Use of a colonoscope for distal duodenal stent placement in patients with malignant obstruction. Surg Endosc. 2009;23:562-567. [PMID: 18389314 DOI: 10.1007/s00464-008-9880-5]

Clinical outcomes of different types of metallic stents in malignant distal duodenum stenosis: A retrospective study

BACKGROUND/PURPOSE

Endoscopic stenting at malignant distal duodenum stenosis (MDDS) is challenging because of the duodenal C-loop configuration, the acute angle of the duodenojejunal junction, and the limited length of the endoscope. Few studies have investigated the clinical outcomes of stenting at the distal duodenum. Therefore, this study aimed to investigate the clinical outcomes of treating MDDS with different types of metallic stents.

METHODS

From January 2012 to December 2020, fifty-six patients with MDDS who underwent duodenal stenting were enrolled for analysis. Thirty-five patients received uncovered self-expandable metallic stents (UC-SEMS), and twenty-one patients received partially covered self-expandable metallic stents (PC-SEMS). All patients were followed up till death or for 18 months. The clinical success rate, stent dysfunction rate, and stent patency were compared between the groups. Multivariate analysis was conducted to identify factors related to stent dysfunction.

RESULTS

The clinical success rates were 85.7 % in both the UC-SEMS and PC-SEMS groups. Stent dysfunction rates (UC-SEMS: 34.3 %, PC-SEMS: 38.1 %, p = 0.773) and the average stent patency (UC-SEMS: 117.2 days, PC-SEMS: 100.0 days, p = 0.576) were not statistically different between the groups. Multivariate analysis disclosed the age ≥65 years was significantly related to stent dysfunction (odds ratio: 4.78, p = 0.031).

CONCLUSION

Both UC-SEMS and PC-SEMS are safe and effective treatment options for MDDS. However, stent dysfunction remains a significant issue to overcome, particularly in the elderly. Further research is needed to explore novel strategies that can improve the effectiveness of stent placement and reduce the risk of stent dysfunction.

Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

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.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

The Great View Forward: The Use of a Colonoscope for Distal Duodenal Stent Placement

INTRODUCTION

Stent placement in the distal duodenum can be difficult. We describe a case report of a 94-year-old man with metastatic pancreatic head cancer compressing the third and fourth portions of the duodenum, treated by endoscopic stent placement using a colonoscope.

AREAS COVERED

A literature review highlighted two possible procedures for stent placement in the distal duodenum, namely forward-viewing and side-viewing endoscopies. Gastroscopes, duodenoscopes, enteroscopes, and colonoscopes have all been suggested for the purpose. For distal lesions, especially when the duodenal wall is stiffened due to compression or infiltration by neoplastic lesions, a conventional upper endoscope can be too short to reach the narrowed site in "push mode," necessitating the use of a longer endoscope.

EXPERT COMMENTARY

A colonoscope can be safely and effectively used to accomplish distal duodenal stent placement.

Endoscopic Palliation of Pancreatic Cancer

OPINION STATEMENT

Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.

Combined use of single-balloon enteroscope and colonoscope for self-expandable metal stent placement in patients with malignant small intestinal obstruction: a single-center comparative clinical observation

Small intestinal obstruction is a common complication of primary gastrointestinal cancer or metastatic cancers. Patients with this condition are often poor candidates for surgical bypasses, and placement of self-expanding metal stent (SEMS) can be technically challenging. In this study, we examined the feasibility of combined application of single-balloon enteroscope (SBE) and colonoscope for SEMS placement in patients with malignant small intestinal obstruction. Thirty-four patients were enrolled in this study, among which 22 patients received SEMS placement by using SBE and colonoscope, while the other 12 patients received conservative medical treatment. The patients were followed up for one year. Stent placement was technically feasible in 95.5% (21/22). Clinical improvement was achieved in 86.4% (19/22). For the 19 clinical success cases, the average time of benefits from a gastric outlet obstruction scoring system (GOOSS) increase ≥1 was 111.9±89.5 days. For the 12 patients receiving conservative medical treatment, no significant improvement in GOOSS score was observed. Moreover, a significant increase of Short-Form-36 health survey score was observed in the 19 patients at time of 30 days after stent placement. By Kaplan-Meier analysis, a significant survival improvement was observed in patients with successful SEMS placement, compared with patients receiving conservative medical treatment. Taken together, combined use of SBE and colonoscope makes endoscopic stent placement feasible in patients with malignant small intestinal obstruction, and patients can benefit from it in terms of prolonged survival and improved quality of life.

Safety and efficacy of self-expandable metallic stents in malignant small bowel obstructions

In this report, we present 3 cases of malignant small bowel obstruction, treated with palliative care using endoscopic self-expandable metallic stent (SEMS) placement, with the aim to identify the safety and efficacy of this procedure. Baseline patient characteristics, procedure methods, procedure time, technical and clinical success rates, complications, and patient outcomes were obtained. All 3 patients had pancreatic cancer with small bowel strictures. One patient received the SEMS using colonoscopy, while the other 2 patients received SEMS placement via double balloon endoscopy using the through-the-overtube technique. The median procedure time was 104 min. The technical and clinical success rates were 100%. Post-treatment, obstructive symptoms in all patients improved, and a low-residue diet could be tolerated. All stents remained within the patients until their deaths. The median overall survival time (stent patency time) was 76 d. SEMS placement is safe and effective as a palliative treatment for malignant small bowel obstruction.

Self-expandable metal stent placement for malignant duodenal obstruction distal to the bulb

OBJECTIVE

Self-expandable metal stents (SEMS) are widely used for the palliative management of malignant proximal gastroduodenal obstruction because of its low morbidity and mortality rates compared with surgical bypass. However, stent placement for duodenal obstruction beyond the first part of the duodenum is considered technically difficult and is not routinely performed. We report our experience with SEMS placement for these patients.

METHODS

Between 2006 and 2015, 51 patients with unresectable or metastatic malignancy underwent SEMS placements under combined endoscopic and fluoroscopic guidance. Eighteen patients had intestinal obstruction distal to the duodenal bulb. Their demographics, technical and clinical outcomes, periprocedural morbidity and mortality, length of hospital stay, further interventions and overall survival were analysed.

RESULTS

Out of the 18 cases, nine cases of intestinal obstruction were due to primary malignancy of the pancreas, three due to gastric malignancy, three from other locoregional cancers and three were the result of metastases. In 12 patients, the obstruction involved the second part (D2), in four the third part (D3) and in two the fourth part (D4) of the duodenum. A front-facing therapeutic gastroscope was used to visualize the duodenum before the stricture was crossed under direct vision and fluoroscopic guidance, with a catheter and guidewire, and a through-the-scope SEMS deployed using an 'over-the-wire' technique. Technical success rate was 89%. The mean gastric outlet obstruction scores improved from 0.63 to 2.57 (P<0.0001). Four patients died within 30 days of the procedure, although none of the deaths were procedure related. The median length of postprocedural hospital stay was 4 days and the median overall survival was 58 days.

Feasibility of self-expandable metal stent placement with side-viewing endoscope for malignant distal duodenal obstruction

BACKGROUND AND AIM

Self-expandable metal stents (SEMSs) have been a good treatment option for malignant intestinal obstruction. However, stent placement with a gastroscope can be technically difficult for the distal duodenum obstruction. A side-viewing duodenoscope may be helpful for these patients. We report our experiences in the insertion of SEMSs to distal duodenum with a side-viewing endoscope.

METHODS

We retrospectively analyzed our database of SEMS placement for malignant distal duodenum obstruction between April 2006 and April 2013. All patients underwent SEMS placement using the side-viewing endoscope (duodenoscope). Main outcomes are technical success, clinical success, complication rates, stent patency, and overall survival. In addition, database from other tertiary center was analyzed, where SEMS insertion was performed with forward-viewing endoscopes (gastroscope or colonoscope). Success and complication rates were compared with ours.

RESULTS

A total of 31 patients were reviewed. Pancreatic cancer was the most common cause (87.1 %). Technical and clinical success was achieved in all cases. Procedure-related complication occurred in one patient, who experienced micro-perforation of the duodenum. The patient improved with conservative treatment. Median duration of stent patency was 125 days (95 % CI 75-175), and median overall survival was 134 days (95 % CI 77-191). Biliary obstruction was present in 12.9 % of patients, who underwent biliary stent placement at the same time without changing endoscopes. In forward-viewing endoscopes group, 15 cases were included. Technical and clinical success was achieved in all cases, and no procedure-related complication occurred.

CONCLUSIONS

The insertion of SEMSs to distal duodenum with a duodenoscope could be performed effectively and safely in patients with malignant obstruction.

A newly designed stent for management of malignant distal duodenal stenosis

PURPOSE

To evaluate the clinical effectiveness of a newly designed stent for the treatment of malignant distal duodenal stenosis.

METHODS

From March 2011 to May 2013, six patients with malignant duodenal stenosis underwent fluoroscopically guided placement of the new duodenal stent consisting of braided, nested stent wires, and a delivery system with a metallic mesh inner layer. Primary diseases were pancreatic cancer in three patients, gastric cancer in two patients, and endometrial stromal sarcoma in one patient. Duodenal obstructions were located in the horizontal part in two patients, the ascending part in two patients, and the duodenojejunal flexure in two patients. Technical success, defined as the successful stent deployment, clinical symptoms before and after the procedure, and complications were evaluated.

RESULTS

Technical success was achieved in all patients. No major complications were observed. Before treatment, two patients could not take any food and the gastric outlet obstruction scoring system (GOOSS) score was 0; the other four patients could take only liquids orally (GOOSS score = 1). After treatment, five patients could take soft food (GOOSS score = 2) and one patient could take a full diet (GOOSS score = 3). The mean duration of primary stent patency was 115.7 days.

CONCLUSIONS

The newly designed stent is associated with a high degree of technical success and good clinical outcome and may be clinically effective in the management of malignant distal duodenal obstruction.

Long-term release of a malignant ileal obstruction by placement of a colorectal self-expandable metal stent

An 84-year-old man underwent the Hartmann procedure with an R1 resection for advanced rectal cancer. One year after surgery, the patient presented with abdominal pain and vomiting. Abdominal radiography and computed tomography revealed an expanding small bowel and ileal obstruction caused by invasion of local, recurrent rectal cancer. In order to release the ileal obstruction, a colorectal self-expandable metal stent was placed via a through-the-scope technique using a colonoscope inserted through a stoma in the transverse colon. After stent placement, the patient's clinical symptoms and signs improved and the symptoms of obstruction did not recur. No major complications associated with the placement of the stent were observed during the 7-month follow-up period. Thus, self-expandable metal stents are a safe and effective palliative treatment for malignant gastroduodenal or colorectal obstructions, and as a bridge to surgery. However, endoscopic placement of these stents in cases of malignant small bowel obstruction is not yet feasible because of the limitations of endoscopic access and the stent delivery system. To our knowledge, this is the first report of malignant ileal obstruction treated with a colorectal self-expandable metal stent using a colonoscope. This case indicates that colorectal self-expandable metal stents can be effectively and safely used to treat malignant ileal obstructions.

Mid-gut stents

PURPOSE OF REVIEW

Gastrointestinal stents offer a feasible, safe, cost effective, and minimally invasive method for reestablishing luminal patency. Previous clinical reports and systematic reviews have demonstrated the role of enteral stents in both the upper and lower gastrointestinal tract. Over the last two decades, the rapid development of deep enteroscopy in concert with the evolution of various stent devices/deployment mechanisms has enabled placement of enteral stents in the mid-gut; hence this has been increasingly reported. The present article focuses on stenting in the mid-gut, a relatively novel term, referring to the small bowel between the ampulla and the ileocecal valve.

RECENT FINDINGS

Mid-gut stenting is technically more difficult than stenting in the upper and lower gastrointestinal tract, and therefore requires particular expertise, restricting its widespread utility. In total, 86 reported cases involving mid-gut stent deployment, by either endoscopic approaches (80.2%) or percutaneous approaches (19.8%), have been published. Although limited, these results have demonstrated that mid-gut stenting is reliable, effective, and a minimally invasive method for palliating malignant obstruction, as well as sealing leaks and fistulae.

SUMMARY

This article reviews the current status of mid-gut stenting, including endoscopic technique. The article also speculates about the potential for future advances within this field.

Palliative Percutaneous Jejunal Stent for Patients with Short Bowel Syndrome

Gastrointestinal obstruction is a common preterminal event in patients with gastric and pancreatic cancer who often undergo palliative bypass surgery. Although endoscopic palliation with self-expandable metallic stents has emerged as a safe and effective alternative to surgery, experience with this technique remains limited. In particular, a proximal jejunal obstruction requires more technical expertise than a duodenal obstruction. Palliative treatment modalities include both surgical and nonsurgical approaches. In this report, we describe the successful placement of self-expandable metallic stents at the proximal jejunum using a combination of percutaneous endoscopic, intraoperative, and transstomal stenting. Usually endoscopy is not indicated in cases of proximal jejunal obstruction, but some cases may require palliative endoscopy instead of bypass operation.