Tumor overgrowth after expandable metallic stent placement: experience in 583 patients with malignant gastroduodenal obstruction. AJR Am J Roentgenol. 2011;196:W831-W836. [PMID: 21606277 DOI: 10.2214/ajr.10.5861]

[Percutaneous Transgastric Stent Placement for Malignant Gastroduodenal Obstruction]

PURPOSE

To evaluate the technical feasibility and clinical efficacy of percutaneous transgastric stent placement after the failure of treatment attempt with the transoral approach in malignant gastroduodenal obstruction patients.

MATERIALS AND METHODS

From October 2008 to April 2016, nine patients (M:F = 4:5; mean age = 66 years) with malignant gastroduodenal obstruction underwent stent placement via a gastrostomy tract, which was attributed to the failure of the transoral approach. The primary etiologies of the obstruction were pancreatic (n = 5), gastric (n = 2), and metastatic (n = 2) cancers. Through percutaneous gastrostomy, dual stents (inner bare metal and outer polytetrafluoroethylene-covered) were deployed at the obstruction site. The technical and clinical success rates, as well as complications were evaluated during the follow-up period.

RESULTS

Stents were successfully inserted in eight patients (88%). We failed to insert stent in one patient due to the presence of a tight obstruction. After stent placement, symptoms improved in seven patients. Gastrostomy tube was removed 9 to 20 days (mean = 12 days) after the stent insertion. During the mean follow-up of 136 days (range, 3-387 days), one patient developed a recurrent symptom due to tumor overgrowth. However, there were no other major complications associated with the procedure.

CONCLUSION

Percutaneous transgastric stent placement appeared to be technically feasible and clinically effective in patients who underwent a failed transoral approach.

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.

Local Heat Treatment for Suppressing Gastroduodenal Stent-Induced Tissue Hyperplasia Using Nanofunctionalized Self-Expandable Metallic Stent in Rat Gastric Outlet Model

Despite the promising results from the placement of covered or uncovered self-expandable metallic stent (SEMS) as a nonsurgical therapeutic option for the malignant gastric outlet obstruction (GOO), the long patency of the stent is still limited because of stent-induced tissue hyperplasia. Here, a local heat treatment using a nanofunctionalized SEMS is proposed for suppressing stent-induced tissue hyperplasia during GOO treatment. Highly efficient photothermal gold nanoparticle (GNP) transducer-coated SEMSs (GNP-SEMSs) were prepared for local heat treatment in rat gastric outlet. The in vivo heating temperature in rat gastric outlet model was evaluated and compared with in vitro heating temperature. Three groups of our developed 45 rat gastric outlet models were used: group A, noncoated SEMS only; group B, GNP-SEMS plus local heating; and group C, GNP-SEMS only to investigate in vivo efficacy of GNP-SEMS mediated local heating. Ten rats per group were sacrificed for 4 weeks, and five rats per group were sacrificed immediately after local heat treatment. The in vivo heating temperature was found to be 10.8% lower than the in vitro heating temperatures. GNP-SEMSs were successfully placed through a percutaneous approach into the rat gastric outlet (n = 45). The therapeutic effects of GNP-SEMS were assessed by histologic examination including hematoxylin-eosin, Masson trichrome, immunohistochemistry (TUNEL and CD31), and immunofluorescence (Ki67), and the results showed significant prevention of tissue hyperplasia following stent placement without adjacent gastrointestinal tissue damage. GNP-SEMS-mediated local heating could be an alternative therapeutic option for the suppression of tissue hyperplasia following stent placement in benign and malignant GOOs.

Endoscopic management of gastric outlet obstruction disease

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient's prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Endoscopic management of gastric outlet obstruction disease

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient’s prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches

PURPOSE

We aimed to evaluate the safety and effectiveness of fluoroscopy-guided gastroduodenal metallic stent placement with different approaches in malignant obstruction.

METHODS

We retrospectively assessed 53 patients (33 men and 20 women; mean age, 58.7±15 years) who underwent stent placement between February 2004 and April 2014. All patients had unresectable tumors. The most common causes of obstruction were gastric (38%) and pancreatic cancers (36%). Uncovered self-expandable metallic stents (SEMS) were placed under fluoroscopic guidance. In addition to transoral approach in 46 patients (86.7%), transgastric and transhepatic approaches were used in six patients (11.3%) and one patient (1.8%), respectively. Gastric outlet obstruction scoring system (GOOSS) was used to evaluate oral intake before and after stenting. Patients were followed until death or the end of the study.

RESULTS

Technical and clinical success rates were 100% and 92%, respectively. The median stent patency was 76 days (range, 4-985 days). Mean preprocedural GOOSS score of 0.1 increased to postprocedural GOOSS score of 2.42 (P < 0.001). Afferent loop decompression was achieved in one symptomatic patient. Neither mortality nor major complications occurred due to stenting. Stent migration occurred in one patient (2%) and stent obstruction occurred in two patients (4%). Combined biliary and duodenal stenting were performed in 21 patients (40%). Post-stenting GOOSS scores were predictive of survival (P = 0.003).

CONCLUSION

Fluoroscopic metallic stent placement for palliation of malignant gastroduodenal obstruction is safe and effective with high technical and clinical success rates and minimal complications. High technical success rates can be achieved using different approaches.

Factors predicting through-the-scope gastroduodenal stenting outcomes in patients with gastric outlet obstruction: a large multicenter retrospective study in West Japan

BACKGROUND AND AIMS

Endoscopic gastroduodenal stenting for malignant gastric outlet obstruction recently has become more effective, but the factors that predict gastroduodenal stenting outcomes are poorly defined. This multicenter retrospective cohort study evaluated the clinical outcomes of gastroduodenal stenting in malignant gastroduodenal obstruction and identified factors predicting clinical ineffectiveness, stent dysfunction, and adverse events.

METHODS

All consecutive patients with malignant gastroduodenal obstruction who underwent through-the-scope gastroduodenal stenting from 2009 to 2014 at 4 tertiary-care medical centers were identified. Clinically ineffective stenting was defined as symptom recurrence and a gastric outlet obstruction scoring system (GOOSS) score <2.

RESULTS

Of the 278 patients (mean age ± standard deviation [SD] 71.7 ± 11.4 years), 121 (43.5%) and 87 (31.3%) had pancreatic and gastric cancer, respectively. Technical success was achieved in 277 patients (99.6%). GOOSS scores rose from 0.5 ± 0.6 to 2.6 ± 0.8. Stenting was ineffective in 32 patients (12.6%). Stent dysfunction that caused symptom recurrence during follow-up developed in 46 patients (16.6%). Adverse events occurred in 49 patients (17.7%). Three or more stenosis sites (odds ratio [OR] = 6.11; P < .01) and Karnofsky performance scores ≤50 (OR = 6.63; P < .01) predicted clinical ineffectiveness. Karnofsky performance scores ≤50 predicted stent dysfunction (hazard ratio [HR] = 3.63; P < .01). Bile duct stenosis (HR = 9.55; P = .02) and liver metastasis (HR = 9.42; P < .01) predicted stent overgrowth. Covered stent predicted stent migration (HR = 12.63; P < .01). Deployment of 2 stents predicted perforation (HR = 854.88; P < .01).

CONCLUSIONS

Through-the-scope gastroduodenal stenting tended to be ineffective in patients with poor performance status and long stenosis sites. Stent dysfunction occurred more frequently in patients with poorer performance status. Deployment of 2 stents was a risk factor for perforation. Identification of these risk variables may help yield better gastroduodenal stenting outcomes.

Self-expandable metal stents for malignant gastric outlet obstruction: A pooled analysis of prospective literature

AIM: To provide an overview of the clinical outcomes of self-expandable metal stent (SEMS) placement for malignant gastric outlet obstruction (MGOO).

METHODS: A systematic literature search was performed in PubMed of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success, defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs (PCSEMSs) and uncovered SEMSs (UCSEMSs) using Fisher’s exact test.

RESULTS: A total of 19 studies, including 1281 patients, were included in the final analysis. Gastric (42%) and pancreatic (37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients, mainly caused by re-obstruction (12.6%) and stent migration (4.3%), and was comparable between PCSEMSs and UCSEMSs (21.2% vs 19.1%, respectively, P = 0.412). Re-obstruction was more common with UCSEMSs (14.9% vs 5.1%, P < 0.001) and stent migration was more frequent after PCSEMS placement (10.9% vs 2.2%, P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients, including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies.

CONCLUSION: The clinical outcomes in this large population showed that enteral stent placement was feasible, effective and safe. Therefore, stent placement is a valid treatment option for the palliation of MGOO.

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.

Bleeding after expandable nitinol stent placement in patients with esophageal and upper gastrointestinal obstruction: incidence, management, and predictors

BACKGROUND

Placement of self-expandable nitinol stents is useful for the treatment of esophageal and upper gastrointestinal (GI) obstruction. However, complications such as stent migration, tumor overgrowth, and bleeding occur. Although stent migration and tumor overgrowth are well documented in previous studies, the occurrence of bleeding has not been fully evaluated.

PURPOSE

To evaluate the incidence, management strategies, and predictors of bleeding after placement of self-expandable nitinol stents in patients with esophageal and upper GI obstruction.

MATERIAL AND METHODS

We retrospectively reviewed the medical records and results of computed tomography and endoscopy of 1485 consecutive patients with esophageal and upper GI obstructions who underwent fluoroscopically guided stent placement.

RESULTS

Bleeding occurred in 25 of 1485 (1.7%) patients 0 to 348 days after stent placement. Early stent-related bleeding occurred in 10 patients (40%) and angiographic embolization was used for 5/10. Late bleeding occurred in 15 patients (60%) and endoscopic hemostasis was used for 7/15. Twenty-two of 25 (88%) patients with bleeding had received prior radiotherapy and/or chemotherapy.

CONCLUSION

Bleeding is a rare complication after placement of expandable nitinol stents in patients with esophageal and upper GI obstruction, but patients with early bleeding may require embolization for control. Care must be exercised on placing stents in patients who have received prior radiotherapy or chemotherapy.

Imaging of abdominal and pelvic surgical and postprocedural foreign bodies

Every form of medical and surgical treatment, even the most trivial one, carries with it some chance of complications. This risk is usually small, and the benefit of the treatment should clearly outweigh the risk. Treatment-related complications may occur, however, presenting either soon after the intervention or remote from it. In this review, the focus is on imaging findings of surgical materials used in abdominal surgery, and of a wide array of implanted abdominal devices. The pertinent complications of these devices and of retained surgical objects are highlighted and illustrated.

SEMS vs cSEMS in duodenal and small bowel obstruction: High risk of migration in the covered stent group

AIM: To compare clinical success and complications of uncovered self-expanding metal stents (SEMS) vs covered SEMS (cSEMS) in obstruction of the small bowel.

METHODS: Technical success, complications and outcome of endoscopic SEMS or cSEMS placement in tumor related obstruction of the duodenum or jejunum were retrospectively assessed. The primary end points were rates of stent migration and overgrowth. Secondary end points were the effect of concomitant biliary drainage on migration rate and overall survival. The data was analyzed according to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

RESULTS: Thirty-two SEMS were implanted in 20 patients. In all patients, endoscopic stent implantation was successful. Stent migration was observed in 9 of 16 cSEMS (56%) in comparison to 0/16 SEMS (0%) implantations (P = 0.002). Stent overgrowth did not significantly differ between the two stent types (SEMS: 3/16, 19%; cSEMS: 2/16, 13%). One cSEMS dislodged and had to be recovered from the jejunum by way of laparotomy. Time until migration between SEMS and cSEMS in patients with and without concomitant biliary stents did not significantly differ (HR = 1.530, 95%CI 0.731-6.306; P = 0.556). The mean follow-up was 57 ± 71 d (range: 1-275 d).

CONCLUSION: SEMS and cSEMS placement is safe in small bowel tumor obstruction. However, cSEMS is accompanied with a high rate of migration in comparison to uncovered SEMS.

Additional gastroduodenal stent placement: retrospective evaluation of 68 consecutive patients with malignant gastroduodenal obstruction

BACKGROUND

Self-expandable metallic stent placement is widely used to manage malignant gastroduodenal obstructions. However, the techniques and effectiveness of additional gastroduodenal stent placement have not been evaluated until now.

PURPOSE

To evaluate the technical feasibility, clinical effectiveness, and complications of additional gastroduodenal stent placement in patients with recurrent obstructive symptoms after primary gastroduodenal stenting.

MATERIAL AND METHODS

We retrospectively analyzed data from 68 consecutive patients who had additional gastroduodenal stents placed for recurrent obstruction. Clinical effectiveness was assessed using technical and clinical success rates, gastric outlet obstruction score improvement after primary and additional stent placement, and complications.

RESULTS

Additional stent placement was technically successful in 66 of the 68 patients (97%) and symptomatic improvement was achieved in 58 (85%). The gastric outlet obstruction score improved after primary stent placement (0.3 to 1.4) and additional stent placement (0.2 to 1.4). Complications occurred in 12 of 68 patients (18%) and were caused by tumor overgrowth (n = 7), stent collapse (n = 2), food impaction (n = 1), jaundice (n = 1), and duodenal perforation (n = 1).

CONCLUSION

Additional gastroduodenal stent placement is technically feasible and clinically effective for patients with recurrent gastric outlet obstruction after stent placement.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction

BACKGROUND

Although a substantial number of patients require secondary stents insertion due to primary stent malfunction in malignant gastric outlet obstruction, data on the outcomes of secondary self-expanding metal stents are sparse.

AIM

To investigate clinical outcomes and factors related with secondary stent malfunction in patients with malignant gastric outlet obstruction given secondary stent-in-stent self-expanding metal stent insertion.

METHODS

For this retrospective study, a total 77 patients who underwent secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction were enrolled. We compared the effectiveness and complications of secondary covered and uncovered stents and explored the predictive factors for stent malfunction.

RESULTS

Stent-in-stent self-expanding metal stent placements were technically successful in all patients. Both groups also had comparable clinical success rates (covered stent, 87.2% and uncovered stent, 90.0%, P = 1.000). Stent malfunction rates (31.9% and 36.7% respectively, P = 0.805) and median patency time of stent (165 [95% confidence interval: 112-218] and 165 [95% confidence interval: 126-204] days, respectively, P = 0.358) were similar between secondary covered and uncovered stents. Longer patients' survival time (≥ 100 days) was associated with increased risk of stent malfunction (odds ratio: 4.598; 95% confidence interval: 1.473-14.355; P = 0.009).

CONCLUSIONS

Secondary stent-in-stent self-expanding metal stent placement is feasible and effective treatment for primary stent malfunctions in malignant gastric outlet obstruction. Covered and uncovered stent are equally acceptable in terms of stent-related complications and stent patency, regardless of primary stent type.