Outcome for self-expandable metal stents in malignant gastroduodenal obstruction: single-center experience with 104 patients

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy for the palliation of gastric outlet obstruction in patients with peritoneal carcinomatosis

BACKGROUND : Gastric outlet obstruction (GOO) with peritoneal carcinomatosis presents a technical challenge. Surgical gastrojejunostomy (SGJ) or enteral stenting have been the standard of care; however, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a favorable alternative. Few data exist that compare these techniques in the setting of peritoneal carcinomatosis. METHODS : This single-center retrospective cohort study included 25 EUS-GE and 27 SGJ consecutive patients. Baseline demographics, cancer diagnosis and stage, clinical and technical success, adverse events, and obstruction recurrence data were collected. The primary outcome was the technical success comparison; secondary outcome was the adverse event rate comparison. Rates were compared with standard statistical tests. RESULTS : Mean age, obstruction location, and symptoms were similar between the groups. The EUS-GE group had more advanced disease (clinical stage 4, 100 % vs. 67 %; P = 0.006) and higher American Society of Anesthesiologists classification (class 3-4, 92 % vs. 50 %; P = 0.004). The technical success rate was 100 % in both groups (P > 0.99) and the adverse event rate was lower for EUS-GE (8 % vs. 41 %; P = 0.01). Clinical success was 88 % for EUS-GE and 85 % for SGJ (P > 0.99) and recurrent obstruction was lower with EUS-GE (28 % vs. 41 %; P = 0.13). The EUS-GE group had shorter procedure duration, length of stay, and time to chemotherapy resumption than the SGJ group. CONCLUSIONS : Although the EUS-GE group was older, with more comorbidity and advanced stages, the technical success rate was similar to SGJ and it had significantly fewer adverse events. EUS-GE is a safe and effective option for the management of malignant GOO with peritoneal carcinomatosis.

Optimizing outcomes for EUS-guided gastroenterostomy: results of a Standardized Clinical Assessment and Management Plan (with video)

BACKGROUND AND AIMS

EUS-guided gastroenterostomy (EUS-GE) has emerged as an option for managing malignant gastric outlet obstruction (GOO). However, there is currently no standardized technique, and outcomes are variable with inconsistencies both within and across centers. The present study aims to develop and assess outcomes of a Standardized Clinical and Assessment Management Plan (SCAMP) for EUS-GE.

METHODS

A SCAMP was created by a multidisciplinary team to develop and optimize a systematic approach for EUS-GE. This is a single-center, prospective cohort study on patients undergoing EUS-GE for GOO, using the developed SCAMP. Baseline demographics, cancer diagnosis and stage, Eastern Cooperative Oncology Group (ECOG) performance score, clinical and technical success, adverse events (AEs), and obstruction recurrence were collected. Primary outcomes included technical and clinical success. Obstruction-free and overall survival were calculated and compared with Kaplan-Meier analysis.

RESULTS

Fifty patients underwent EUS-GE in accordance with the SCAMP. Mean age was 67 years, 54% were women, and pancreatic cancer represented the largest cancer type (51%). Technical success was 100% and clinical success 92%. AEs occurred in 2 patients (4%). Recurrent obstruction occurred in 16%, related to distal small-bowel obstruction from carcinomatosis. Estimated mean obstruction-free survival was 217 days. Median overall survival was 230 days among patients with ECOG scores 0 to 2 and 82 days for ECOG scores ≥3 (P = .008).

CONCLUSIONS

The standardized technique used was associated with high technical and clinical success and low rates of AEs, morbidity and procedure-related mortality. Adopting a similar uniform systematic approach may improve procedural outcomes and dissemination.

Double Stenting for Malignant Biliary and Duodenal Obstruction: A Systematic Review and Meta-Analysis

Data about the efficacy of palliative double stenting for malignant duodenal and biliary obstruction are limited.

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.

Laparoscopic Gastrojejunostomy for Patients with Unresectable Gastric Cancer with Gastric Outlet Obstruction

BACKGROUND

There have been no comparative studies of open gastrojejunostomy (OGJ) and laparoscopic gastrojejunostomy (LGJ) in gastric cancer (GC) patients with gastric outlet obstruction (GOO) to explore both short- and long-term outcomes. The aim of this study was to compare the safety and feasibility of short-term oral intake as well as the long-term oncological outcome of OGJ and LGJ.

METHODS

This was a retrospective study of 53 consecutive unresectable GC patients who underwent GJ for GOO in our institute. OGJ (n = 23) was performed between 2010 and 2012 and LGJ (n = 30) was performed between 2013 and 2015.

RESULTS

We found a higher rate of postoperative delayed gastric emptying in the OGJ group than in the LGJ group (26.1 vs 0%; P = 0.004). OGJ had more unfavorable results regarding the median time to resumption of oral feeding (4 vs 2 days; P < 0.001). Palliative LGJ did not offer survival benefit over OGJ in patients with unresectable GC with GOO.

CONCLUSION

LGJ is a useful and feasible alternative to OGJ regarding short-term outcomes.

Application of Y-shaped, coated self-expandable metallic stents for anastomotic stenosis after gastrojejunostomy (Billroth II)

BACKGROUND

Anastomotic stenosis is an infrequent but life-threatening complication after gastrojejunostomy (Billroth II). Tubular or single tubular stents have limited efficacy due to the particular anatomy.

PURPOSE

To assess the feasibility of a Y-shaped, fully-coated, self-expandable, metallic stent (SEMS) for anastomotic stenosis after gastrojejunostomy (Billroth II).

MATERIAL AND METHODS

Between January 2008 and August 2014, 14 patients (10 with gastric carcinoma and four with duodenal ulcers) had anastomotic stenoses following Billroth II reconstructions. Eight patients with gastric cancer had tumor recurrence near the anastomosis; two had benign strictures. The four duodenal ulcer patients had benign stenoses. An integrated Y-shaped, fully coated SEMS was designed to accord with the anatomy of residual gastrojejunal anastomotic strictures. Fourteen stents were inserted under fluoroscopic control. Follow-up was at 1, 3, 9, and 12 months, and then annually.

RESULTS

All 14 stents were inserted successfully at the first attempt with a technical success rate of 100%. After stenting, abdominal symptoms resolved in all patients. All patients were followed up for 4-27 months (mean, 13.9 months). One of the eight recurrent cases died of multiple tumor metastases and liver failure after 7 months, without obstruction symptoms. In all six patients with benign anastomotic stenosis, the stents were removed successfully without complication and with no evidence of restenosis based on clinical evaluation and imaging.

CONCLUSION

A Y-shaped, fully-coated SEMS proved to be a feasible and minimally invasive procedure for treating anastomotic stenosis after gastrojejunostomy (Billroth II).

Stents and surgical interventions in the palliation of gastric outlet obstruction: a systematic review

Background and study aims: Palliative treatment of gastric outlet obstruction can be done with surgical or endoscopic techniques. This systematic review aims to compare surgery and covered and uncovered stent treatments for gastric outlet obstruction (GOO). Patients and methods: Randomized clinical trials were identified in MEDLINE, Embase, Cochrane, LILACs, BVS, SCOPUS and CINAHL databases. Comparison of covered and uncovered stents included: technical success, clinical success, complications, obstruction, migration, bleeding, perforation, stent fracture and reintervention. The outcomes used to compare surgery and stents were technical success, complications, and reintervention. Patency rate could not be included because of lack of uniformity of the extracted data. Results: Eight studies were selected, 3 comparing surgery and stents and 5 comparing covered and uncovered stents.The meta-analysis of surgical and endoscopic stent treatment showed no difference in the technical success and overall number of complications. Stents had higher reintervention rates than surgery (RD: 0.26, 95 % CI [0.05, 0.47], NNH: 4). There is no significant difference in technical success, clinical success, complications, stent fractures, perforation, bleeding and the need for reintervention in the analyses of covered and uncovered stents. There is a higher migration rate in the covered stent therapy compared to uncovered self-expanding metallic stents (SEMS) in the palliation of malignant GOO (RD: 0.09, 95 % CI [0.04, 0.14], NNH: 11). Nevertheless, covered stents had lower obstruction rates (RD: - 0.21, 95 % CI [-0.27, - 0.15], NNT: 5). Conclusions: In the palliation of malignant GOO, covered SEMS had higher migration and lower obstruction rates when compared with uncovered stents. Surgery is associated with lower reintervention rates than stents.

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.

Gastric outlet obstruction in gastric cancer: a comparison of three palliative methods

BACKGROUND

Gastric outlet obstruction (GOO) commonly occurs in advanced gastric cancer. Our aim was to evaluate the results of endoscopic stenting (ES), palliative resection (PR), and gastrojejunostomy (GJ) as palliation of GOO.

METHODS

A total of 97 patients (50 ES, 26 PR, 21 GJ) were included in this retrospective study. All the patients had primary gastric cancer and symptoms of GOO.

RESULTS

Compared to surgery, ES resulted in a faster improvement on oral intake and symptom relief (P < 0.001) and a shorter hospitalization (P < 0.001). Complication rates, hospital re-admissions, occurrence of biliary obstruction, and the number of patients receiving chemotherapy were similar. The median symptom-free and overall survival were longest in the PR group (P < 0.001). In multivariate survival analysis, independent prognostic factors were age, BMI, pre-procedure GOOSS, palliative resection as treatment modality, and chemotherapy.

CONCLUSIONS

In gastric cancer and GOO, the clinical condition of the patient before treatment affects survival and should be taken into account in determining the treatment. PR seems to provide a survival benefit and should be considered as treatment option for patients suitable for surgery. For patients unfit for surgery, ES provides rapid and efficient palliation. Chemotherapy also seems to improve survival in gastric cancer and GOO.

Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery

BACKGROUND

In patients with gastric outlet obstruction (GOO) caused by gastric cancer, choosing between self-expandable metal stent (SEMS) placement and gastrojejunostomy (GJJ) is of concern, especially in those with good performance status.

OBJECTIVE

To compare SEMS placement and GJJ.

DESIGN

Retrospective study.

SETTING

Single tertiary referral center.

PATIENTS

Patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 who had GOO caused by unresectable gastric cancer.

INTERVENTIONS

SEMS placement and GJJ.

MAIN OUTCOME MEASUREMENTS

Success rate, adverse events, patency, and survival duration.

RESULTS

Of the 113 patients in this study, 72 underwent SEMS placement and 41 underwent GJJ. The 2 groups did not differ in the technical and clinical success and incidence of early adverse events. However, the rate of late adverse events was significantly higher in the SEMS group (44.4% vs 12.2%; P < .001). The median patency duration was shorter after SEMS placement than after GJJ (125 days vs 282 days; P = .001), even after additional SEMS placement (210 days vs 282 days; P = .044). The median survival was also significantly shorter after SEMS placement than after GJJ (189 days vs 293 days; P = .003). Survival differed between treatments in patients with ECOG 0-1 (P = .006) but not in those with an ECOG performance status of 2 (P = .208).

LIMITATIONS

Retrospective and single-center study.

CONCLUSIONS

GJJ is preferable to SEMS placement for the palliation of GOO caused by unresectable or metastatic gastric cancer in patients with a good performance status, especially ECOG 0-1.

An assessment of radiologically inserted transoral and transgastric gastroduodenal stents to treat malignant gastric outlet obstruction

INTRODUCTION

Self-expanding metallic stents (SEMS) are used to palliate malignant gastric outlet obstruction (GOO) and are useful in patients with limited life expectancy or severe medical comorbidity, which would preclude surgery. Stenting can be performed transorally or by a percutaneous transgastric technique. Our goal was to review the outcome of patients who underwent radiological SEMS insertion performed by a single consultant interventional radiologist.

METHODS

Patients were identified from a prospectively collected database held by one consultant radiologist. Data were retrieved from radiological reports, multidisciplinary team meetings, and the patients' case notes. Univariate survival analysis was performed.

RESULTS

Between December 2000 and January 2011, 100 patients (63 males, 37 females) had 110 gastroduodenal stenting procedures. Median age was 73 (range 39-89) years. SEMS were inserted transorally (n = 66) or transgastrically (n = 44). Site of obstruction was the stomach (n = 37), duodenum (n = 50), gastric pull-up (n = 10), or gastroenterostomy (n = 13). Seven patients required biliary stents. Technical success was 86.4 %: 83.3 % for transoral insertion, 90.9 % for transgastric insertion. Eleven patients developed complications. Median GOO severity score: 1 pre-stenting, 2 post-stenting (p = 0.0001). Median survival was 54 (range 1-624) days. Post-stenting GOO severity score was predictive of survival (p = 0.0001).

CONCLUSIONS

The technical success rate for insertion of palliative SEMS is high. Insertional technique can be tailored to the individual depending on the location of the tumor and whether it is possible to access the stomach percutaneously. Patients who have successful stenting and return to eating a soft/normal diet have a statistically significant increase in survival.

Long-term outcome of palliative treatment with self-expanding metal stents for malignant obstructions of the GI tract

BACKGROUND

Self-expanding metal stents (SEMS) are commonly used in the palliative treatment of malignant gastrointestinal (GI) obstructions with favorable short-term outcome. Data on long-term outcome are scarce, however.

AIM

To evaluate long-term outcome after palliative stent treatment of malignant GI obstruction.

METHOD

Between October 2006 and April 2008, nine Norwegian hospitals included patients treated with SEMS for malignant esophageal, gastroduodenal, biliary, and colonic obstructions. Patients were followed for at least 6 months with respect to stent patency, reinterventions, and readmissions.

RESULTS

Stent placement was technically successful in 229 of 231 (99%) and clinically successful after 1 week in 220 of 229 (96%) patients. Long-term follow-up was available for 219 patients. Of those, 72 (33%) needed reinterventions. Stent occlusions or migrations (92%) were the most common reasons. Esophageal stents required reinterventions most frequently (41%), and had a significantly (p = 0.02) shorter patency (median 152 days) compared to other locations (gastroduodenal, 256 days; colon, 276 days; biliary, 460 days). Eighty percent of reinterventions were repeated endoscopic procedures that successfully restored patency. Readmissions were required for 156 (72%) patients. Progression of the underlying cancer was the most common reason, whereas 24% were readmitted due to stent complications.

CONCLUSIONS

Long-term outcome after palliative treatment with SEMS for malignant GI and biliary obstruction shows that 70% had a patent stent until death, and that most reobstructions could be solved endoscopically. Hospital readmissions were mainly related to progression of the underlying cancer disease.

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.

Stent treatment of malignant gastric outlet obstruction: the effect on rate of gastric emptying, symptoms, and survival

BACKGROUND

Advanced pancreatic cancer and other malignancies located proximal to the small bowel might cause gastric outlet obstruction (GOO) resulting in nausea, vomiting, dehydration, and malnutrition. Self-expandable metal stents (SEMS) to a large extent have replaced surgical treatment, with gastro-entero-anastomosis as palliative treatment for GOO. The aim of the present study was to evaluate the effect of duodenal stenting on the rate of gastric emptying, symptoms, and survival.

METHODS

Patients with endoscopically verified malignant obstruction of the proximal duodenum were included. Gastric emptying rate was measured prior to and within 1 week after stent placement using a meal containing (13)C-octanoic acid as a marker. Symptoms related to GOO were assessed by the patients before and 2 weeks after stent treatment and during the gastric emptying tests. All patients were followed up until death.

RESULTS

In the patients included (n = 17), all studied variables of gastric emptying improved significantly following treatment, and a reduction in self-reported obstructive symptoms was observed. There was no correlation between survival and the rate of gastric emptying before or after, or the change in the rate of emptying.

CONCLUSION

The present study demonstrated that treatment with SEMS results in improved gastric emptying in most patients with GOO and a corresponding reduction in self-reported obstruction symptoms. However, survival and emptying were not related. The present findings provide further evidence that treatment with stents is an effective palliative treatment in patients with GOO.

Duodenal stenting for malignant gastric outlet obstruction: Prospective study

AIM: To evaluate the results of duodenal stenting for palliation of gastroduodenal malignant obstruction by using a gastric outlet obstruction score (GOOS).

METHODS: A prospective, non-randomized study was performed at a tertiary center between August 2005 and April 2010. Patients were eligible if they had malignant gastric outlet obstruction (GOO) and were not candidates for surgical treatment. Medical history and patient demographics were collected at baseline. Scheduled interviews were made on the day of the procedure and 15, 30, 90 and 180 d later or unscheduled as necessary.

RESULTS: Fifteen patients (6 male, 9 female; median age 61 years) with GOO who had undergone duodenal stenting were evaluated. Ten patients had metastasis at baseline (66.6%) and 14 were unable to accept oral intake (93.33%), including 7 patients who were using a feeding tube. Laboratory data showed biliary obstruction in eight cases (53.33%); all were submitted to biliary drainage. Two patients developed obstructive symptoms due to tumor ingrowth after 30 d and another due to tumor overgrowth after 180 d. Two cases of stent migration occurred. A good response to treatment was observed, with a mean time of approximately 1 d (19 h) until toleration of a liquid diet and slightly more than 2 d for both soft solids (51 h) and a solid food/normal diet (55 h). The mean time to first failure to maintain liquid intake (GOOS ≥ 1) was 93 d. During follow-up, the mean time to first failure to maintain the previously achieved GOOS of 2-3 (solid/semi-solid food), considered technical failure, was 71 d. On the basis of oral intake a GOOS is defined: 0 for no oral intake; 1 for liquids only; 2 for soft solids only; 3 for low-residue or full diet.

CONCLUSION: Enteral stenting to alleviate gastroduodenal malignant obstruction improves quality of life in patients with limited life expectancy, which can be evaluated by using a GOO scoring system.