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

Endoscopic Ultrasonography-guided Gastrojejunostomy for Patients with Gastric Outlet Obstruction and Pyloric Metal Stent Dysfunction

A 52-year-old woman with a gastric outlet obstruction (GOO) caused by pyloric cancer underwent pyloric endoscopic self-expandable metal stent (SEMS) insertion. She presented with abdominal distension 40 days later. The SEMS was dysfunctional, and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) was performed using an endoscopic nasobiliary drainage tube. A 16 mm×31 mm Niti-S ™ HOT SPAXUS™ (TaeWoong Medical, Gimpo, Korea) was inserted successfully between the stomach and the adjacent jejunum. After the procedure, the patient had a good oral intake for more than seven months. GOO is a mechanical obstructive condition caused by various benign and malignant conditions. Traditionally, surgical GJ and SEMS insertion have been used to treat GOOs. EUS-GJ is a feasible treatment option for patients with GOO and a pyloric metal stent dysfunction.

Photodynamic Therapy and Hyperthermia in Combination Treatment-Neglected Forces in the Fight against Cancer

Cancer is one of the leading causes of death in humans. Despite the progress in cancer treatment, and an increase in the effectiveness of diagnostic methods, cancer is still highly lethal and very difficult to treat in many cases. Combination therapy, in the context of cancer treatment, seems to be a promising option that may allow minimizing treatment side effects and may have a significant impact on the cure. It may also increase the effectiveness of anti-cancer therapies. Moreover, combination treatment can significantly increase delivery of drugs to cancerous tissues. Photodynamic therapy and hyperthermia seem to be ideal examples that prove the effectiveness of combination therapy. These two kinds of therapy can kill cancer cells through different mechanisms and activate various signaling pathways. Both PDT and hyperthermia play significant roles in the perfusion of a tumor and the network of blood vessels wrapped around it. The main goal of combination therapy is to combine separate mechanisms of action that will make cancer cells more sensitive to a given therapeutic agent. Such an approach in treatment may contribute toward increasing its effectiveness, optimizing the cancer treatment process in the future.

Clinical outcomes after multiple self-expandable metallic stent placement using stent-in-stent technique for malignant gastric outlet obstruction

Self-expandable metallic stent (SEMS) placement is widely used for relieving symptoms in malignant gastric outlet obstruction (MGOO). This study aimed to evaluate the efficacy and safety of multiple gastroduodenal stent placement using the stent-in-stent technique and to identify factors predictive of stent patency.We retrospectively analyzed data from 170 patients with GOO receiving SEMS using the stent-in-stent technique between July 2006 and July 2018. Of these, 90 had been treated with SEMS placement for MGOO. Technical and clinical success rates were evaluated. Clinical outcomes and predictors of stent patency were also analyzed.Second SEMS placement was used in 34.4% of cases and 9.7% were treated with third SEMS placement because of prior stent dysfunction. Median stent patency time was 15.7 weeks for the first SEMS, 10.4 weeks for the second, and 11.3 weeks for the third. The technical and clinical success rates were 100% and 97.8% for the first SEMS, 100% and 90.3% for the second, respectively, and both 100% for the third. Multivariable analysis showed that use of covered SEMS and chemotherapy after first and second SEMS placement was significant predictors of stent patency. Serious complications such as bleeding or perforation did not occur in any patient.Second and third gastroduodenal SEMS placement using the stent-in-stent technique is safe and effective for management of first stent dysfunction in MGOO. Stent patency is significantly associated with the use of covered SEMS and chemotherapy after SEMS placement.

Modified Devine Exclusion for Unresectable Distal Gastric Cancer in Symptomatic Patients

Background

In patients with outlet obstruction syndrome and/or severe anemia secondary to unresectable gastric cancer (GC), partial stomach-partitioning gastrojejunostomy, or modified Devine exclusion, is a surgical alternative.

Methods

A retrospective study was conducted on patients with unresectable distal GC treated with modified Devine exclusion as palliative surgery between February 2005 and December 2015. It consisted of a series of 10 patients with outlet obstruction syndrome and/or severe anemia. The outcomes of this technique were based on oral tolerance, blood transfusions, postoperative complications, and survival.

Results

Early oral tolerance and a low rate of blood transfusions were observed postoperatively. There was no postoperative mortality and a very low complication rate without anastomotic leakage. Median survival was 9 months.

Conclusions

Partial stomach-partitioning gastrojejunostomy is a safe procedure for unresectable GC which can improve the quality of life of these patients.

Long-Term Palliative Effect of Stenting in Gastric Outlet Obstruction Due to Transarterial Chemoembolization with Yttrium-90 in a Patient with Metastatic Neuroendocrine Tumor

Internal radioembolization with yttrium-90 is a promising treatment method, predominantly for liver tumors. However, the shifting of yttrium-90-loaded spherules into the arteries and veins that supply the duodenum and stomach, leading to ulceration, hemorrhage, perforation, and outlet obstruction of these organs, is one of the major undesirable consequences of this technique. We report a case of gastric outlet obstruction (GOO) due to antropyloric stenosis with ulceration, edema, and inflammation following transarterial yttrium-90 treatment for a metastatic neuroendocrine tumor in a 58-year-old man. Stenting was used for palliation in this case. GOO improved after stenting and recovery of oral intake was permanent after stent removal.

Clinical outcomes of re-stenting in patients with stent malfunction in malignant gastric outlet obstruction

BACKGROUND AND AIMS

Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastric outlet obstruction (GOO). The aim of this study was to evaluate the clinical outcomes of salvage SEMS for stent malfunction and to identify the prognostic factors for a longer patency.

METHODS

A total of 108 patients who underwent a secondary salvage SEMS placement for a primary stent malfunction were retrospectively reviewed at the Seoul National University Hospital between August 2004 and May 2013. The duration of patency for salvage SEMS was defined as the time between salvage SEMS placement and the recurrence of obstructive symptoms that were confirmed either endoscopically or radiologically.

RESULTS

The technical and clinical success rates for salvage SEMS were 100 and 82.4% (95% confidence interval [CI] 74.0-89.0), respectively. A salvage SEMS malfunction occurred in 29 (26.9%) of the 108 patients. The median duration of patency for salvage SEMS was 59.5 days (range 3-928, 95% CI 73.7-118.3). Longer SEMS patencies of more than 60 days were significantly associated with palliative chemotherapy (odds ratio = 2.539, 95% CI 1.031-6.252, p = .043). For salvage SEMS, covered-uncovered stents had a longer patency duration, as compared with other combinations of primary and salvage stent types.

CONCLUSIONS

Longer patency durations for salvage SEMS were associated with palliative chemotherapy after salvage SEMS insertion. Salvage SEMS could be a feasible and effective treatment for primary stent malfunction in malignant GOO.

Efficacy and safety of a partially covered duodenal stent for malignant gastroduodenal obstruction: a pilot study

BACKGROUND

Duodenal stent placement has emerged as an effective and safe palliative treatment for patients with malignant gastroduodenal obstruction. An uncovered enteral stent, however, is susceptible to repeat stenosis because of tumor ingrowth. Although covering an enteral stent with a membrane prevents tumor ingrowth, stent migration continues to be a major unresolved problem. Partially covered metal stents may avoid both tumor ingrowth and stent migration.

OBJECTIVE

To evaluate the clinical and technical efficacy and the safety of a partially covered duodenal stent for malignant gastroduodenal obstruction.

DESIGN

Retrospective, observational study.

SETTING

Tertiary-care medical center.

PATIENTS

Twenty patients with malignant gastroduodenal obstruction received palliative treatment with partially covered duodenal stents.

INTERVENTIONS

Endoscopic stent placement.

MAIN OUTCOME MEASUREMENTS

Technical success, clinical success, patency, and adverse events.

RESULTS

Stent placement was successful in all 20 patients (technical success rate, 100%), and symptoms improved in 19 (clinical success rate, 95%). The Gastric Outlet Obstruction Scoring System score improved significantly (P < .001). Eight patients (40%) developed tumor overgrowth, whereas none showed stent migration. Median stent patency was 79.5 days (range 13-198 days). Adverse events occurred in 3 patients, including 2 with transient bacteremia and 1 with asphyxia because of impaction of food material into the stent.

LIMITATIONS

Single center, retrospective design, and a small number of patients.

CONCLUSION

Partially covered duodenal stents were effective and safe for malignant gastroduodenal obstruction and may prevent tumor ingrowth and stent migration.

Nausea and vomiting in advanced cancer

Nausea and vomiting are very common symptoms in cancer both treatment and non-treatment related. Many complications of advanced cancer such as gastroparesis, bowel and outlet obstructions, and brain tumors may have nausea and vomiting or either symptom alone. In a non-obstructed situation, nausea may be more difficult to manage and is more objectionable to patients. There is little research on management of these symptoms except the literature on chemotherapy induced nausea where guidelines exist. This article will review the etiologies of nausea and vomiting in advanced cancer and the medications which have been used to treat them. An etiology based protocol to approach the symptom is outlined.