Effects of the temporary placement of a self-expandable metallic stent in benign pyloric stenosis

Efficacy and safety of self-expandable metallic stents for management of benign gastric outlet obstruction-A prospective study

INTRODUCTION

We aimed at evaluating the safety and efficacy of self-expandable metallic stent (SEMS) insertion for managing patients with benign gastric outlet obstruction (GOO).

METHODS

This prospective interventional study included 23 patients. All consecutive treatment-naïve symptomatic patients with benign GOO were recruited. Fully covered SEMS were deployed across the stricture under fluoroscopic and endoscopic guidance. Technical success, clinical success and sustained treatment response (STR) were assessed. Technical success was defined as the successful deployment of SEMS at the desired anatomic location. Clinical success was defined as the resolution of symptoms and an increase in Gastric Outlet Obstruction Scoring System (GOOSS) of at least 1 point from the baseline score on Day 7. STR was assessed at four and eight weeks post stent removal in patients who had a response at week four. Factors associated with stent migration and non-response at week four were also assessed.

RESULTS

The median age of the study population was 30 years (range 19-65 years). Males constituted 65.22%. Most patients presented with vomiting (100%) and abdominal pain (95.65%). Peptic stricture was most common etiology for GOO (60.9%) followed by tubercular (26.1%) and corrosive (13%). Most common site of obstruction was junction of first and second part of duodenum (69.57%) followed by pyloric (30.43%). Median length of stricture was 2 cm (range 1.5-4). Technical success was achieved in all 23 patients (100%). Clinical success was achieved in 21 patients (91.3%). Response at Day 28 was seen in 20 patients (86.95%). Eighteen of 20 (90%) patients who had a response at week four had STR at week four and week eight after stent removal. Stent migration occurred in five (21.7%) patients. On univariate analysis, stricture length, calibre and stent length were found to predict migration.

CONCLUSIONS

Fully covered SEMS was an effective and safe management modality in patients with benign GOO. Stent migration remains a troublesome disadvantage.

Peptic ulcer disease

Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.

Endoscopic Treatment of Gastric Outlet Obstruction

Endoscopic management of gastric outlet obstruction includes balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to relieve mechanical blockage and reestablish per oral intake. Based on the degree of obstruction, patients may experience debilitating symptoms that can quickly lead to malnutrition and delays in chemotherapy. Compared with surgery, minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations. EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates. This article aims to describe endoscopic treatment options and future considerations.

Best Practices in Esophageal, Gastroduodenal, and Colonic Stenting

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting.

Endoscopic Management of Luminal Strictures: Beyond Dilation

Luminal strictures can occur as part of many different gastrointestinal (GI) disorders anywhere along the GI tract and affect all age groups. The end goal of managing any stricture is to re-establish an adequate and durable luminal patency that is sufficient to resolve the presenting clinical symptoms. Treatment options can be generally categorized into medical, endoscopic, and surgical. However, within each of these categories, multiple different options are available. Therefore, choosing the best treatment modality is often challenging and depends on multiple factors including the type, location, and complexity of the stricture, as well as the preference of the treating physician. In this article, we will review the most current literature regarding foregut strictures, particularly esophageal and gastric, beyond dilation.

Percutaneous Transgastric Duodenal Stenting and Gastrostomy Repair Using a Vascular Closure Device: Proof of Concept in a Porcine Model

Introduction. Gastroduodenal stenting is efficacious and safe in both benign and malignant foregut diseases. Transgastric duodenal stenting has been described and however requires a gastrostomy tube to remain in situ for 4 to 6 weeks post-procedure which can lead to complications. We present a technique for immediate gastric repair using a suture-mediated vascular closure device, without the need for a gastrostomy tube in porcine models. Methods. Percutaneous access into the stomach was achieved using fluoroscopy. Two or 3 Perclose Proglide devices were pre-deployed. The tract was dilated and a wire advanced into the distal duodenum. A 15.5 cm covered enteric stent was delivered through the gastrostomy, deployed and position confirmed. The gastrostomy was closed using Perclose Proglide sutures. Necropsy leak pressure measurement was performed to assess integrity of gastrostomy closure in the porcine models. Results. Two (n = 8) or 3 (n = 2) Perclose Proglide devices were deployed in ten porcine models, with 1 misfire (4.5%). Percutaneous transgastric access and stent delivery was successful in all porcine models. Mean leak pressure in the animals with adequately deployed devices was 219 mmHg (range 172 mmHg-270 mmHg). Conclusion. This study demonstrates percutaneous transgastric duodenal stenting with immediate gastric repair using suture-mediated vascular closure devices is a feasible procedure.

Palliation in Gallbladder Cancer: The Role of Gastrointestinal Endoscopy

Gallbladder cancer is a rare malignancy burdened by poor prognosis with an estimated 5-year survival of 5% to 13% due to late presentation, early infiltration of surrounding tissues, and lack of successful treatments. The only curative approach is surgery; however, more than 50% of cases are unresectable at the time of diagnosis. Endoscopy represents, together with surgery and chemotherapy, an available palliative option in advanced gallbladder cancers not eligible for curative treatments. Cholangitis, jaundice, gastric outlet obstruction, and pain are common complications of advanced gallbladder cancer that may need endoscopic management in order to improve the overall survival and the patients’ quality of life. Endoscopic biliary drainage is frequently performed to manage cholangitis and jaundice. ERCP is generally the preferred technique allowing the placement of a plastic stent or a self-expandable metal stent depending on the singular clinical case. EUS-guided biliary drainage is an available alternative for patients not amenable to ERCP drainage (e.g., altered anatomy). Gastric outlet obstruction is another rare complication of gallbladder malignancy growing in contact with the duodenal wall and causing its compression. Endoscopy is a less invasive alternative to surgery, offering different options such as an intraluminal self-expandable metal stent or EUS-guided gastroenteroanastomosis. Abdominal pain associated with cancer progression is generally managed with medical treatments; however, for incoercible pain, EUS-guided celiac plexus neurolysis has been described as an effective and safe treatment. Locoregional treatments, such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and intraluminal brachytherapy (IBT), have been described in the control of disease progression; however, their role in daily clinical practice has not been established yet. The aim of this study is to perform a review of the literature in order to assess the role of endoscopy and the available techniques in the palliative therapy of advanced gallbladder malignancy.

Endoscopic management of malignant gastric outlet obstruction

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

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Endoscopic ultrasound-guided luminal remodeling as a novel technique to restore gastroduodenal continuity

Pyloric exclusion is a method of treatment for duodenal injury. Surgery is usually needed to restore digestive continuity in due time, yet a new surgical procedure can be challenging due to fibrotic adhesion development. We present here a retrospective case series of three patients with pyloric exclusion who underwent endoscopic ultrasound–guided duodenal repermeabilization using metallic stents. All procedures were successful with no complication and allowed regular feeding. This case series shows that endoscopic ultrasound–guided recanalization is a feasible and safe procedure.

Endoscopic management of iatrogenic EUS-related duodenal perforations with over-the-scope clips

Background and study aims  Iatrogenic endoscopic ultrasound (EUS) perforations are life-threatening adverse event and to date, surgery has been the main treatment for them. The aim of this study was to assess feasibility and safety of conservative treatment with over-the-scope clips (OTSC). Patients and methods  We performed a retrospective study, including iatrogenic EUS duodenal perforation with conservative endoscopic management from 2011 to August 2018. Patients who initial had surgical management were excluded. Results  In 8504 EUS procedure occurred, 13 perforations occurred (0.15 %). Eleven patients were included in the study, all women. Mean patient age was 75 years (range 68 - 88). Eighth of 11 perforations (72.7 %) were due to a radial probe and three of 11 (27.3 %) were due to a curvilinear probe. Eleven procedures (100 %) were performed as diagnostic. Defect size ranged from 10 to 15 mm. All procedures were successful. Three of eleven patients (27 %) had a stay in intensive care unit for less than 72 hours and length of total hospital stay ranged from 3 to 22 days. Conclusion  Conservative endoscopic treatment of Iatrogenic EUS perforation, with OTSC is feasible, efficient and safe.

Clinical outcomes of lumen-apposing metal stent in the management of benign gastrointestinal strictures: a systematic review and meta-analysis

Background and aims: Lumen-apposing metal stent (LAMS) have been considered as a viable alternative to treat benign gastrointestinal (GI) strictures. We aimed to determine the efficacy and safety of LAMS for benign GI strictures. Methods: Medline, Embase, Cochrane, and PubMed databases were searched using the keywords 'benign stricture', 'gastrointestinal stricture', 'lumen-apposing metal stent' and related terms on December 2018. Articles were selected for review by two authors independently according to predefined inclusion criteria and exclusion criteria. A meta-analysis using a random effects model was performed. Results: Six studies with a total of 144 patients were included in the final analysis (60 males, 41.7%). Overall, the pooled technical success rate was 98.3% [95% confidence interval (CI): 0.962-1.004], clinical success rate was 73.8% (95% CI: 0.563-0.912) and adverse events rate was 30.6% (95% CI: 0.187-0.425). The most common complication associated with LAMS for benign GI strictures was migration, and the pooled events rate was 10.9% (95% CI: 0.058-0.160). According to locations of stricture, subgroup analysis was performed in terms of clinical success [Esophagogastric: 63.9% (95% CI: 0.365-0.914); Gastroduodenal: 67.4% (95% CI: 0.421-0.927); Gastrojejunal: 78% (95% CI: 0.638-0.922); Pylorus: 77.6% (95% CI: 0.551-1.002); Colonic: 85.3% (95% CI: 0.515-1.191)]. Conclusions: Although the safety of LAMS placement in benign GI strictures is not very satisfactory, it is associated with a low migration rate. LAMS can achieve clinical symptom improvement or resolution in most patients with benign GI strictures, and it might be an alluring prospect for treating patients with this difficult condition.

Choledochoscope with stent placement for treatment of benign duodenal strictures: A case report

BACKGROUND

Endoscopically or fluoroscopically guided dilation is a safe and effective alternative to surgery for patients with benign strictures of the gastric outlet.

CASE SUMMARY

We describe two cases where a novel approach with a Spyglass^® choledochoscope in assessing the extent of benign duodenal strictures and aiding in placement of duodenal stents for treatment of the strictures. Choledochoscope-guided wire and stent placement was successful in all cases, leading to symptom resolution related to benign duodenal obstruction. No major adverse events were observed.

CONCLUSION

Choledochoscope-guided assessment and endoscopic therapy is a viable approach in relieving duodenal obstruction, if the conventional combined fluoroscopic and endoscopic methods fail.

Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction

Background and study aims  EUS-guided gastroenterostomy (GE) is a novel, minimally invasive endoscopic procedure for the treatment of gastric outlet obstruction (GOO). The direct-EUS-GE (D-GE) approach has recently gained traction. We aimed to report on a large cohort of patients who underwent DGE with focus on long-term outcomes. Patients and methods  This two-center, retrospective study involved consecutive patients who underwent D-GE between October 2014 and May 2018. The primary outcomes were technical and clinical success. Secondary outcomes were adverse events (AEs), rate of reintervention, procedure time, time to resume oral diet, and post-procedure length of stay (LOS). Results  A total of 57 patients (50.9 % female; median age 65 years) underwent D-GE for GOO. The etiology was malignant in 84.2 % and benign in 15.8 %. Technical success and clinical success were achieved in 93 % and 89.5 % of patients, respectively, with a median follow-up of 196 days in malignant GOO and 319.5 days in benign GOO. There were 2 (3.5 %) AEs, one severe and one moderate. Median procedure time was 39 minutes (IQR, 26 - 51.5 minutes). Median time to resume oral diet after D-GE was 1 day (IQR 1 - 2 days). Median post D-GE LOS was 3 days (IQR 2 - 7 days). Rate of reintervention was 15.1 %. Conclusions  D-GE is safe and effective in management of both malignant and benign causes of GOO. Clinical success with D-GE is durable with a low rate of reintervention based on a long-term cohort.

Endoscopic balloon dilatation is an effective management strategy for caustic-induced gastric outlet obstruction: a 15-year single center experience

Background and study aims  There is sparse data on the endoscopic management of caustic-induced gastric outlet obstruction (GOO). The present retrospective study aimed to define the response to endoscopic balloon dilatation (EBD) in such patients and their long-term outcome. Patients and methods  The data from symptomatic patients of caustic-induced GOO who underwent EBD at our tertiary care center between January 1999 and June 2014 were retrieved. EBD was performed using wire-guided balloons in an incremental manner. Procedural success and clinical success of EBD were evaluated, including complications and long-term outcome. Results  A total of 138 patients were evaluated of whom 111 underwent EBD (mean age: 30.79 ± 11.95 years; 65 male patients; 78 patients with isolated gastric stricture; 33 patients with both esophagus plus gastric stricture). The initial balloon diameter at the start of dilatation, and the last balloon diameter were 9.6 ± 2.06 mm (6 - 15 mm) and 14.5 ± 1.6 mm (6 - 15 mm), respectively. Procedural and clinical success was achieved in 95 (85.6 %) and 108 (97.3 %) patients, respectively, requiring a mean (SD) of 5.3 (2.6) and 7.21 (3.86) sessions, respectively. Patients with isolated gastric obstruction had a better response than those with combined esophagus and gastric stricture. Minor complications such as self-limited pain or bleeding were seen in 18 (16.2 %) and 16 (14.4 %), respectively. Perforation occurred in two patients. Over a follow-up period of 98 months, there were no recurrences. Conclusion  Caustic-induced GOO can be successfully managed using EBD with 97.3 % clinical success.

Adhering to quality medical care: a case report of upper gastrointestinal bleeding due to self-expandable metal stent placed for benign duodenal obstruction

Endoscopic placement of self-expandable metal stent (SEMS) is an efficient method for the palliative decompression of malignant gastro duodenal obstruction. However, its role in treating benign obstructive conditions is controversial. We herein present an unusual case of recurrent upper gastrointestinal (GI) bleeding episodes due to ischemic lesions induced by an uncovered SEMS placed several years before to treat post peptic ulcer pyloric obstruction. Patient's advanced age precluded any attempt for endoscopic or surgical removal of the stent and the patient was successfully treated only with proton pump inhibitors, remaining uneventful on the long term. This case speaks to the need for rational use of innovative treatment modalities for quality of care provision.

Off label use of lumen-apposing metal stent for persistent gastro-jejunal anastomotic stricture

We are reporting a novel “off-label” use of lumen apposing metal stent (LAMS) for management of refractory gastro-jejunal (GJ) anastomotic stricture after Roux-en-y gastric bypass (RYGB). With increasing prevalence of obesity, bariatric surgery is performed more frequently than ever. RYGB is one of the most commonly performed bariatric procedures. GJ anastomotic stricture is a late complication of this procedure. Our patient, seven years after RYGB developed GJ anastomotic ulcer and subsequently a stricture not amendable to repeated pneumatic dilations. Instead of using the conventional fully covered self-expanding metal stent (fcSEMS) we deployed the relatively new LAMS keeping in mind its novel dumbbell shaped design. Our patient’s symptoms were controlled successfully and she remained asymptomatic on follow-up. Despite initial approval for pancreatic pseudocyst drainage, LAMS has been used with increased frequency at various locations within gastrointestinal tract including GJ anastomotic strictures. Future randomized control trials are warranted to compare the efficacy of fcSEMS to LAMS.

Novel Uses of Lumen-Apposing Metal Stents

The lumen apposing metal stent (LAMS) has historically been used for drainage of pancreatic fluid collections. The unique design of this stent has allowed endoscopists to develop novel uses, including drainage of abscesses adjacent to gastrointestinal lumens, maintaining patency in gastrointestinal strictures, and creating a fistulous tract to bypass altered or compromised anatomy. These alternative uses for the LAMS take advantage of its ability to form a sealed, well-approximated anastomosis. Future applications of the LAMS are continuously being developed as clinicians provide minimally invasive approaches for management of these disease processes.

EUS-guided gastroenterostomy in management of benign gastric outlet obstruction

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in malignant gastric outlet obstruction (GOO) appears to be promising; however, its role in benign GOO is unclear. The aim of this study was to ascertain the clinical efficacy and safety of EUS-GE in benign GOO.

PATIENTS AND METHODS

This was an international retrospective series involving 5 tertiary centers. Consecutive patients who underwent EUS-GE between 1/2013 - 10/2016 for benign GOO were included. The primary endpoint was the rate of clinical success defined as ability to tolerate oral intake without vomiting. Secondary endpoints included technical success and rate of adverse events (AE).

RESULTS

Overall, 26 patients (46.2 % female; mean age 57.7 ± 13.9 years) underwent EUS-GE for benign GOO due to strictures from chronic pancreatitis (n = 11), surgical anastomosis (n = 6), peptic ulcer disease (n = 5), acute pancreatitis (n = 1), superior mesentery artery syndrome (n = 1), caustic injury (n = 1), and hematoma (n = 1). Technical success was achieved in 96.2 %. Dilation of the lumen apposing metal stent was performed in 13/25 (52 %) with a mean maximum diameter of 14.6 ± 1.0 mm. Mean procedure time was 44.6 ± 26.1 min. Clinical success was observed in 84.0 % with a mean time to oral intake of 1.4 ± 1.9 days and a median follow-up of 176.5 (IQR: 47 - 445.75) days. Rate of unplanned re-intervention was 4.8 %. 3 AE were noted including 2 misdeployed stents and 1 gastric leak needing surgical intervention following elective GE stent removal.

CONCLUSIONS

EUS-GE is a promising treatment for benign GOO. Larger and prospective data are needed to further validate this novel endoscopic technique in treating benign GOO of various etiologies.

Lumen-apposing metal stents for benign gastrointestinal tract strictures: An international multicenter experience

AIM

To investigate technical feasibility, outcomes and adverse events of the lumen-apposing metal stent (LAMS) for benign gastrointestinal (GI) tract strictures.

METHODS

Between July 2015 and January 2017, patients undergoing treatment by LAMS for benign GI strictures at three tertiary referral centers were included in this study. Primary outcomes included technical success, short-term clinical success, long-term clinical success, and adverse events. Short-term clinical success was defined as symptom resolution at 30 d after stent placement. Long-term clinical success was defined by symptom resolution at 60 d in patients who continued to have indwelling stent, or continued symptom resolution at 30 d after elective stent removal.

RESULTS

A total of 21 patients (mean age 62.6 years, 47.6% males) underwent placement of LAMS for benign GI strictures. A 15 mm × 10 mm LAMS was placed in 16 patients, a 10 mm × 10 mm LAMS was placed in 2 patients, and a 16 mm × 30 mm LAMS was placed in 3 patients. Technical success was obtained in all cases. Short-term clinical success was achieved in 19 out of 21 cases (90.5%), and long-term clinical success was achieved in 12 out of 18 (66.7%). Mean (range) stent indwell time was 107.2 (28-370) d. After a mean (range) dwell time of 104.3 (28-306) d, 9 LAMSs were removed due to the following complications: ulceration at stent site (n = 1), angulation (n = 2), migration (n = 4) and stricture overgrowth (n = 2). Migration occurred in 4 cases (19.0%), and it was associated with stricture resolution in one case. Median (range) follow-up period was 119 (31-422) d.

CONCLUSION

Utilization of LAMS for benign strictures has shown to be technically feasible and safe, but adverse events highlight the need for further study of its indications.

Safety and efficacy of coaxial lumen-apposing metal stents in the management of refractory gastrointestinal luminal strictures: a multicenter study

BACKGROUND AND AIMS

 Benign gastrointestinal (GI) strictures are often refractory to standard endoscopic interventions. Fully covered coaxial lumen-apposing metal stents (LAMS) have emerged as a novel therapy for these strictures. The aim of this study was to evaluate the safety and efficacy of LAMS for refractory GI strictures.

PATIENTS AND METHODS

 A retrospective analysis was performed for patients who underwent LAMS placement for benign luminal strictures in three US centers between January 2014 and December 2016. The primary outcomes were technical success and initial clinical success of LAMS placement. Secondary outcomes were stent migration, rate of re-intervention, and adverse events.

RESULTS

 A total of 49 patients underwent 56 LAMS placement procedures. Previous treatment had failed in 39 patients (79.6 %), and anastomotic strictures were the indication in 77.6 % (38/49), with the most common site being gastrojejunal (34.7 % [17/49]). Technical success was achieved in all procedures and initial clinical success was achieved in 96.4 % of all procedures (54/56). Patient initial clinical success was 95.9 % (47/49). Stent migration occurred in 17.9 % of procedures, and was more likely to occur at sites in the lower GI tract ( P  = 0.02). The mean stent dwell time was 100.6 days, and the mean follow-up was 169.8 days. Minor adverse events, not requiring hospitalization, occurred in 33.9 % of procedures, including subsequent stricture progression (10.7 %). In cases where LAMS were removed, mean follow-up time was 102.2 days. The re-intervention rate was 75 % at 300 days follow-up after stent removal. Of the LAMS placed at anastomotic strictures, 36.4 % required re-intervention, with approximately two-thirds of these re-interventions requiring placement of a new stent or surgery.

CONCLUSION

 LAMS placement was successful for the management of refractory GI strictures, with good technical and initial clinical success rates. However, re-intervention rates after LAMS removal were high, and many strictures were not resolved by an extended period of stenting with these coaxial stents. LAMS placement offers additional therapeutic options and in selected cases might be considered a destination therapy for patients with recalcitrant benign strictures.

Novel Use of a Uniquely Designed, Lumen-Apposing, Metal Stent in Benign Gastric Outlet Obstruction in Two Patients

Current guidelines recommend management of benign gastric outlet obstruction (GOO) with serial dilations. Self-expanding metal stents are effective, but their use is complicated by high rates of migration. We present two cases from our institution where a uniquely designed, lumen-apposing metal stent (LAMS) was successfully used to alleviate benign GOO without stent migration.

Endoscopic Approach for Major Complications of Bariatric Surgery

As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.

Efficacy of Retrievable Metallic Stent with Fixation String for Benign Stricture after Upper Gastrointestinal Surgery

Objective

To determine the efficacy of retrievable metallic stent with fixation string for benign anastomotic stricture after upper gastrointestinal (UGI) surgery.

Materials and Methods

From June 2009 to May 2015, a total of 56 retrievable metallic stents with fixation string were placed under fluoroscopy guidance in 42 patients who were diagnosed with benign anastomotic stricture after UGI surgery. Clinical success was defined as achieving normal regular diet (NRD).

Results

The clinical success rate after the first stent placement was 57.1% (24/42). After repeated stent placement and/or balloon dilation, the clinical success rate was increased to 83.3% (35/42). Six (14.3%) patients required surgical revision to achieve NRD. One (2.4%) patient failed to achieve NRD. Stent migration occurred in 60.7% (34/56) of patients. Successful rate of removing the stent using fixation string and angiocatheter was 94.6% (53/56). Distal migration occurred in 12 stents. Of the 12 stents, 10 (83.3%) were successfully removed whereas 2 could not be removed. No complication occurred regarding distal migration.

Conclusion

Using retrievable metallic stent with a fixation string is a feasible option for managing early benign anastomotic stricture after UGI surgery. It can reduce complications caused by distal migration of the stent.

Temporary duodenal stenting as a bridge to ERCP for inaccessible papilla due to duodenal obstruction: a retrospective study

BACKGROUND AND STUDY AIMS

Duodenal obstruction may prevent performance of endoscopic retrograde cholangiopancreatography (ERCP). Percutaneous transhepatic biliary drainage (PTBD) or Endoscopic ultrasonograhy-guided biliary access (EUS-BD) are alternative treatments but are associated with a higher morbidity and mortality rate. The aim of the study is to report overall technical success rate and clinical outcome with deployment of temporary fully or partially covered self-expanding duodenal stent (pc/fcSEMS) as a bridge to ERCP in case of inaccessible papilla due to duodenal strictures.

PATIENTS AND METHODS

This retrospective study included 66 consecutive patients presenting with a duodenal stricture impeding the ability to perform an ERCP. Provisional duodenal stenting was performed as a bridge to ERCP. A second endoscopic session was performed to remove the provisional stent and to perform an ERCP. Afterward, a permanent duodenal stent was delivered if necessary.

RESULTS

Sixty-six duodenal stents (17 pcSEMS and 49 fcSEMS) were delivered with a median indwelling time of 3.15 (1 - 7) days. Two migrations occurred in the pcSEMS group, 1 of which required lower endoscopy for retrieval. No other procedure-related complications were observed. At second endoscopy a successful ERCP was performed in 56 patients (85 %); 10 patients (15 %) with endoscopic failure underwent PTBD or EUS-BD. Forty patients needed permanent duodenal stenting.

CONCLUSIONS

Provisional removable covered duodenal stenting as a bridge to ERCP for duodenal obstruction is safe procedure and in most cases allows successful performance of therapeutic ERCP. This technique could be a sound option as a step up approach before referring such cases for more complex techniques such as EUS-BD or PTBD.

Per-Oral Pyloromyotomy (POP): An Emerging Application of Submucosal Tunneling for the Treatment of Refractory Gastroparesis

A growing body of literature supports the use of laparoscopic pyloroplasty as a minimally invasive treatment of refractory gastroparesis that has failed conservative measures and for benign gastric outlet obstruction. Endoscopic pyloric dilation, stent placement, and Botox have been described for similar indications, but often with transient or mixed results. Per-oral pyloromyotomy has recently been proposed as an endoscopic alternative to surgical pyloroplasty or pylormyotomy because it is less invasive by its nature and potentially more durable than current endoscopic treatments.

Lumen-apposing covered self-expanding metal stent for management of benign gastrointestinal strictures

BACKGROUND AND AIMS

Self-expanding metal stents (SEMS) are safe and effective for endoscopic management of malignant gastrointestinal strictures, but there is limited experience with their use in refractory benign strictures. We assessed the use of a new lumen-apposing covered SEMS for the management of benign gastrointestinal strictures.

METHODS

A single-center case-series of five patients who underwent lumen-apposing covered SEMS placement for benign gastrointestinal strictures.

RESULTS

Three patients had a benign gastroduodenal stricture, one had a distal colonic anastomotic stricture, and one with complete gastrojejunal anastomotic stenosis underwent endoscopic creation of a new gastrojejunostomy. None of the patients developed any immediate or delayed stent-related adverse events. In two patients, the stents were left in place indefinitely. Stents were removed from the other three patients with successful resolution of their symptoms during follow-up.

CONCLUSION

Lumen-apposing, fully covered SEMS appear to be safe and effective for management of selected benign gastrointestinal strictures.

EUS-guided gastroenterostomy: the first U.S. clinical experience (with video)

BACKGROUND AND AIMS

There are limitations to enteral self-expandable metal stents and surgical gastrojejunostomy in the treatment of patients with gastric outlet obstruction (GOO). EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers long-lasting luminal patency without the risk of tumor ingrowth and/or overgrowth, while avoiding the morbidity of a surgical procedure. The aims of this study were to report the first U.S. clinical experience with EUS-GE in terms of technical success, clinical success, and adverse events and to detail the technical aspects of performing EUS-GE.

METHODS

This was a retrospective study from two tertiary-care centers. EUS-GE was performed by using either the direct EUS-GE or balloon-assisted EUS-GE technique. Technical success was defined as adequate positioning and deployment of the stent as determined endoscopically and radiologically. Clinical success was defined as the patient's ability to tolerate oral intake without vomiting.

RESULTS

A total of 10 patients underwent attempted EUS-GE. Malignant GOO was present in 3 patients, whereas benign obstruction was found in the remaining 7. One patient had complete GOO and underwent successful direct EUS-GE. In the remaining 9 patients, balloon-assisted EUS-GE was attempted and was successful in 8. Thus, technical success occurred in 9 patients (90%). There were no procedure-related adverse events. Mean procedure time was 96 minutes (range 45-152 minutes), and mean length of hospital stay was 2.2 days. Clinical success with resumption of solid oral intake was achieved in all 9 patients (100%) who underwent successful EUS-GE. A total of 8 patients were able to tolerate almost a normal diet and/or full diet, and 1 patient tolerated a soft diet. There was no symptom recurrence during a mean follow-up period of 150 days.

CONCLUSIONS

EUS-GE is a promising new technique for the treatment of symptoms of benign and malignant GOO. Prospective, multicenter trials are needed to confirm these results.

Clinical efficacy of endoscopic treatment for benign colorectal stricture: balloon dilatation versus stenting

BACKGROUND/AIMS

There has been a lack of research comparing balloon dilatation and self-expandable metal stent (SEMS) placement to determine which is better for long-term clinical outcomes in patients with benign colorectal strictures. We aimed to compare the clinical efficacy and complication rates of balloon dilatation and SEMS placement for benign colorectal strictures from a variety of causes.

METHODS

Between January 1999 and January 2012, a total of 43 consecutive patients who underwent endoscopic treatment for benign colorectal stricture (balloon only in 29 patients, SEMS only in seven patients, and both procedures in seven patients) were retrospectively reviewed.

RESULTS

Thirty-six patients underwent endoscopic balloon dilatation, representing 65 individual sessions, and 14 patients received a total of 17 SEMS placements. The initial clinical success rates were similar in both groups (balloon vs SEMS, 89.1% vs 87.5%). Although the reobstruction rates were similar in both groups (balloon vs SEMS, 54.4% vs. 57.1%), the duration of patency was significantly longer in the balloon dilatation group compared with the SEMS group (65.5±13.3 months vs. 2.0±0.6 months, p=0.031).

CONCLUSIONS

Endoscopic balloon dilatation is safe and effective as an initial treatment for benign colorectal stricture and as an alternative treatment for recurrent strictures.

Stent implantation technique through PEG-like pathway for treatment of malignant gastroduodenal obstruction

OBJECTIVE

To investigate feasibility and safety of stent implantation technique through percutaneous endoscopic gastrostomy (PEG)-like pathway for treatment of malignant gastroduodenal obstructions.

METHODS

Twelve patients with malignant gastroduodenal obstructions accepted PEG-like operations. A stent implantation pathway was established in abdominal wall under endoscopic guide. A guide wire and a stent release device were introduced through this pathway followed by an intestinal stent implantation. After operation, efficacy and safety of this technique were assessed by collecting data such as operation time, complications, postoperative medication, and hospitalization time during postoperative 2-12 months of follow-up.

RESULTS

Twelve patients were successfully treated with stent implantation technique through PEG-like pathway for the first time. The average operation time was 31 minutes. No severe complications occurred during treatment. On the fourth days after operation, patents were give liquid diet and treatment of rehydration, acid suppression, hemostasis and anti-inflammation. The average hospitalization time was 5 days. The follow-up time was 2-12 months. Twelve (100%) patients achieved complete remissions. The stent related complications and obstruction did not appear within 2 months after operations. The quality of life improved significantly.

CONCLUSION

The stent implantation technique through PEG-like pathway for treatment of malignant gastroduodenal obstruction is a feasible, effective, and safe choice.

Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders

Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.

Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders

Upper gastrointestinal (GI) stents are increasingly being used to manage upper GI obstructions. Initially developed for palliative treatment of esophageal cancer, upper GI stents now play an emerging role in benign strictures of the upper GI tract. Because recurrent obstruction and stent-related complications are common, new modifications of stents have been implemented. Self-expandable metal stents (SEMS) have replaced older plastic stents. In addition, newly designed SEMS have been developed to prevent complications. This review provides an overview of the various types, indications, methods, complications, and clinical outcomes of upper GI stents in a number of malignant and benign disorders dividing the esophagus and gastroduodenum.

Biliary stenting is not a prerequisite to endoscopic placement of duodenal covered self-expandable metal stents

BACKGROUND

Duodenal covered self-expandable metal stent (cSEMS) can be used in malignant or benign gastroduodenal obstruction. The need for biliary stenting in patients with no concomitant biliary stricture, before duodenal cSEMS placement, remains unknown. The aim of this study was to determine whether cSEMS placement is responsible for biliary obstruction.

METHODS

This is a single-center, retrospective, case-controlled study, including 106 patients with symptomatic gastric outlet obstruction or duodenal fistula who received a covered nitinol duodenal stent by using through-the-scope/over-the-wire placement procedure. The main outcome measurement was the occurrence comparison of jaundice and bilirubin level, between patients with previous or concomitant biliary stenting (cSEMS + BS group), and patients with no biliary stent (cSEMS group) during an observational period of 90 days.

RESULTS

Hundred and six patients underwent cSEMS placement between June 2005 and March 2014: 53 in the cSEMS group (58% male, mean age 66.4 ± 13.3 years) and 53 in cSEMS + BS group (60% male, mean age 70.4 ± 11.6 years). The obstruction was due to cancer in 45% in cSEMS group and 87% in cSEMS + BS group. No case of jaundice was reported in the cSEMS group or in the cSEMS + BS group. In cSEMS group, the mean bilirubin level (μmol/L ± SD) was 8.0 ± 4 at baseline and 8.5 ± 4.6 at day 10, while in the cSEMS + BS group it was 91.4 ± 108 at baseline and 35.3 ± 39 at day 10 (p < 0.01). Patients from the two groups were matched on age, gender and bilirubin level at baseline. Evolution of bilirubinemia was +0.98 ± 2.76 µmol/L in experimental group and +0.39 ± 522 µmol/L in the control group (p = 0.34). No significant difference was observed between the two groups in term of technical success, clinical effectiveness, migration and other complications.

CONCLUSIONS

Previous biliary stenting is not required before endoscopic covered duodenal stent placement in patients with no associated biliary obstruction. Prospective studies are needed.

Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction

AIM: To evaluate the safety and efficacy of partially covered self-expandable metallic stents (SEMSs) in benign pyloric obstruction.

METHODS: We retrospectively analyzed data from 10 consecutive patients with peptic ulcer-related pyloric obstructive symptoms (gastric outlet obstruction scoring system (GOOSS) score of 1) between March 2012 and September 2013. The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center. We assessed the technical success, symptom improvement, and adverse events after stenting.

RESULTS: Early symptoms were improved just 3 d after SEMS placement in all 10 patients. The GOOSS score of all patients improved from 1 to 3. There were no serious immediate adverse events. The overall rate of being symptom free was 90% at a median of 11 mo of follow-up (range: 4-43 mo). Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation. Among them, four patients had sustained symptom improvement after the SEMS procedure. During the follow-up period, migration of the SEMS was observed in two patients (20.0%), both of whom had previous endoscopic balloon dilatation before SEMS insertion.

CONCLUSION: Despite the small number in this study, partially covered SEMSs showed a favorable and safe outcome in the treatment of naïve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.

Etiology and non-surgical treatment of pyloric obstruction

Pyloric stenosis is a common type of upper gastrointestinal obstruction, which is a result of progression of many diseases. This paper will review the common causes of pyloric stenosis and its non-surgical treatments, mainly endoscopic treatment, in recent years. With the development of endoscopic technology, endoscopic treatment will gradually replace surgical treatment for treatment of pyloric obstruction.