Metallic stent placement in patients with recurrent cancer after gastrojejunostomy

Clinical management for malignant afferent loop obstruction

Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Percutaneous drainage for afferent limb syndrome and pancreatic fistula via the blind end of the jejunal limb after pancreatoduodenectomy or bile duct resection

PURPOSE

To investigate the feasibility of percutaneous drainage via the blind end of the jejunal limb (BEJL) for afferent limb syndrome and pancreatic fistula.

MATERIALS AND METHODS

Percutaneous drainage via the BEJL was performed in eight patients (seven men and one woman; mean age, 63 y; range, 42-71 y) presenting with afferent limb syndrome (n = 6) or pancreatic fistula (n = 2) following pancreatoduodenectomy or bile duct resection with reconstruction at our institute from March 2005 to June 2013. Reconstruction was performed by using a modified Child method or the Roux-en-Y method, and the BEJL was surgically fixed to the abdominal wall. Afferent limb syndrome was caused by tumor recurrence or postoperative complications. Technical success, clinical success, and complications were evaluated retrospectively.

RESULTS

Technical success of drainage via BEJL was achieved in all patients. Drainage catheters (5-10 F) were inserted into the afferent limbs of six patients, into the pancreatic duct of one patient, and into the pancreatic fistula of one patient. Metallic stents were subsequently placed to address malignant afferent limb obstruction in two patients. Clinical success was achieved in seven patients (87.5%), and no patients developed major complications. Drainage catheters were removed from four patients. The mean catheter indwelling period in all patients was 143 days (range, 21-292 d).

CONCLUSIONS

Percutaneous drainage via BEJL after pancreatoduodenectomy or bile duct resection may be a feasible treatment for afferent limb syndrome and pancreatic fistula.

Self-expandable metallic stent placement in the palliative treatment of malignant obstruction of gastric outlet and duodenum

Background/Aims

To asses the usefulness of flexible metallic stents in the palliation of malignant obstruction of gastric outlet and duodenum.

Methods

Retrospective review was performed between January 2006 and December 2011 in 30 patients. Thirty consecutive patients with obstruction of the gastric outlet underwent palliative treatment with self-expandable flexible metallic stents. Complications and clinical outcomes were assessed.

Results

Twenty-four patients had advanced gastric carcinoma at the antrum and/or pylorus, four patients had obstruction at the pylorus due to pancreas tumours and one patient had duodedum and one patient had gall bladder tumour. Symptoms improved in 82.7% of the patients after the procedure. The improvement in ability to eat using the score system was statistically significant (p<0.001). Tumor ingrowth and/or overgrowth were seen in four patients (13.3%), and a second stent was inserted in these patients. The mean stent patency was 100 days (range, 5 to 410). The mean survival was 120.76±38.96 days.

Conclusions

Endoscopic placement of self-expendable metallic stents under fluoroscopy is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach or pancreas cancer.

WallFlex™ Duodenal Stent Placement in a Gastric Cancer Patient with Malignant Stenosis of a Roux-en-Y Gastrojejunostomy following Distal Gastrectomy

A 69-year-old Japanese woman with a history of distal gastrectomy with a Roux-en-Y reconstruction for advanced gastric cancer was admitted to our hospital complaining of severe dysphagia. On admission, the patient was only able to take liquids, and a firm, fist-sized tumor was palpable in her left upper abdomen. An endoscopic examination disclosed stenosis of the jejunal limb of the gastrojejunostomy. Abdominal computed tomography revealed that a recurrent tumor, 5.0 cm in diameter, was compressing the jejunal limb of the gastrojejunostomy. A knitted nitinol self-expandable metallic stent (WallFlex™ duodenal stent) was placed endoscopically at the stenotic jejunum from the gastrojejunostomy. The time required for stenting and total endoscopic manipulation was 12 and 35 minutes, respectively. No stent-related complications were observed. The patient could resume oral ingestion 1 day after endoscopic stenting and was discharged on the fifth day after treatment. She survived for 201 days after stenting. She continued oral ingestion for 194 days and stayed at home for 165 days. The WallFlex duodenal stent allows safe endoscopic stenting, even in cases of malignant stenosis of a gastrojejunostomy following distal gastrectomy. This stenting device will extend the indications for endoscopic palliation of gastric cancer patients with gastric outlet stenosis.

Self-expandable metallic stent placement for malignant obstruction in patients with locally recurrent gastric cancer

BACKGROUND

Self-expandable metallic stents (SEMSs) provide effective palliation for inoperable malignant gastric outlet obstruction (GOO). The objective of this study was to evaluate the effectiveness of SEMSs in patients with recurrent gastric cancer after radical gastrectomy.

METHODS

We retrospectively analyzed data from patients with gastric cancer who underwent endoscopic SEMS placement. The patients had obstructive symptoms due to recurrent gastric cancer after curative-intent subtotal or total gastrectomies. Technical and clinical success rates of stent placement were evaluated and clinical outcomes were compared according to operation types.

RESULTS

A total of 15 patients underwent total gastrectomies with esophagojejunostomies and Roux-en-Y reconstructions, 8 underwent subtotal gastrectomies with Billroth I reconstructions, and 12 underwent subtotal gastrectomies with Billroth II reconstructions. Four patients in the Billroth II group received stents in afferent and efferent loops, so a total of 39 stents were placed. Technical success was achieved with 92% (36/39) of stents, and clinical success occurred with 90% (35/39) of stents, with no significant differences among surgery groups or between stent types (covered vs. uncovered). The GOO score (preprocedure: 0.45±0.62) increased by 1 week (2.06±0.51, p<0.001) and was maintained up to 1 month (1.71±1.15, p<0.001 compared with initial score). Complications occurred with 17 of 39 stents (44%) and included 2 perforations, 3 migrations, and 12 restenoses. Median stent patency duration was 10.7 weeks and median survival was 21.3 weeks; these did not significantly differ by surgery group (p=0.25 and 0.93, respectively) or stent type (covered vs. uncovered, p=0.51 and 0.96, respectively).

CONCLUSION

Endoscopic SEMS placement for obstruction due to recurrent cancer after total or subtotal gastrectomy is feasible and provides effective short-term palliation, independent of the type of surgical procedure or stent (covered vs. uncovered) used.

Malignant gastric outlet obstructions: treatment with self-expandable metallic stents

Unresectable malignant gastric outlet obstruction (GOO) severely affects the quality of life, with complications that include nausea, vomiting, aspiration, pain, and malnutrition. Although palliative surgical procedures have been traditionally performed, they are associated with high morbidity and mortality rates. Placing self-expandable metallic stents is associated with higher clinical success rates, lower morbidity, shorter time from the procedure to starting oral intake, lower incidence of delayed gastric emptying, and a shorter hospital stay than palliative surgery. Fluoroscopic or endoscopic placement of either bare or covered self-expandable metallic stents is a safe, nonsurgical, palliative treatment option for unresectable malignant GOOs, with a high clinical success rate and a low rate of serious complications. Stent obstruction and migration are the most common complications, but most can be managed by interventional treatments. Although there have been substantial developments in stent design over the past decade, large prospective, randomized studies are required to determine the ideal stent for malignant GOOs.

Clinical outcomes of self-expandable metal stents in palliation of malignant anastomotic strictures caused by recurrent gastric cancer

AIM: To examine the technical feasibility and clinical outcomes of the endoscopic insertion of a self-expandable metal stent (SEMS) for the palliation of a malignant anastomotic stricture caused by recurrent gastric cancer.

METHODS: The medical records of patients, who had obstructive symptoms caused by a malignant anastomotic stricture after gastric surgery and underwent endoscopic insertion of a SEMS from January 2001 to December 2007 at Kangnam St Mary’s Hospital, were reviewed retrospectively.

RESULTS: Twenty patients (15 male, mean age 63 years) were included. The operations were a total gastrectomy with esophagojejunostomy (n = 12), subtotal gastrectomy with Billroth-I reconstruction (n = 2) and subtotal gastrectomy with Billroth-II reconstruction (n = 8). The technical and clinical success rates were 100% and 70%, respectively. A small bowel or colon stricture was the reason for a lack of improvement in symptoms in 4 patients. Two of these patients showed improvement in symptoms after another stent was placed. Stent reobstruction caused by tumor ingrowth or overgrowth occurred in 3 patients (15%) within 1 mo after stenting. Stent migration occurred with a covered stent in 3 patients who underwent a subtotal gastrectomy with Billroth-II reconstruction. Two cases of partial stent migration were easily treated with a second stent or stent repositioning. The median stent patency was 56 d (range, 5-439 d). The median survival was 83 d (range, 12-439 d).

CONCLUSION: Endoscopic insertion of a SEMS provides safe and effective palliation of a recurrent anastomotic stricture caused by gastric cancer. A meticulous evaluation of the presence of other strictures before inserting the stent is essential for symptom improvement.

Metallic stent placement in the palliative treatment of malignant gastric outlet obstructions: primary gastric carcinoma versus pancreatic carcinoma

OBJECTIVE

The objective of our study was to compare the clinical effectiveness of metallic stent placement for relief of gastric outlet obstruction caused by gastric carcinoma and pancreatic carcinoma.

MATERIALS AND METHODS

A total of 207 patients with gastric outlet obstruction caused by inoperable gastric carcinoma (n = 147) or pancreatic carcinoma (n = 60) underwent metallic stent placement.

RESULTS

Technical success of metallic stent placement was achieved in all patients. Clinical success was achieved in 97% and 93% of patients with gastric and pancreatic carcinoma, respectively (p = 0.286). The overall complication rate did not differ significantly between the gastric (29%) and pancreatic (23%) carcinoma groups (p = 0.441). Stent collapse was significantly more frequent in the gastric carcinoma group (11%) than the pancreatic carcinoma group (2%) (p = 0.027), whereas serious complications, including gastrointestinal bleeding and intestinal perforation, occurred more frequently in the pancreatic (7%) than the gastric (1%) carcinoma group (p = 0.026). The cumulative survival period was significantly longer in the gastric carcinoma (median, 153 days) than the pancreatic carcinoma (median, 90 days) group (p = 0.041), but cumulative stent patency did not differ significantly between the gastric carcinoma (median, 350 days) and pancreatic carcinoma (median, 385 days) groups (p = 0.415).

CONCLUSION

Metallic stent placement was clinically effective in the palliative treatment of gastric outlet obstruction in patients with gastric and pancreatic carcinoma. The two groups differed significantly in the rates of stent collapse and serious complications and patient survival after stent placement.