Endoscopic fenestration of duodenal stents using argon plasma to facilitate ERCP

Endoscopic management of malignant gastric outlet obstruction

Malignant gastric outlet obstruction (MGOO) is a late complication of advanced malignancies, mostly occurring due to gastrointestinal cancers or external compression outside the lumen. It causes nausea, vomiting, poor appetite, weight loss, and decreased quality of life. In the past, surgical bypass was the gold standard for the management of MGOO. However, the introduction of self-expandable metallic stent (SEMS) provides several advantages over surgical bypass, including earlier oral intake, rapid symptom relief, less invasiveness, and shorter hospital stays; therefore, it has replaced surgical bypass as the mainstream management approach in most situations. Although SEMS placement is a safe and effective way for palliation of MGOO, stent dysfunction with obstruction or migration limits the utilization and increases repeated intervention. Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stent has emerged as an alternative way to bypass the obstruction site and restore the oral intake of patients. Although a lower stent dysfunction rate was reported, further prospective studies are warranted to validate its effectiveness and safety.

Endoscopic Management of Combined Biliary and Duodenal Obstruction

Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.

Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in West Japan

BACKGROUND AND AIMS

Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) often is performed after unsuccessful placement of an endoscopic transpapillary stent (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS placement and EUS-BD in patients with an indwelling gastroduodenal stent (GDS).

METHODS

We recorded the clinical outcomes of patients at 5 tertiary-care medical centers who required biliary drainage after GDS placement between March 2009 and March 2014.

RESULTS

Thirty-nine patients were included in this study. Patients' mean age was 68.5 years; 23 (59.0%) were men. The GDS overlay the papilla in 23 patients (59.0%). The overall technical success rate was significantly higher with EUS-BD (95.2%) than with ETS placement (56.0%; P < .01). Furthermore, the technical success rate was significantly higher with EUS-BD (93.3%) than with ETS placement (22.2%; P < .01) when the GDS overlies the papilla. The overall clinical success rate of EUS-BD also was significantly higher than for ETS placement (90.5% vs 52.0%, respectively; P = .01), and there was no significant difference in the incidence of adverse events (ETS, 32.0% vs EUS-BD, 42.9%; P = .65).

CONCLUSION

Endoscopic double stent placement with EUS-BD is technically and clinically superior to ETS placement in patients with an indwelling GDS. EUS-BD should be considered the first-line treatment option for patients with an indwelling GDS that overlies the papilla. ETS placement remains a reasonable alternative when the papilla is not covered by the GDS.

Covered duodenal self-expandable metal stents prolong biliary stent patency in double stenting: The largest series of bilioduodenal obstruction

BACKGROUND AND AIM

Endoscopic biliary and duodenal stenting (DS; double stenting) is widely accepted as a palliation therapy for malignant bilioduodenal obstruction. The aim of the current study was to investigate the patency and adverse events of duodenal and biliary stents in patients with DS.

METHODS

Patients who underwent DS from April 2004 to March 2017 were analyzed retrospectively with regard to clinical outcomes and predictive factors of recurrent biliary and duodenal obstruction (recurrent biliary obstruction [RBO] and recurrent duodenal obstruction [RDO]).

RESULTS

A total of 109 consecutive patients was enrolled. Technical success of DS was achieved in 108 patients (99.1%). Symptoms due to biliary and duodenal obstruction were improved in 89 patients (81.7%). RBO occurred in 25 patients (22.9%) and RDO in 13 (11.9%). The median times to RBO and RDO from DS were 87 and 76 days, respectively. Placement of a duodenal uncovered self-expandable metal stent (U-SEMS) was significantly associated with RBO in the multivariable analysis (P = 0.007). Time to RBO was significantly longer in the duodenal covered self-expandable metal stent group than in the U-SEMS group (P = 0.003). No predictive factors of RDO were detected, and duodenal stent type was not associated with the time to RDO (P = 0.724).

CONCLUSIONS

Double stenting was safe and effective for malignant bilioduodenal obstruction. Duodenal U-SEMS is a risk factor for RBO. The covered self-expandable metal stent is the preferred type of duodenal SEMS in patients with DS (Clinical trial registration number: UMIN000027606).

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.

Endoscopic management of combined malignant biliary and gastric outlet obstruction

Patients with periampullary cancer or gastric cancer often develop malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), and combined MBO and GOO is not rare in these patients. Combined MBO and GOO is classified by its location and sequence, and treatment strategy can be affected by this classification. Historically, palliative surgery, hepaticojejunostomy and gastrojejunostomy were carried out, but the current standard treatment is combined transpapillary stent and duodenal stent placement. Although a high technical success rate is reported, the procedure can be technically difficult and duodenobiliary reflux with subsequent cholangitis is common after double stenting. Recent development of endoscopic ultrasound (EUS)-guided procedures enables the management of MBO as well as GOO under EUS guidance. EUS-guided biliary drainage is now increasingly reported as an alternative to percutaneous transhepatic biliary drainage in failed endoscopic retrograde cholangiopancreatography (ERCP), and GOO is one of the major reasons for failed ERCP. In addition to EUS-guided biliary drainage, the feasibility of EUS-guided double-balloon-occluded gastrojejunostomy bypass for MBO was recently reported, and EUS-guided double stenting can potentially become the treatment of choice in the future. However, as each procedure has its advantages and disadvantages, treatment strategy should be selected based on the type of obstruction and the prognosis and performance status of the patient.

Role of stenting in gastrointestinal benign and malignant diseases

Advances in stents design have led to a substantial increase in the use of stents for a variety of digestive diseases. Initially developed as a non-surgical treatment for palliation of esophageal cancer, the stents now have an emerging role in the management of malignant and benign conditions as well as in all segments of the gastrointestinal tract. In this review, relevant literature search and expert opinions have been used to evaluate the key-role of stenting in gastrointestinal benign and malignant diseases.

Endoscopic double stenting for the treatment of malignant biliary and duodenal obstruction due to pancreatic cancer

BACKGROUND

The purpose of the present study was to retrospectively evaluate endoscopic double stenting by endoscopic retrograde cholangiopancreatography-guided biliary drainage (ERCP-BD) and by endoscopic ultrasonography-guided biliary drainage (EUS-BD) for the treatment of non-resectable malignant biliary and duodenal obstruction.

PATIENTS AND METHODS

Medical records of 11 patients that underwent endoscopic double stenting from January 2008 to September 2012 were analyzed retrospectively.

RESULTS

Technical success rate was 100%, clinical success rate was 100%, early complication rate was 0% and late complication rate was 27.3% (cholangitis: two, perforation: one). Mean survival time from double stenting was 76.5 ± 67.8 days, mean patent period of the duodenal stent was 73.5 ± 69.7 days, and mean patent period of the biliary stent was 62.6 ± 60.4 days. Three (27.3%) patients were discharged (mean duration of hospitalization, 21.3 days). All patients could take food orally, and mean Gastric Outlet Obstruction Scoring System score after double stenting was 2.2 ± 0.9 points. ERCP-BD and EUS-BD were done in three and eight patients, respectively. There was no statistically significant difference between ERCP-BD and EUS-BD in terms of success rate and complication rate.

CONCLUSION

Our study revealed that endoscopic double stenting appears to be feasible and useful for the treatment of non-resectable malignant biliary and duodenal obstruction. In terms of selection criteria of ERCP-BD patients and EUS-BD patients, further prospective studies are mandatory.

Endoscopic double-metallic stenting for malignant biliary and duodenal obstructions

BACKGROUND

Endoscopic metallic stenting is a safe, effective treatment for malignant biliary obstructions, but can be technically difficult when combined malignant biliary and duodenal obstructions exist. Available duodenal metallic stents feature a tight mesh unsuitable for transpapillary biliary stenting. We evaluated the feasibility and usefulness of new endoscopic procedures for endoscopic double-stent placement in managing such obstructions.

METHODS

The through-the-scope duodenal metallic stent has a central cross-wired, unfixed structure that allows insertion of the biliary stent through the mesh wall of a duodenal stent. Transpapillary endoscopic placement of a biliary stent was performed through the lumen of this duodenal stent. Endoscopic ultrasound (EUS)-guided biliary drainage was performed successfully through the duodenal bulb after puncturing with a 19G needle. Biliary metallic stenting through the choledochoduodenal tract and effective drainage were achieved.

CONCLUSIONS

Use of a combined endoscopic biliary and duodenal stent inserted through the mesh of the new duodenal metallic stent is feasible and effective in managing the aforementioned obstructions. EUS-guided biliary metal stenting is a therapeutic option for endoscopic management when a failed transpapillary approach through the lumen of the duodenal stent occurs. The continued development of endoscopic procedures and devices should resolve issues associated with complicated strictures.

Self-expandable metallic stents for malignant gastric outlet obstruction

Duodenal self-expandable metal stents (SEMS) are designed for palliation and prompt relief of malignant gastric outlet obstruction (GOO). This mini-invasive endoscopic treatment is preferable to surgery due to its lower morbidity and mortality, shorter hospitalization, and earlier symptoms relief; furthermore endoscopic enteral stenting can be performed under conscious sedation, reducing the risk of general anesthesia in these already fragile patients. The stent placement technique is well established and should be performed in referral centers with adequate materials and equipment. Duodenal stents can be covered and uncovered. Nitinol stents have almost replaced other materials, being more flexible with a satisfactory axial and radial force. Common duodenal SEMS-related complications are recurrence of GOO symptoms due to stent clogging (tissue ingrowth/overgrowth and food impaction) and stent migration. These complications can be usually managed endoscopically. Perforation and bleeding are the most severe, but rare, complications. After stent placement, malignant GOO patients usually have improvement of the GOO symptoms with good resumption of fluids and solids. Choosing the most appropriate type of stent is arduous and should be done mainly in relation to the morphological aspects of the stricture. Endoscopic duodenal SEMS placement is indicated in symptomatic GOO patients suffering from unresectable malignancy or those inoperable due to advanced age or comorbidities. The absence of peritoneal carcinomatosis and multiple small bowel strictures is a key point for the clinical success of duodenal SEMS. Almost all symptomatic malignant GOO patients are candidates for the duodenal SEMS procedure; resolution of GOO, avoiding the need for a permanent naso-gastric or percutaneous endoscopic gastrostomy tube, significantly improves the patients' quality of life and dignity, even if life expectancy is short. Endoscopic duodenal SEMS insertion, after an adequate training, is a reproducible, simple, safe, and cost-effective procedure.

Management of simultaneous biliary and duodenal obstruction: the endoscopic perspective

Obstructive jaundice often develops in patients with unresectable malignancy in and around the head of the pancreas. Duodenal obstruction can also occur in these patients, and usually develops late in the disease course. Palliation of both malignant biliary and duodenal obstruction is traditionally performed with surgical diversion of the bile duct and stomach, respectively. With the advent of nonsurgical palliation of biliary obstruction using endoscopic transpapillary expandable metal stent placement, a similar approach can be used to palliate duodenal obstruction by placement of expandable metal gastroduodenal stents. Endoscopic palliation can be achieved in patients who require relief of both biliary obstruction and duodenal obstruction, although this can be technically difficult to achieve depending on the level of duodenal obstruction in relation to the major papilla. This article reviews the endoscopic approaches for combined palliative relief of malignant biliary and duodenal obstruction.

Large-balloon technique for one-step endoscopic biliary stenting in patients with an inaccessible major papilla owing to difficult duodenal stricture (with video)

BACKGROUND

Marked duodenal stenosis makes endoscopic biliary stenting (EBS) impossible, although it is the most common method for treating obstructive jaundice in patients with benign or malignant biliary strictures. Large-balloon dilation can be used to enable endoscope passage in the GI tract.

OBJECTIVE

We describe 4 cases of successful EBS combined with the use of a large balloon for the treatment of difficult duodenal strictures in patients with benign and malignant biliary strictures.

DESIGN

A retrospective case series.

SETTING

Two tertiary referral centers.

PATIENTS

Four patients: 1 with hilar carcinoma, 1 with gallbladder carcinoma, and 2 with chronic pancreatitis.

INTERVENTIONS

After duodenal dilation, the slightly deflated balloon was pushed with the endoscope into the major papilla through the duodenal stricture (pushing method used in 2 patients). In the cases in which the major papilla was not accessible with the pushing method, a large dilation balloon was deflated completely after dilation, advanced beyond the stricture into the third portion of the duodenum, and reinflated to the maximum size. Pulling the dilation balloon catheter into the working channel while hooking the inflated balloon as the anchor at the anal side of the duodenal stricture, the endoscope was straightened to advance to the major papilla (hooking method used in 2 patients).

MAIN OUTCOME MEASUREMENT

Successful EBS.

RESULTS

Reaching the major papilla and EBS was accomplished in all 4 patients.

LIMITATION

Small number of cases.

CONCLUSIONS

Use of large-balloon dilation can contribute to successful ERCP in patients with difficult duodenal strictures.