Enteral self-expandable stents

CIRSE Standards of Practice on Placement of Upper Gastrointestinal Stents

BACKGROUND

Image-guided insertion of stents in the upper gastrointestinal trunk is an effective, minimally invasive treatment option to provide immediate relief of symptoms caused by upper gastrointestinal tract obstruction related to advanced-stage malignant causes or benign causes that lead to lumen narrowing.

PURPOSE

This document, as with all CIRSE Standards of Practice documents, is not intended to impose a standard of clinical patient care but will recommend a reasonable approach to best practices for performing stenting of the upper gastrointestinal tract, namely the oesophageal and gastroduodenal segments. Our purpose is to provide up-to-date recommendations for placement of upper gastrointestinal tract stents based on the previously published guidelines on this topic in 2005 and 2007.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of a group of internationally recognised experts in performing upper gastrointestinal stenting. The writing group reviewed the existing literature using PubMed to search for relevant publications in the English language up to September 2021. The final recommendations were formulated through consensus.

CONCLUSION

Insertion of stents in the oesophageal and gastroduodenal tracts has an established role in the successful management of malignant or benign obstructions. This Standards of Practice document provides up-to-date recommendations for the safe performance of upper gastrointestinal stent placement.

Impact of endoscopic metallic stent placement and emergency surgery on detection of viable circulating tumor cells for acute malignant left-sided colonic obstruction

BACKGROUND

Self-expanding metal stents (SEMS) served as a bridge to surgery (BTS). However, this method may be associated with worse long-term prognosis and relapse of CRC patients. Therefore, we attempted to clarify this in the angle of circulating tumor cells (CTCs).

METHODS

A multicenter study was performed from March 2018 to January 2021. Thirty-two colorectal cancer patients with obstruction were selected, of which 21 patients were performed SEMS as a BTS while 11 patients were performed emergency surgery. Bloods samples were collected in two groups of patients for further detecting CTCs. In the SEMS group, the samples were collected before and after stent insert and after radical surgery performed. In the ES group, the samples were collected before stent insert and after emergency surgery performed.

RESULTS

The number of CTCs did not show statistically significant differences before and after stent placement (34.90 vs 38.33, p=0.90), neither between the SEMS group and ES group in initial CTC levels (34.90 vs 58.09, p=0.394). No significant differences (38.33 vs 58.09, p=0.632) were observed after stent insert in the SMES group and the initial CTC levels in the ES group. Moreover, no major differences (24.17 vs 42.27, p=0.225) were observed after radical operation performed in both groups.

CONCLUSION

The treatment of SEMS does not cause an increase in the number of CTC after stent insertion. Furthermore, there are may be other factors besides CTC to cause these poorer oncologic outcomes after SEMS placement.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.

Colonic Stent as Bridge to Surgery for Malignant Obstruction Induces Gene Expressional Changes Associated with a More Aggressive Tumor Phenotype

BACKGROUND

Colonic stent is recommended as a bridge to elective surgery for malignant obstruction to improve short-term clinical outcomes for patients with colorectal cancer. However, since the oncological outcomes remain controversial, this study aimed to investigate the impact of self-expandable metallic stent (SEMS) on the tumor microenvironment.

METHODS

Patients treated with colonic stent as a bridge to surgery from 2010 to 2015 were identified from hospital records. Tumor biopsies and resected tumor samples of the eligible patients were retrieved retrospectively. Gene expression analysis was performed using the NanoString nCounter PanCancer IO 360 gene expression panel.

RESULTS

Of the 164 patients identified, this study included 21 who underwent colonic stent placement as a bridge to elective surgery. Gene expression analysis revealed 82 differentially expressed genes between pre- and post-intervention specimens, of which 72 were upregulated and 10 downregulated. Among the significantly upregulated genes, 46 are known to have protumor functions, of which 26 are specifically known to induce tumorigenic mechanisms such as proliferation, migration, invasion, angiogenesis, and inflammation. In addition, ten differentially expressed genes were identified that are known to promote antitumor functions.

CONCLUSION

SEMS induces gene expressional changes in the tumor microenvironment that are associated with tumor progression in colorectal cancer and may potentiate a more aggressive phenotype. Future studies are warranted to establish optimal timing of surgery after SEMS insertion in patients with obstructive colorectal cancer.

Propensity score-matched comparison of stenting as a bridge to surgery and emergency surgery for acute malignant left-sided colonic obstruction

Background

Bridge to elective surgery (BTS) using self-expanding metal stents (SEMSs) is a common alternative to emergency surgery (ES) for acute malignant left-sided colonic obstruction (AMLCO). However, studies regarding the long-term impact of BTS are limited and have reported unclear results.

Methods

A multicenter observational study was performed at three hospitals from April 2012 to December 2019. Propensity score matching (PSM) was introduced to minimize selection bias. The primary endpoint was overall survival. The secondary endpoints included surgical approaches, primary resection types, total stent-related adverse effects (AEs), surgical AEs, length of hospital stay, 30-day mortality and tumor recurrence.

Results

Forty-nine patients in both the BTS and ES groups were matched. Patients in the BTS group more often underwent laparoscopic resection [31 (63.3%) vs. 8 (16.3%), p < 0.001], were less likely to have a primary stoma [13 (26.5%) vs. 26 (53.1%), p = 0.007] and more often had perineural invasion [25 (51.0 %) vs. 13 (26.5 %), p = 0.013]. The median overall survival was significantly lower in patients with stent insertion (41 vs. 65 months, p = 0.041). The 3-year overall survival (53.0 vs. 77.2%, p = 0.039) and 5-year overall survival (30.6 vs. 55.0%, p = 0.025) were significantly less favorable in the BTS group. In multivariate Cox regression analysis, stenting (hazard ratio(HR) = 2.309(1.052–5.066), p = 0.037), surgical AEs (HR = 1.394 (1.053–1.845), p = 0.020) and pTNM stage (HR = 1.706 (1.116–2.607), p = 0.014) were positively correlated with overall survival in matched patients.

Conclusions

Self-expanding metal stents as “a bridge to surgery” are associated with more perineural invasion, a higher recurrence rate and worse overall survival in patients with acute malignant left-sided colonic obstruction compared with emergency surgery.

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.

Management of gastric outlet obstruction: Focusing on endoscopic approach

Gastric outlet obstruction (GOO) is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction. The obstructions typically involved in GOO can be benign or malignant. Peptic ulcer disease is the most common cause of benign GOO, and malignant causes include gastric cancer, lymphoma, and gastrointestinal stromal tumor. With the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors, the predominant causes have changed from benign to malignant diseases. Treatment of GOO depends on the underlying cause: Proton pump inhibitors, H. pylori eradication, endoscopic treatments including balloon dilatation or the placement of self-expandable stents, or surgery.

Comparison of big funnel and individualized stents for management of stomach cancer with gastric outlet obstruction

BACKGROUND

Previous studies reported a similar rate of complications, including stent migration and obstruction, between individualized stents and the standard uncovered stents in gastric outlet obstruction (GOO) caused by distal stomach cancer. The objective of this study was to evaluate the efficacy and safety of funnel stents for management of GOO caused by distal stomach cancer.

METHODS

This study was designed as a multicenter, controlled, prospective, and randomized clinical trial involving 4 hospitals. The individualized stent group (44 cases) received cup and funnel covered stents, and the funnel group (44 cases) received only funnel covered stents for management of GOO caused by distal gastric cancer.

RESULTS

All patients with GOO were treated with cup and funnel stents according to their assigned groups. The rate of GOO resolution was 100% in the funnel group and 97.7% in the individualized stent group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group, and proximal partial stent migration was observed in 1 patient in each group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group. There was no statistical difference in stent migration, obstruction, and survival between groups.

CONCLUSION

Big funnel stents and individualized stents resulted in similar shaping effect and prevention of stent migration and obstruction, suggesting that funnel shaped stents can be used to treat cup or funnel shaped GOO caused by distal stomach cancer.

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis, a novel technique for malignant obstruction: A case report and review of literature

For patients suffering from both biliary and duodenal obstruction, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the treatment of choice. ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct (CBD). We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma. The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.

Fluoroscopy-Guided Peroral Placement of a Self-Expandable Metallic Stent for Malignant Jejunal Obstruction in a Non-surgically Altered Stomach

Malignant small bowel obstruction is a common and distressing complication in advanced cancer patients. Recently, stent placement was reported to be a safe and effective alternative treatment. However, there are only a few case reports associated with stent placement in malignant jejunal obstruction. Furthermore, most patients had a history of gastrectomy before stent placement, which shortens the catheterization pathway. In our case series, we present five cases of malignant proximal jejunal obstruction in a non-surgically altered stomach in the management of fluoroscopy-guided self-expandable metallic stent placement and discuss the interventional management and clinical outcomes. LEVEL OF EVIDENCE: Level 4, Case Series.

Fluoroscopic Gastroduodenal Stent Placement in 55 Patients with Endoscopic Stent Placement Failure

PURPOSE

To evaluate the technical feasibility and clinical effectiveness of fluoroscopic self-expandable metal stent (SEMS) placement in malignant gastroduodenal obstructions after failed endoscopic SEMS placement.

MATERIALS AND METHODS

Between September 2010 and July 2017, 874 patients underwent endoscopic SEMS placement for dysphagia caused by malignant gastroduodenal obstructions. Endoscopic SEMS placement failed in 55 of 874 patients (6.3%). These patients were referred for fluoroscopic SEMS placement. In case of failed fluoroscopic SEMS placement, combined endoscopic and fluoroscopic SEMS placement was attempted at the same setting.

RESULTS

Fluoroscopic SEMS placement was technically successful in 40 of 55 patients (72.7%). Combined endoscopic and fluoroscopic SEMS placement was technically successful in 6 of 15 patients with fluoroscopic SEMS placement failure. Failures in the nine patients were due to complete obstruction (n = 5) and acute angulation at the stricture site (n = 4). The overall technical success rate was 83.6% (46/55). Clinical success was achieved in 95.6% of patients (44/46). Complications occurred in 7 of 46 patients (15.2%), including tumor overgrowth (n = 3), SEMS migration (n = 3), and bleeding (n = 1). The median SEMS patency and patient survival periods were 515 (95% confidence interval (CI), 266.6-761.5) and 83 (95% CI 60.6-105.4) days, respectively.

CONCLUSIONS

Fluoroscopic SEMS placement is technically feasible and clinically effective in cases of endoscopic SEMS placement failure. A combined endoscopic and fluoroscopic approach increases the technical success rate after failure of the endoscopic or fluoroscopic approach.

LEVEL OF EVIDENCE

Level IV.

Fluoroscopic-guided stent placement in failed tentative endoscopic approaches to malignant gastroduodenal obstructions

Background Fluoroscopic or endoscopic placement of metallic stents is used as a safe, non-surgical, palliative treatment option for malignant gastroduodenal obstructions. However, endoscopic stent placement is not always feasible, due to the tight or tortuous stricture of the obstructed area and insufficient visualization of the stomach due to remnant food material. Purpose To assess the technical feasibility and clinical outcomes of fluoroscopic-guided stent placement in malignant gastroduodenal obstructions following the technical failure of endoscopic stent placement. Material and Methods In all, 19 patients (14 men, 5 women; age range, 36-85 years) were referred due to technical failures of tentative endoscopic stent placement. Indications were failure to pass the guide wire through the obstruction (n = 13), failure to reach the stricture lesion due to short endoscope (n = 5), and acute angulation of the stricture lesion (n = 1). Data were retrospectively collected regarding the technical and clinical success of the fluoroscopy, the dysphagia score before and after stent placement, and major complications and their management. Results Fluoroscopic stent placement was technically successful in 15/19 patients (79%). Failures were due to complete obstruction (n = 3) and acute angulation of the stricture lesion (n = 1). Clinical success was achieved in all 15 patients with successful stent placement. The dysphagia score significantly improved after stent placement ( P < 0.001). Complications occurred in 4/15 patients (27%), including tumor overgrowth (n = 2), stent collapse (n = 1), and jaundice (n = 1). Conclusion Fluoroscopic stent placement in malignant gastroduodenal obstructions following a technical failure of endoscopic stent placement is technically feasible and has an acceptable clinical outcome.

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.

Delay of surgery after stent placement for resectable malignant colorectal obstruction is associated with higher risk of recurrence

BACKGROUND

Self-expanding metal stents can be used as bridge to elective surgery for acute malignant colonic obstruction. However, the impact on long-term oncological outcome and the optimal timing of surgery are still unknown.

METHOD

This was a retrospective multicenter study performed at four colorectal centers. Patients undergoing stent placement as bridge to surgery, between January 2010 and December 2013, were included in the study. Primary outcomes were survival and recurrence rates along with location of the metastases. Additionally, we recorded time from stent placement to elective surgery. Secondary outcomes were postoperative complication rates. Complications were classified according to the Clavien-Dindo classification score. A logistic regression model was used to describe impact of delayed stent removal on risk of recurrence.

RESULTS

This study included 112 patients, with a median follow-up of 43 months. Survival rate was 70%. We found a recurrence rate of 37%, primarily local recurrences (17%). Procedure-related complications at the stent placement were seen in 18%, and complications after subsequent elective surgery were seen in 39%. A significantly higher risk of recurrence with increased time from stent placement to elective surgery (OR 5.1 [1.6-15.8], p = 0.005) was found.

CONCLUSION

Delay of elective surgery after stent placement may have a negative influence on long-term oncologic outcomes.

The role of stents in the treatment of Crohn's disease strictures

BACKGROUND AND AIMS

Stenosis is one of the most frequent local complications in Crohn's disease (CD). Surgery is not the ideal treatment because of the high rate of postoperative recurrence. Endoscopic balloon dilation (EBD) currently is the current treatment of choice for short strictures amenable to the procedure. However, it is not applicable or effective in all the cases, and it is not without related complications. Our goal was to summarize the published information regarding the use and the role of the stents in the treatment of CD stricture. A Medline search was performed on the terms "stricture," "stenosis," "stent" and "Crohn's disease."

RESULTS

a total of 19 publications met our search criteria for an overall number of 65 patients. Placing a self-expanding metal stent (SEMS) may be a safe and effective alternative to EBD and/or surgical intervention in the treatment of short stenosis in patients with CD. Indications are the same as those for EBD. In addition, SEMS may be useful in stenosis refractory to EBD and may be suitable in the treatment of longer or more complex strictures that cannot be treated by EBD. With the current information, it seems that the best treatment option is the placement of a fully covered stent for a mean time of 4 weeks. Regarding the use of biodegradable stents, the information is limited and showing poor results.

CONCLUSIONS

the use of stents in the treatment of strictures in CD should be taken into account either as a first endoscopic therapy or in case of EBD failure.

Factors associated with clinical failure of self-expandable metal stent for malignant gastroduodenal obstruction

OBJECTIVE

Endoscopic self-expandable metal stent (SEMS) placement has emerged as an effective palliative treatment for inoperable malignant gastric outlet obstruction (GOO). In spite of successful stent placement, some patients complain of ongoing dysphagia and vomiting. Most reported data on SEMS to date are about technical success of different types of stents and low complication rates. The aim of this study was to evaluate the associated factors of clinical failure after endoscopic SEMS placement for inoperable malignant GOO.

METHODS

A total 122 patients who underwent successful endoscopic SEMS placement for malignant GOO in an academic referral center were included in the analyses. We retrospectively evaluated variables associated with clinical outcomes after successful SEMS placement.

RESULTS

The clinical success rate was 81.1%. The common causes of GOO were pancreatic (39%) and gastric cancers (32%). The mean length of the stents (± standard deviation) was 10.06 ± 2.42 cm. Multivariate analysis revealed that gallbladder cancer (p = 0.016, OR 6.486, 95% CI, 1.509-59.655), poor performance status (ECOG ≥ 3) (p = 0.001, OR 10.200, 95% CI, 2.435-42.721), the presence of carcinomatosis peritonei (p < 0.001, OR 35.714, 95% CI, 5.556-250.000) and the failure of endoscope passage (p = 0.039, OR 6.945, 95% CI, 1.101-43.818).

CONCLUSION

Our results suggest that gallbladder cancer, poor performance status (ECOG ≥ 3) and the presence of carcinomatosis peritonei related with clinical failure of palliative SEMS placement.

Gastroduodenal stent placement versus surgical gastrojejunostomy for the palliation of gastric outlet obstructions in patients with unresectable gastric cancer: a propensity score-matched analysis

OBJECTIVES

To compare the outcomes between stent placement and surgical gastrojejunostomy (GJ) for the palliation of gastric outlet obstruction (GOO) in patients with unresectable gastric cancer.

METHODS

A retrospective study was performed in a single university hospital in 224 patients with GOO, and who were treated either by stent placement (n = 124) or surgical GJ (n = 100). The outcomes were assessed with reference to the following variables with the use of propensity-score matching: success rates; complications; dysphagia scores, albumin, and body mass index; survival; symptom-free duration; and hospitalization.

RESULTS

We identified a well-balanced cohort of 74 pairs of patients, matched on the basis of propensity score. The dysphagia score 7 days after treatment was significantly better in the stent group (P < 0.001). Albumin level 1 month after treatment was significantly lower in the stent group (P < 0.001). Symptom-free duration and hospitalization were significantly longer in the surgery group (P = 0.002, P < 0.001, respectively). The recurrence rate was significantly higher in the stent group (P = 0.032).

CONCLUSIONS

Stent placement can provide faster symptom relief and shorter hospitalization, while surgical GJ can provide longer symptom-free duration, less recurrent obstruction symptoms and better nutritional status.

KEY POINTS

• The two methods are equally effective in palliating gastric outlet obstruction symptoms • The stent group showed rapid and efficient palliation of symptoms • Recurrent symptoms were more frequent in the stent group • Surgical gastrojejunostomy provides a longer symptom-free duration and better nutritional status.

Impact of Carcinomatosis on Clinical Outcomes after Self-Expandable Metallic Stent Placement for Malignant Gastric Outlet Obstruction

BACKGROUND

It is still unclear whether the peritoneal carcinomatosis had a negative effect on the clinical outcomes of patients who underwent self-expandable metallic stent (SEMS) placement for malignant gastric outlet obstruction (GOO). Although carcinomatosis may be associated with the development of multifocal gastrointestinal (GI) tract obstruction or decreased bowel movement, previous studies investigated the occurrence of stent failure only and thus had limitation in evaluating clinical outcomes of patients with carcinomatosis.

METHODS

Between 2009 and 2013, 155 patients (88 patients without carcinomatosis and 67 patients with carcinomatosis) underwent endoscopic SEMS placement for malignant GOO. Factors affecting clinical success and obstructive symptom-free survival (time period between SEMS placement and the recurrence of obstructive symptoms due to multifocal GI tract obstruction or decreased bowel movement as well as stent failure) were assessed.

RESULTS

Patients with carcinomatosis showed higher Eastern Cooperative Oncology Group (ECOG) scale than those without carcinomatosis. Clinical success rates were 88.1% in patients with carcinomatosis and 97.7% in patients without carcinomatosis. In multivariate analysis, only ECOG scale was identified as an independent predictor of clinical success. During follow-up period, patients with carcinomatosis showed significantly shorter obstructive symptom-free survival than those without carcinomatosis. In multivariate analysis, the presence of carcinomatosis, chemotherapy or radiation therapy after SEMS placement, and obstruction site were identified as independent predictors of obstructive symptom-free survival. For patient without carcinomatosis, stent failure accounted for the recurrence of obstructive symptoms in 84.6% of cases. For patients with carcinomatosis, multifocal GI tract obstruction or decreased bowel movement accounted for 37.9% of cases with obstructive symptom recurrence and stent failure accounted for 44.8% of cases.

CONCLUSIONS

Carcinomatosis predicts unfavorable long-term clinical outcomes in patients undergoing SEMS placement for malignant GOO. This is mainly due to the development of multifocal GI tract obstructions or decreased bowel movement as well as stent failure.

Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer

BACKGROUND

Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma.

OBJECTIVE

To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer.

DESIGN

Retrospective study.

SETTING

Single tertiary hospital.

PATIENTS

A total of 292 patients with malignant GOO.

INTERVENTION

Stent placement.

MAIN OUTCOME MEASUREMENTS

Post-stent placement survival and clinical outcome.

RESULTS

In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post-stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post-stent placement chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P < .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009).

LIMITATIONS

Retrospective study.

CONCLUSIONS

In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post-stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post-stent placement survival in both groups.

Colorectal Stents: Current Status

A self-expandable metal stent (SEMS) is an effective and safe method for the decompression of colon obstruction. Based on recent evidence, colorectal SEMS is now recommended for the palliation of patients with colonic obstruction from incurable colorectal cancer or extracolonic malignancy and also as a bridge to surgery in those who are a high surgical risk. Prophylactic SEMS insertion in patients with no obstruction symptoms is not recommended. Most colorectal SEMS are inserted endoscopically under fluoroscopic guidance. The technical and clinical success rates of colorectal SEMS are high, and the complication rate is acceptable. Advances in this technology will make the insertion of colorectal SEMS better and may expand the indications of colorectal SEMS in the future.

Secondary stent-in-stent self-expanding metallic stent placement for early stent occlusion due to mucosal oedema in the gastrojejunal anastomosis after palliative subtotal gastrectomy for locally advanced gastric cancer

Herein, we report a case of early in-stent occlusion due to the ingrowth of soft oedematous mucosal tissue through the lattices of an uncovered stent, which was used for palliation of a postoperative gastrojejunal anastomotic stricture. The in-stent occulsion was treated with the deployment of a second stent, which was covered, within the first stent. This led to successful resolution of the occlusion.

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.

Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy

BACKGROUND

Self-expandable metal stent (SEMS) placement and palliative gastrojejunostomy (GJJ) are palliative treatment options for malignant gastric outlet obstruction.

OBJECTIVE

To compare clinical outcomes of palliative treatments for gastric outlet obstruction caused by unresectable gastric cancer.

DESIGN

Retrospective study.

SETTING

University-affiliated tertiary-care hospital in the Republic of Korea.

PATIENTS

Two hundred fifty-six patients with gastric outlet obstruction caused by unresectable gastric cancer.

INTERVENTION

SEMS placement and palliative GJJ.

MAIN OUTCOME MEASUREMENTS

Patency duration and overall survival duration.

RESULTS

In total, 217 and 39 patients underwent SEMS placement and palliative GJJ, respectively, as an initial palliative treatment. Treatment modality affected reobstruction after clinical success (hazard ratio [HR] [95% confidence interval {CI}], 0.5 [0.3-0.8] of palliative GJJ). In addition, carcinomatosis with ascites was an independent associated factor of clinical success and reobstruction (HR [95% CI], 0.3 [0.1-0.7] and 1.4 [1.0-2.0], respectively). In a subgroup of patients with good performance who had neither carcinomatosis nor ascites, patency duration and overall survival duration did not differ between the 2 groups (P = .079 and P = .290, respectively). In patients with good performance who had carcinomatosis without ascites, patency duration was longer in the palliative GJJ group than in the SEMS placement group (P = .016). Overall survival, however, did not differ between the 2 groups (P = .062). In a subgroup of patients with good performance who had carcinomatosis with ascites, both patency duration and overall survival were longer in the palliative GJJ group than in the SEMS placement group (P = .007 and P = .012, respectively).

LIMITATIONS

Nonrandomized, retrospective study.

CONCLUSION

Long-term clinical outcomes of the palliative treatment modality for gastric outlet obstruction caused by unresectable gastric cancer were affected by carcinomatosis and ascites status.

Percutaneous biliary covered stent insertion in patients with malignant duodenobiliary obstruction

BACKGROUND

Although the use of polytetrafluoroethylene (PTFE)-covered biliary stents has proven to be feasible for the treatment of benign and malignant biliary disease, less is known regarding the outcomes of percutaneous placement of a covered stent in patients with malignant duodenobiliary obstruction.

PURPOSE

To investigate the technical and clinical efficacy of the percutaneous placement of a PTFE-covered biliary stent in patients with malignant duodenobiliary obstruction.

MATERIAL AND METHODS

From April 2007 to September 2012, the medical records of 45 consecutive patients with malignant duodenobiliary obstruction were retrospectively reviewed. All percutaneous biliary stent deployment was performed using PTFE-covered stents, whereas duodenal stent insertion was performed either fluoroscopically or endoscopically using covered or uncovered stents.

RESULTS

Biliary stent deployment was technically successful in all patients. None of the stents migrated after deployment. Procedure-related minor complications, including self-limiting hemobilia, occurred in three (7%) patients. Successful internal drainage was achieved in 39 (87%) of the 45 patients. The median survival time after biliary stent placement was 62 days (95% confidence interval, 8-116 days), and the cumulative stent patency rates at 1, 3, 6, and 12 months were 96%, 92%, 75%, and 38%, respectively. The causes of biliary stent dysfunction included stent occlusion caused by a subsequently inserted duodenal stent (n = 7), food impaction (n = 3), and sludge incrustation (n = 1). One patient developed acute cholecystitis 131 days after biliary stent placement and underwent percutaneous transhepatic gallbladder drainage.

CONCLUSION

Percutaneous insertion of a PTFE-covered stent is a safe and effective method for palliative treatment of patients with malignant duodenobiliary obstruction. If possible, subsequent biliary stent insertion is preferable in order to prevent possible biliary stent dysfunction caused by subsequent insertion of a duodenal stent.

Use of self-expanding covered stent and negative pressure wound therapy to manage late rectal perforation after injury from an improvised explosive device: a case report

Blast injuries, caused by explosions accompanied by high-pressure waves, produce tissue damage in the acute period, followed in the later period by circulatory disorders due to vascular endothelial damage and related tissue necrosis. Blunt rectal perforation is rare and difficult to diagnose. In the acute period following blast pelvic injuries, the main objectives are to stop bleeding, minimise contamination and preserve the patient's life. The patient in this report had major vascular injuries, severe pelvic injury and, in the later period, rectal perforation because of vascular endothelial damage caused by the blast effect. Our aim was to treat the patient conservatively because of his poor general condition. We placed a self-expanding covered stent (SECS) into the rectum and then applied negative pressure wound therapy (NPWT; V.A.C.® Therapy, KCI) to the pelvic region and perirectal area. At the end of the treatment, the rectal perforation was closed, and the patient was discharged with healing. In this article, we discuss the novel use of an SECS with NPWT and review related literature.

A One-step Procedure by Using Linear Echoendoscope to Perform EUS-guided Choledochoduodenostomy and Duodenal Stenting in Patients with Irresectable Periampullary Cancer

Objective:

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CD) has become an alternative method after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) treatment. We present a case series study and its feasibility by using only a linear therapeutic channel echoendoscope to create both a biliary-enteral fistula and anatomic enteral recanalization.

Methods:

We presented seven cases of unresectable periampullary cancer with both biliary and duodenal obstruction. In these cases, the EUS-guided technique might be an alternative to double stenting (biliary and enteral) in the same procedure and equipment.

Results:

In all cases, the location of the biliary obstruction was in the distal common bile duct (CBD) and the grade of proximal dilation diameter varied from 15 mm to 20 mm. Two patients had type I (28.6%) and five had type II (71.4%) duodenal obstruction. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Biliary drainage was effective clinically as well as in laboratory in 6 cases (6/7), by relieving obstructive jaundice and decreasing bilirubin levels.

Conclusion:

EUS equipment may offer an alternative to double stenting in the same procedure and with palliative propose.

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.

Decompression of acute left-sided malignant colorectal obstruction: comparing transanal drainage tube with metallic stent

BACKGROUND AND AIM

Acute left-sided colorectal malignant obstruction is a life-threatening condition and need emergent treatment. Many nonsurgical treatments to palliate obstruction have been developed in clinics. The aim of this study was to evaluate the clinical effects of transanal drainage tube (TDT) and metallic stent for the decompression of acute left-sided malignant colorectal obstruction.

MATERIALS AND METHODS

Twenty-nine patients with acute left-sided malignant colorectal obstruction were enrolled in this study from January 2005 to December 2010, they were randomly divided into TDT group (13 patients) and metallic stent group (16 patients).

RESULTS

There were 13 cases in TDT group (male:female=8:5, age from 65 to 80 y, mean age was 72.6±4.7 y). The sites of lesions were located in the rectum of 3 patients, sigmoid colon of 7 patients, and descending colon of 3 patients. TDT was successfully inserted in 11 cases (84.6%). Among the 11 patients, 1-stage operation with sufficient lymph node dissection was performed in 8 cases after adequate lavage without complications. One case underwent emergent Hartmann operation because of colonic tumor perforation 3 days after ileus tube decompression. Two cases were discharged without surgery after relief of symptom. There were 16 cases in the metallic stent group (male:female=10:6 age from 48 to 86 y, mean age was 73.3±8.5 y). The sites of the lesions were located in the rectum of 4 patients, sigmoid colon of 6 patients, and descending colon of 6 patients. Successful stent placement was achieved in 13 cases (81.3%) with no severe complications. Among the 13 patients, 1-stage operation with sufficient lymph node dissection was performed in 7 cases and 6 cases refused to underwent surgery with stent as the definitive palliative treatment. The price of a TDT is only one third of an expandable metallic stent.

CONCLUSIONS

Both TDT and metallic stent can achieve preoperative colonic lavage for 1-stage operation for patients with acute left-sided malignant colorectal obstruction with no increase in complications.

Ultrathin endoscope-assisted self-expandable metallic stent placement following initial unsuccessful attempt in malignant upper gastrointestinal obstruction

BACKGROUND

Conventional endoscopy for self-expandable metallic stent (SEMS) placement may be technically limited in long and tortuous strictures. Therefore, we analyzed the feasibility, safety and usefulness of ultrathin endoscopy (UTE)-guided SEMS placement.

PATIENTS AND METHODS

This study involved 24 patients with upper gastrointestinal obstruction and unsuccessful initial attempts to place SEMS using conventional endoscopy. After completely passing a UTE across the stricture, the UTE was withdrawn, leaving a guidewire placed via the working channel. Through-the-scope SEMS placement was done using a conventional endoscope inserted along the guidewire. The primary endpoints were assessed by technical/clinical success and stent patency duration.

RESULTS

Stents were successfully placed at target locations in all but one case with a long tortuous stricture, with 95.8% (23/24) technical success. One week after stent placement, mean gastricoutlet obstruction score improved significantly from baseline (1.74 ± 0.62 and 0.33 ± 0.48, respectively; P < 0.001). Stent migration, restenosis, and fracture occurred in four (17.4%), six (26.1%), and one (4.3%) of 23 stents, respectively. Median stent patency duration was 79 days. Mean stent patency was significantly longer in patients who received palliative chemotherapy than in those who did not (122.9 ± 11.0 and 38.3 ± 4.6, respectively; P < 0.001).

CONCLUSIONS

UTE guidance SEMS delivery can be a feasible and safe rescue treatment method for malignant upper gastrointestinal obstruction in cases of failed attempts to place SEMS using conventional endoscopy. Our result warrants a further study to define the efficacy of this method in difficult SEMS placement cases.

Carcinomatosis matters: clinical outcomes and prognostic factors for clinical success of stent placement in malignant gastric outlet obstruction

BACKGROUND

Although carcinomatosis is not a contraindication to stenting in selected patients with malignant gastric outlet obstruction (GOO), associate factors for clinical success rate of self-expandable metallic stent (SEMS) placement in GOO patients with carcinomatosis have not been fully characterized.

METHODS

We analyzed a total 228 patients who were scheduled for SEMS placement for malignant GOO in tertiary-care academic medical center. All patients were treated with an uncovered or covered SEMS by using the over-the-wire placement procedure. We retrospectively evaluated clinical outcomes of SEMS placement.

RESULTS

Technical success was achieved in all patients. Patients were categorized into two groups according to the presence of carcinomatosis. Clinical success rates of patients without carcinomatosis group and with carcinomatosis group were 93.9 % (92 of 98) and 80.8 % (105 of 130), respectively (P = 0.004). In subgroup analysis of patients with carcinomatosis, the clinical success rate was lower in patients with ascites (64.8 %) than in those without ascites (92.1 %, P < 0.001). Multivariate logistic regression model revealed that carcinomatosis without ascites did not decrease clinical success rate compared with absence of carcinomatosis; meanwhile, carcinomatosis with ascites showed lower clinical success rates compared with absence of carcinomatosis (adjusted odds ratio 0.163, 95 % confidence interval 0.058-0.461). In addition, poor performance status [Eastern Cooperative Oncology Group (ECOG) status ≥ 3, adjusted odds ratio 0.178, 95 % confidence interval 0.078-0.409] was also an independent poor predictive factor for clinical success of SEMS placement.

CONCLUSIONS

In palliation for malignant GOO, the status of carcinomatosis with ascites and poor performance status (ECOG status ≥ 3) are significant predictive factors for poor clinical success of SEMS placement.

Therapeutic endoscopy and endoscopic ultrasound for gastrointestinal malignancies

Gastrointestinal endoscopy and endoscopic ultrasound not only provide strategies to diagnose and stage malignancy, but also to administer palliative and definitive care. Options for anticancer therapy include endoscopic mucosal resection, photodynamic therapy, thermal therapy, self-expanding metal stents and recently, endoscopic ultrasound-guided therapy, such as intratumoral injection. This review summarizes the available endoscopic techniques with a discussion of indications and recent clinical data pertaining to gastrointestinal malignancy. This review will inform the reader of emerging treatment options and stress the importance of incorporating gastroenterologists into the multidisciplinary approach in the management of gastrointestinal cancers.

Endoscopic ultrasound-guided choledochoduodenostomy and duodenal stenting in patients with unresectable periampullary cancer: one-step procedure by using linear echoendoscope

OBJECTIVE

Describe a case series of endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CD) associated with duodenal self-expandable metal stents (SEMS) placement using solely the linear echoendoscope in seven patients with obstructive jaundice and duodenal obstruction due to unresectable periampullary cancer.

MATERIAL AND METHODS

EUS-CD in the first portion of the duodenum, associated with duodenal SEMS placement was performed in seven patients with unresectable periampullary cancer with obstructive jaundice and invasive duodenal obstruction. Laboratory tests and clinical follow-up were performed until patient's death. The procedure was performed by an experienced endoscopist under conscious sedation. The puncture position was chosen based on EUS evaluation, at the common bile duct (CBD) above the tumor, through the distal part of the duodenal bulb. After that, the needle was withdrawn and a wire-guided needle knife was used to enlarge the site puncture in the duodenal wall. Then, a partially covered SEMS was passed over the guide, through the choledochoduodenal fistula. Duodenal SEMS placement was performed during the same endoscopic procedure.

RESULTS

The procedure was performed in seven patients, ranging between 34 and 86 years. Technical success of EUS-CD, by the stent placement, occurred in 100% of the cases. There were no early complications. Duodenal SEMS placement was effective in 100% of the cases that remained alive after a follow-up of 7 and 30 days.

CONCLUSION

The results suggest therapeutic EUS one-step procedure drainage as an alternative for these patients, with good clinical success, feasible technique and safety.

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.

Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction

BACKGROUND AND AIMS

Endoscopic placement of enteral self-expandable metallic stents is an alternative to surgical gastrojejunostomy (GJ) for palliation of malignant gastric outlet obstruction (GOO). Factors associated with clinical outcomes are not known. The aims of this study are to compare the overall complication rate and effectiveness (duration of oral intake) between endoscopic stenting (ES) and GJ in patients with GOO and identify predictors of clinical outcomes.

PATIENTS AND METHODS

This was a retrospective cohort study at a single tertiary academic center. Patients who underwent ES or GJ for treatment of GOO between 1/2001 and 12/2010 were identified using an institutional claims database. The electronic medical records for each patient were reviewed. Univariate and multivariate logistic regression analyses were performed to study the association of treatment outcomes with patient factors and cancer therapy.

RESULTS

120 patients had ES while 227 had GJ. Technical success was higher for GJ (99 vs. 96 %, p = 0.004). Complication rates were higher in the GJ group (22.10 vs. 11.66 %, p = 0.02). Reintervention was more common with ES [adjusted odds ratio (OR) 9.18, p < 0.0001]. Mean length of hospital stay (LOHS) was shorter (adjusted p = 0.005) in the ES compared with the GJ group. However, mean hospital charges, including reinterventions, were greater in the ES group (US $34,250 vs. US $27,599, p = 0.03). ES and GJ had comparable reintervention-free time in patients who had reintervention (88 vs. 106 days, respectively, p = 0.79). Chemotherapy [adjusted hazard ratio (HR) 3 > 0.57, p = 0.04] and radiation therapy (adjusted HR 0.35, p = 0.03) were associated with significantly longer duration of oral intake after ES or GJ.

CONCLUSION

ES is associated with fewer complications, shorter LOHS, but higher reintervention rates and overall charges.

Uncovered self-expandable metallic stent placement as a first-line palliative therapy in unresectable malignant duodenal obstruction

OBJECTIVE

To report treatment outcomes and complications of uncovered self-expandable metallic stents (SEMS) as a first-line therapy for inoperable malignant duodenal obstructions in our hospital.

METHODS

A retrospective analysis was performed in patients who had undergone placement of uncovered SEMS as a first-line therapy for inoperable malignant duodenal obstruction from August 2001 to July 2011. Treatment outcomes and complications of the procedures were investigated.

RESULTS

In total, 47 patients (25 men; mean age 65 years) underwent the procedure. The technical and clinical success rates were 93.6% and 83.0%, respectively. Early complications occurred in 8 patients, including two guidewire-induced micro-perforations and six pancreatitis. All these 8 patients recovered with conservative treatment. Six late complications requiring additional procedures consisted of five stent occlusions due to tumor ingrowth and one stent migration. Four stent occlusions and one migration were treated by the placement of an additional covered stent and the remaining case was treated by balloon dilatation. The median primary stent patency period and median survival period after primary stent placement were 103 days and 131 days, respectively.

CONCLUSIONS

Uncovered SEMS placement is effective as a first-line palliative therapy for inoperable malignant duodenal obstruction. Complications such as stent occlusion or migration can be easily managed with additional covered SEMS.

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.

Predictive factors of solid food intake in patients with malignant gastric outlet obstruction receiving self-expandable metallic stents for palliation

AIM

As for self-expandable metallic stents (SEMS) for malignant gastric outlet obstruction (GOO), some predictive factors of stent patency have been reported, although re-canalization of GOO by SEMS does not necessarily lead to favorable food intake. Therefore, we analyzed the predictive factors of oral food intake following SEMS placement.

METHODS

A total of 97 consecutive patients in whom SEMS were placed for malignant GOO in five hospitals were included in this retrospective study. Clinical outcomes and predictive factors influencing solid food intake were analyzed.

RESULTS

The technical and clinical success rates were 97.9% and 87.6%, respectively. The mean gastric outlet obstruction scoring system (GOOSS) improved from 0.39 to 2.24 after SEMS placement (P<0.01). The median eating period was 2.1 months (95% CI, 1.1-3.0 months), and the median survival time was 3.1 months (95% CI, 2.0-4.2 months). A Karnofsky performance status of ≤ 50 (odds ratio, 3.65; 95% CI, 1.17-13.1; P=0.03) and ascites (odds ratio, 3.28; 95% CI, 1.23-9.05; P=0.02) were identified as statistically significant independent poor predictive factors of solid food intake.

CONCLUSION

SEMS is an effective treatment for patients with malignant GOO. Ascites and a poor performance status were poor predictive factors of solid food intake.

Oral intake throughout the patients' lives after palliative metallic stent placement for malignant gastroduodenal obstruction: a retrospective multicentre study

OBJECTIVES

Patients with inoperable malignant gastric outlet obstruction (GOO) have been managed with self-expandable metal stents to improve oral intake. Recent studies have shown conflicting results on the capacity of self-expandable metal stents to restore food intake in the long term. This study evaluated the clinical effectiveness of enteral stent placement for GOO throughout the patients' lives.

METHODS

This was a multicentre, retrospective study with a long-term follow-up of 74 patients who underwent enteral stenting for symptomatic GOO. Data were collected to analyse improvements in oral intake for the patients' entire lives as assessed by the GOO scoring system (GOOSS), technical success, stent patency, complications, the need for reintervention, survival and the prognostic factors associated with stent patency.

RESULTS

Technical and clinical success was achieved in 100 and 97.2% of the patients, respectively. A total of 71/74 patients (95.9%) continued oral intake for the rest of their lives and 58/74 patients (78.4%) needed no further intervention until death. Solid food intake (GOOSS 2-3) continued until death in 47/74 patients (63.5%). The GOOSS score improved (P<0.001) during the follow-up compared with the baseline. The median survival and the mean stent patency were 8 and 76.6 weeks, respectively. The complication rate was 18.9%. Malignant stent reobstruction was observed in 7/74 patients (9.5%). A Cox multivariate analysis showed that duodenal location of the obstruction was the only independent factor associated with stent patency (hazard ratio=5.28; 95% confidence interval=1.14-24.45; P=0.033).

CONCLUSION

Enteral stenting in patients with unresectable GOO is safe and clinically effective. Ninety-five per cent of patients are able to resume oral intake for the rest of their lives, and the great majority remain free from further intervention. In approximately two-thirds of patients, solid food intake continues until death.

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.

Endoscopic palliation of pancreatic cancer

There is no doubt that our long-range goal is to cure pancreatic cancer. Realistically, most of what we can do currently is treat the disabling symptoms of this dreadful disease. Biliary decompression, intestinal stenting, celiac plexus neurolysis, and fiducial placement are some of the endoscopic procedures that aim to provide better quality of life to patients suffering from this disease. A thorough understanding of these options will help patients make good decisions in choosing the proper treatment. Endoscopists who perform these procedures must possess great skills, but importantly, they must also be compassionate and act with good judgment.

Use of bio-degradable stents for the treatment of refractory benign gastrointestinal stenoses

Bio-degradable stents are be made of different synthetic polymers (like polylactide or polyglycolide) or their co-polymers (polydioxanone). They can be used for treating benign stenoses of the small and large intestine, particularly in Crohn's disease. Endoscopic introduction of bio-degradable stents into small and large intestinal stenoses is feasible and relatively simple. Initial results are encouraging and the complication rate is low. However, there are still some difficulties that need to be overcome. The rate of early stent migration is still rather high (up to one third of patients). This might be solved by changes in the shape or rigidity of the stents as well as by further improvement in the design. Proof of long-term efficacy and safety requires further studies.

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.

A comparative study between fluoroscopic and endoscopic guidance in palliative esophageal stent placement

Self-expanding metallic stents (SEMS) are the treatment of choice for incurable obstructive malignant esophageal strictures. Although the placement of SEMS is usually performed with fluoroscopic control (FC), recently several authors have shown the feasibility of placing SEMS under endoscopic control alone (EC). However, studies comparing the two techniques are lacking. The objective of this study was to compare the feasibility and safety of SEMS insertion under fluoroscopic control and endoscopic control. The study was performed through the retrospective analysis of patients who underwent SEMS insertion for malignant dysphagia between January 2005 and January 2010. Data concerning early and late complications and survival were retrieved. Early complications were defined as pain, vomiting, bleeding, malposition/migration, perforation, and/or dysphagia occurring until 30 days of SEMS insertion; and late complications as tumor ingrowth and overgrowth, migration, hemorrhage, fistulae, food impaction, and/or esophagitis occurring after 30 days. We placed 126 SEMS of which 87% for esophageal stricture, 8% for esophagus-respiratory fistula, and 5% for extrinsic compression. The mean age of the patients was 62 years, and 93 were male. SEMS insertion was performed with FC in 66 patients and EC in 60. Early complications occurred in 34 patients (52%) in the FC group and 28 (47%) in the EC group (P=0.71), including: pain in 22 patients of the FC group and 15 of the EC group (P=0.31); vomiting in 15 of the FC group and nine of the EC group (P=0.27); malposition/migration in three of the FC group and four of the EC group (P=0.60); hemorrhage in one of the FC group and two of the EC group (P=0.27); and dysphagia in two of the FC group and three of the EC group (P=0.57). Late complications occurred in 20 patients (30%) in the FC group and 22 (37%) in the EC group (P=0.44), including: tumor in/overgrowth in 13 patients of the FC group and 10 of the EC group (P=0.66); prostheses migration in five of the FC group and eight of the EC group (P=0.28); hemorrhage in two of the FC group and two of the EC group (P=0.54); appearance of esophageal fistulae in seven of the FC group and four of the EC group (P=0.43); food impaction in nine of the FC group and eight of the EC group (P=0.96); esophagitis in 12 of the FC group and 15 of the EC group (P=0.35). Median survival was 107 days (95% confidence interval [CI]=6-369 days) with no difference between the two groups. There were no statistical significant differences in the incidence of complications and in survival between patients undergoing SEMS placement under fluoroscopic control or endoscopic control.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.