13 esophageal, in 1 gastric and in 1 duodenal. The stenosis was due to scarring in 5 patients and was malignant in 24 patients (primary in 17 cases and secondary in 7 cases).

Results

The procedure achieved technical success in all cases but 2. For each of the different segments the technical difficulties and the adopted procedural solutions were analyzed.

Conclusions

The interventional radiology approach yielded results comparable to those reported for the endoscopic method and was always well tolerated. The need to rely on materials mostly designed for endoscopic use can make radiological use difficult in some cases.

Protocol for the treatment of malignant inoperable bowel obstruction: a prospective study of 80 cases at Grenoble University Hospital Center

A prospective protocol for treatment of malignant inoperable bowel obstruction was implemented at Grenoble University Hospital Center for 4 years. All 80 episodes of obstruction resulted from peritoneal carcinomatosis and none could expect another treatment cure. The protocol comprised three successive stages. Stage I included treatment for 5 days with a corticosteroid, antiemetic, anticholinergic, and analgesic. Stage II provided a somatostatin analogue if vomiting persisted. After 3 days, Stage III provided a venting gastrostomy. Obstruction relief with symptom control was obtained by medical treatment in 29 cases and symptom control occurred alone in an additional 32 cases. Ten patients were relieved by venting gastrostomy. Symptom control without permanent nasogastric tube (NGT) placement occurred in 72 episodes (90%). Eight patients with refractory vomiting were obliged to continue the NGT until death. Fifty-eight obstruction episodes (73%) were controlled in 10 days or less. Median time before gastrostomy was 17 days. Median survival was 31 days. This series suggests that a staged protocol for the treatment of inoperable malignant bowel obstruction is highly effective in relieving symptoms. A subgroup experiences relief of obstruction using this approach.

Preoperative colonoscopy after self-expandable metallic stent placement in patients with acute neoplastic colon obstruction

BACKGROUND

In patients with colorectal cancer, a preoperative colonoscopy is recommended to exclude synchronous lesions. Unfortunately, between 7% and 29% of patients with colorectal cancer present with acute colonic obstruction, making complete colonoscopy impossible.

OBJECTIVE

The aim of our study was to evaluate the feasibility of a preoperative colonoscopy after effective stent placement in patients with acute neoplastic obstruction.

DESIGN

Single-center prospective study.

SETTING

All examinations were carried out at a tertiary referral center with 24-hour emergency endoscopy service.

PATIENTS

Fifty-seven patients with acute neoplastic colon obstruction.

INTERVENTIONS

Patients who recovered from an acute colon obstruction by an effective stent placement and who had a resectable cancer underwent a preoperative colonoscopy.

MAIN OUTCOME MEASUREMENTS

Patients with a resectable cancer, complete preoperative colonoscopies, and synchronous lesions rates.

RESULTS

Self-expandable metallic stents (SEMS) were placed in 50 of 57 patients (87.8%). Thirty-one of 50 patients had a resectable cancer (62%), and a complete preoperative colonoscopy was possible in 29 of 31 patients (93.4%). A synchronous cancer was detected in 3 patients (9.6%), changing the surgical plan.

LIMITATIONS

Seven patients in whom the SEMS placement (12.2%) was unsuccessful underwent an urgent surgical intervention. Nineteen of 50 patients who had stent placement were not eligible for our study because of unresectable cancer.

CONCLUSIONS

Our study indicates that it is feasible in a majority of patients to perform full preoperative colonoscopy after relief of acute colonic obstruction with SEMS before surgical resection.

[Advantages of endoscopic stenting for malignant gastrointestinal obstructions]

Self-expanding stents play a major role in the interdisciplinary treatment of gastrointestinal obstructions in patients with local nonresectable tumors, advanced metastasis, and pronounced comorbidity. Reinstenting the passage and sealing esophagotracheal fistulae is very effective as palliative treatment for esophageal tumor complications. In hepatobiliary occlusions, the success rate against cholestasis is also high. Enteral and colorectal stents are gaining favor. Required are an experienced endoscopy team and adequate equipment. The rate of procedural complications is generally low, but rare and severe complications such as perforation must be considered. Further improvements in the materials and construction of stents can be expected.

Endoscopic approaches for palliation of luminal gastrointestinal obstruction

Much of the workload of a typical gastroenterologist is devoted to screening patients for gastrointestinal malignancies. Efforts such as colorectal cancer screening via colonoscopy and endoscopic surveillance of patients with Barrett's esophagus are widespread and widely endorsed. In recent years, the armamentarium of endoscopy has broadened considerably and now affords physicians a variety of nonsurgical means to palliate malignant obstruction of the gastrointestinal tract. This article reviews endoscopic techniques to treat malignant esophageal, biliary, small bowel, and colonic obstruction.

Balloon sheaths for gastrointestinal guidance and access: a preliminary phantom study

Objective

We wanted to evaluate the feasibility and usefulness of a newly designed balloon sheath for gastrointestinal guidance and access by conducting a phantom study.

Materials and Methods

The newly designed balloon sheath consisted of an introducer sheath and a supporting balloon. A coil catheter was advanced over a guide wire into two gastroduodenal phantoms (one was with stricture and one was without stricture); group I was without a balloon sheath, group ll was with a deflated balloon sheath, and groups III and IV were with an inflated balloon and with the balloon in the fundus and body, respectively. Each test was performed for 2 minutes and it was repeated 10 times in each group by two researchers, and the positions reached by the catheter tip were recorded.

Results

Both researchers had better performances with both phantoms in order of group IV, III, II and I. In group IV, both researchers advanced the catheter tip through the fourth duodenal segment in both the phantoms. In group I, however, the catheter tip never reached the third duodenal segment in both the phantoms by both the researchers. The numeric values for the four study groups were significantly different for both the phantoms (p < 0.001). A significant difference was also found between group III and IV for both phantoms (p < 0.001).

Conclusion

The balloon sheath seems to be feasible for clinical use, and it has good clinical potential for gastrointestinal guidance and access, particularly when the inflated balloon is placed in the gastric body.

Surgical Treatment of Colon Cancer

Over 100,000 Americans are diagnosed each year with colon cancer and approximately 90% are treated surgically. Most undergo a curative intent resection, but 30 to 50 percent will have a recurrence of their disease. While much of the variability in outcomes depends on the stage of the disease and other tumor variables, it is now clear that surgeon variables such as caseload and training affect both local recurrence and patient survival. Operative techniques including laparoscopic and other minimally invasive procedures and surgical decisions including choice of operative procedure, management of cancer arising in polyps and treatment of metastatic disease affect outcomes. The role of postoperative surveillance for recurrence remains controversial.

Colonic stenting: technique, technology, and outcomes for malignant and benign disease

Self-expandable metal stents (SEMS) have gained acceptance for use in the gastrointestinal tract to relieve malignant lumenal obstruction. In the colon, SEMS are used to avoid permanent or temporary colostomy during palliation and as a bridge to surgery for left-sided colonic obstruction. Limited data exist on their use for benign disease. This article reviews the latest in stent technology and the outcomes after their placement for benign and malignant disease.

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.

Use of guiding sheaths in peroral fluoroscopic gastroduodenal stent placement

Our purpose was to assess the safety and usefulness of guiding sheaths in peroral fluoroscopic gastroduodenal stent placement. Two types of guiding sheath were made from straight polytetrafluoroethylene tubes. Type A was 80 cm in length, 4 mm in outer diameter and 3 mm in inner diameter. Type B was 70 cm in length, 6 mm in outer diameter and 5 mm in inner diameter. The type A sheath was used in 18 patients in whom a catheter-guide wire combination failed to pass through a stricture. The type B sheath was used in 22 patients in whom a stent delivery system failed to pass through the stricture due to loop formation within the gastric lumen. The overall success rate for guiding a catheter-guide wire through a stricture after using the type A sheath was 89%. The overall success rate for passing a stent delivery system through a stricture after using the type B sheath was 100%. All procedures were tolerated by the patients without any significant complications. The guiding sheaths were safe and useful in peroral fluoroscopic gastroduodenal stent placement.

Management of malignant colonic obstruction

Malignant large bowel obstruction remains a clinical entity that is commonly encountered despite our advances in screening for colorectal cancer. Patients with malignant large bowel obstruction usually have advanced colorectal cancer and are often poor operative candidates, yet these patients are in need of treatment and colonic decompression. Surgical therapies are available and can offer good outcomes in selected patients. Patients who have curative or palliative surgeries planned should routinely undergo preoperative endoscopic decompression. Available options for decompression include the placement of colonic decompression tubes, ablative methods such as the use of lasers, argon plasma coagulators, and the use of self-expanding metal stents. The author favors the use of self-expanding metal stents, as these devices provide rapid colonic decompression, create a wide luminal diameter, and are applicable in patients requiring preoperative decompression and bowel preparation as well as in patients undergoing palliative therapy only. Patients who go on to surgery can have the stent and tumor removed en bloc at the time of the procedure, whereas patients who are only candidates for palliation can have the stents left in place as permanent decompressive devices with minimal morbidity and mortality.

Palliation of malignant rectal obstruction with self-expanding metal stents

BACKGROUND

Surgical management of patients with metastatic or recurrent rectal cancer remains controversial. Self-expanding metal stents are increasingly used for palliative treatment of advanced tumors, although long-term results are not yet available.

METHODS

Between 1996 and 2003, 521 patients underwent surgery for rectal neoplasms. In the same time period, self-expanding metal stents were used for palliation of 34 patients with malignant rectal obstruction and incurable disease. The outcome of the patients was analyzed retrospectively.

RESULTS

Rectal stents were successfully placed in 33 of 34 patients (97%) without major complications. Early failure occurred in 7 patients (21%) because of stent migration, pain, or incontinence. Long-term success with a mean patency of 5.3 months was observed in 26 patients (79%), but restenting was required in 2 patients. Despite the initial success of stenting, a colostomy was created in 2 other patients after 3.4 months and 9.2 months because of incontinence and rectovesical fistula. Overall, 6 of 33 patients (18%) underwent palliative surgery because of early complications (n = 4) or long-term failure of stent treatment (n = 2).

CONCLUSIONS

Self-expanding metal stents are useful to avoid a colostomy in selected patients with incurable rectal cancer and limited life expectancy. Nonetheless, a considerable number (18%) of patients will require surgical palliation because of failure of stent treatment.

Management of upper gastrointestinal obstruction in advanced ovarian cancer with intraluminal stents

BACKGROUND

The course of many patients with end-stage gynecologic malignancy will be complicated by malignant bowel obstruction. Intraluminal stents are a novel alternative to standard surgical intervention which can involve considerable patient risk.

CASES

Two cases are presented of patients with upper gastrointestinal obstruction due to recurrent ovarian cancer. In the first case, a stent was utilised to provide relief from nocturnal vomiting secondary to duodenal obstruction. In the second case, stent insertion for subtotal gastric outlet obstruction provided initial relief from vomiting. However, recurrence of symptoms occurred due to stent occlusion from tumour ingrowth.

CONCLUSIONS

In patients with upper gastrointestinal obstruction due to recurrent gynecologic malignancy, intraluminal stents can provide useful palliation.

Colonic stent vs. emergency surgery for management of acute left-sided malignant colonic obstruction: a decision analysis

BACKGROUND

Acute colonic obstruction because of malignancy is often a surgical emergency. Surgical decompression with colostomy with or without resection and eventual re-anastomosis is the traditional treatment of choice. Endoscopic colonic stent insertion effectively decompresses the obstructed colon, allowing for surgery to be performed electively. This study sought to determine the cost-effectiveness of colonic stent vs. surgery for emergent management of acute malignant colonic obstruction.

METHODS

Decision analysis was used to calculate the cost-effectiveness of two competing strategies in a hypothetical patient presenting with acute, complete, malignant colonic obstruction: (1) emergent colonic stent followed by elective surgical resection and re-anastomosis; (2) emergent surgical resection followed by diversion (Hartmann's procedure) or primary anastomosis. Cost estimates were obtained from a third-party payer perspective. Primary outcome measures were mortality, stoma requirement, and total number of operative procedures.

RESULTS

Colonic stent resulted in 23% fewer operative procedures per patient (1.01 vs. 1.32 operations per patient), an 83% reduction in stoma requirement (7% vs. 43%), and lower procedure-related mortality (5% vs. 11%). Colonic stent was associated with a lower mean cost per patient ($45,709 vs. $49,941).

CONCLUSIONS

Colonic stent insertion followed by elective surgery appears more effective and less costly than emergency surgery under base-case conditions. This finding remains robust over a wide range of assumptions for clinical inputs in sensitivity analysis. Our findings suggest that colonic stent insertion should be offered, whenever feasible, as a bridge to elective surgery in patients presenting with malignant colonic obstruction.

Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice?

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.

Use of a newly designed multifunctional coil catheter for stent placement in the upper gastrointestinal tract

PURPOSE

To evaluate the usefulness of a newly designed multifunctional coil catheter for stent placement in patients with upper gastrointestinal tract strictures.

MATERIALS AND METHODS

Constructed in our research laboratory, the coil catheter was used in 202 consecutive patients with malignant (n = 191) or corrosive (n = 11) upper gastrointestinal tract strictures. The coil catheter was made of a stainless-steel coil (1.3-mm inner diameter, 1.8-mm outer diameter), a 0.4-mm nitinol wire, a polyolefin tube, and a hemostasis valve. Usefulness of the coil catheter was evaluated based on whether the coil catheter could pass the stricture over a guide wire and whether measurement of the stricture length was possible while the guide wire was in place.

RESULTS

The passage of the coil catheter over a guide wire beyond the stricture was technically successful and well tolerated in 199 of 202 patients (99%). Negotiation of a guide wire or a coil catheter through the stricture of the stomach (n = 2) or duodenum (n = 1) under fluoroscopic guidance failed in three patients. In two of these three patients, it was possible to negotiate a guide wire and a coil catheter under combined endoscopic and fluoroscopic guidance; it was not possible in the third. There were no procedure-related complications.

CONCLUSION

The newly designed multifunctional coil catheter is useful in stent placement in patients with upper gastrointestinal tract strictures.

Treatment of recurrent malignant obstruction with a flexible covered metal stent after gastric surgery

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.

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.

Small Bowel Adenocarcinoma: A Rare but Aggressive Disease

Unlike the colon and rectum, the small intestine is associated with a very low rate of tumor occurrence. Adenocarcinomas represent the most frequent of these rare digestive tumors and are often fatal as a result of tardy diagnosis. Regardless of the stage, surgery usually remains the cornerstone of small bowel adenocarcinoma therapy. Because of the rarity of the disease, very few significant clinical trials have identified any efficient nonsurgical treatment; however, recent data indicate these tumors might be sensitive to chemotherapy alone or in association with radiation therapy. Conversely, a great deal of progress has been achieved in diagnosis of the tumor, whether by adaptation of existing techniques or development of new ones. We reviewed the clinical aspects of this rare but aggressive disease, focusing on new diagnostic procedures as well as on recent advances in their therapeutic management.