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Abstract
The evolution of advanced pancreaticobiliary endoscopy in the past 50 years is remarkable. Endoscopic retrograde cholangiopancreatography (ERCP) has progressed from a diagnostic test to an almost entirely therapeutic procedure. The endoscopist must have a clear understanding of the indications for ERCP to avoid unnecessary complications, including post-ERCP pancreatitis. Endoscopic ultrasound initially was used as a diagnostic tool but now is equipped with accessary channels allowing endoscopic ultrasound-guided interventions in various pancreaticobiliary conditions. This review discusses the endoscopic management of common pancreatic and biliary diseases along with the techniques, indications, outcomes, and complications of pancreaticobiliary endoscopy.
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Affiliation(s)
- Catherine F Vozzo
- Department of Gastroenterology, Cleveland Clinic, 9500 Euclid Avenue / A30, Cleveland, OH 44195, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Cleveland Clinic, 9500 Euclid Avenue / Q30, Cleveland, OH 44195, USA.
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2
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Abstract
INTRODUCTION Endoscopic papillectomy (EP) has been established as a useful endoscopic therapy by the efforts of many pancreatobiliary endoscopists and is presently accepted as a reliable alternative therapy to surgery in patients with ampullary adenoma. Moreover, there have been numerous advancements in EP techniques in recent years. Various approaches and attempts toward expanding the indications of endoscopic resection have been reported. Furthermore, the management and prevention of adverse events (AEs) and endoscopic treatment for remnant or recurrent lesions have also been reported. In the present review, we focus on recent advancements in the EP technique, as well as speculate on the future issues of EP. AREA COVERED This review of EP encompasses the indications, preoperative assessments, endoscopic techniques, outcomes, and AEs of EP, post-EP surveillance techniques, and treatments for remnant or recurrence lesions. EXPERT OPINION The ultimate goal of EP is the complete resection of ampullary tumors, regardless of whether they are adenomatous or carcinomatous lesions, without causing any AEs. Therefore, the most important issue is preoperative evaluation, that is, the accurate diagnosis of lesions contraindicated for EP. In addition, further research on the prevention of AEs is also necessary towards establishing EP as a safe endoscopic procedure.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine , Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
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Shim CS, Kim JH, Bok GH. Development of Biliary and Enteral Stents by the Korean Gastrointestinal Endoscopists. Clin Endosc 2016; 49:113-23. [PMID: 26956192 PMCID: PMC4821526 DOI: 10.5946/ce.2016.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 11/22/2022] Open
Abstract
Stenting in the gastrointestinal tract is a common procedure used for palliation of obstruction in the enteral and biliary tract. Today, stenting of malignant and benign strictures is performed at almost every major tertiary hospital in Korea. Moreover, Korea has become a major global supplier of cutting edge technology in the field of self-expanding metal stents. However, the history of stenting in Korea is relatively short and was far behind that of other nations such as Japan and Germany. The authors are humbled and gratified to have been able to observe the development and application of these stents in Korea, first hand. In this article, the authors review the overall history of stenting with a specific focus on the development of stenting in Korea. The development of esophageal, gastroduodenal, biliary, and colonic stents in Korea are reviewed in this article from a chronological and historical point of view, and a personal account of some of the significant moments of stent development in Korea are described.
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Affiliation(s)
- Chan Sup Shim
- Digestive Disease Center, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Jin Hong Kim
- Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Gene Hyun Bok
- Department of Internal Medicine, Min Hospital, Seoul, Korea
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4
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Abstract
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.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kang HW, Kim SG. Upper Gastrointestinal Stent Insertion in Malignant and Benign Disorders. Clin Endosc 2015; 48:187-93. [PMID: 26064817 PMCID: PMC4461661 DOI: 10.5946/ce.2015.48.3.187] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 04/22/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Hyoun Woo Kang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Sang Gyun Kim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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6
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Kim JW, Jeong JB, Lee KL, Kim BG, Ahn DW, Lee JK, Kim SH. Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction. World J Gastroenterol 2015; 21:1580-1587. [PMID: 25663777 PMCID: PMC4316100 DOI: 10.3748/wjg.v21.i5.1580] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/03/2014] [Accepted: 10/21/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the clinical outcomes of uncovered and covered self-expandable metal stent placements in patients with malignant duodenal obstruction.
METHODS: A total of 67 patients were retrospectively enrolled from January 2003 to June 2013. All patients had symptomatic obstruction characterized by nausea, vomiting, reduced oral intake, and weight loss. The exclusion criteria included asymptomatic duodenal obstruction, perforation or peritonitis, concomitant small bowel obstruction, or duodenal obstruction caused by benign strictures. The technical and clinical success rate, complication rate, and stent patency were compared according to the placement of uncovered (n = 38) or covered (n = 29) stents.
RESULTS: The technical and clinical success rates did not differ between the uncovered and covered stent groups (100% vs 96.6% and 89.5% vs 82.8%). There were no differences in the overall complication rates between the uncovered and covered stent groups (31.6% vs 41.4%). However, stent migration occurred more frequently with covered than uncovered stents [20.7% (6/29) vs 0% (0/38), P < 0.05]. Moreover, the overall cumulative median duration of stent patency was longer in uncovered than in covered stents [251 d (95%CI: 149.8 d-352.2 d) vs 139 d (95%CI: 45.5 d-232.5 d), P < 0.05 by log-rank test] The overall cumulative median survival period was not different between the uncovered stent (70 d) and covered stent groups (60 d).
CONCLUSION: Uncovered stents may be preferable in malignant duodenal obstruction because of their greater resistance to stent migration and longer stent patency than covered stents.
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Kang MK, Song HY, Kim JW, Kim JH, Park JH, Na HK, Lee JJ, Oh SJ. Additional gastroduodenal stent placement: retrospective evaluation of 68 consecutive patients with malignant gastroduodenal obstruction. Acta Radiol 2013; 54:944-948. [PMID: 23761545 DOI: 10.1177/0284185113485500] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Min Kyoung Kang
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Fiori E, Lamazza A, Demasi E, Decesare A, Schillaci A, Sterpetti AV. Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group. Am J Surg 2013; 206:210-217. [PMID: 23735668 DOI: 10.1016/j.amjsurg.2012.08.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 07/28/2012] [Accepted: 08/19/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND The authors report the final results of a prospective single-center randomized study whose aim was to compare the endoscopic placement of self-expandable stents with open surgical gastroenterostomy to relieve gastric outlet obstruction (GOO) in patients with advanced antropyloric adenocarcinoma. A systematic review of the medical literature from December 1999 to December 2011 was carried out to determine the results of endoscopic stenting in patients with GOO from unresectable primary cancer of the antropyloric region. METHODS In the prospective study, 18 patients with advanced adenocarcinoma of the antropyloric region and symptoms of GOO were enrolled. In 9 patients, self-expandable stents were placed, and in 9 patients, open surgical gastroenterostomy was performed. Patients were followed until death. Six hundred seventy-two patients with primary unresectable cancer of the antropyloric region and GOO syndrome who underwent endoscopic stenting were identified from the literature. RESULTS In the prospective study of 18 patients, there was no case of postprocedural mortality. Efficient gastric emptying resumed more quickly in patients who received stents, although 3 months after the procedures, there was no difference between the 2 groups. Mean crude survival was 258 days in patients who received stents and 283 days in those who underwent surgical gastroenterostomy (P = NS). In patients who underwent stent placement, there were 2 cases of stent migration and 2 cases of food impaction, which were resolved with endoscopy at a mean follow-up of 70 days. In the 672 patients from the literature, operative mortality and morbidity were very low. In prospective studies, complications related to stents were more common than previously thought. CONCLUSIONS Endoscopic placement of metallic stents offers an effective therapy in patients with advanced primary adenocarcinoma of the antropyloric region and poor general condition. In patients with longer life expectancies, the form of therapy should be chosen individually, considering that surgical gastroenterostomy has fewer complications in the medium term and that in patients with endoscopic stenting, very careful follow-up is required, with the possibility of new operative endoscopy in half of the patients.
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Affiliation(s)
- Enrico Fiori
- Department of Surgery Pietro Valdoni, University of Rome La Sapienza, Rome, Italy.
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Khashab M, Alawad AS, Shin EJ, Kim K, Bourdel N, Singh VK, Lennon AM, Hutfless S, Sharaiha RZ, Amateau S, Okolo PI, Makary MA, Wolfgang C, Canto MI, Kalloo AN. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc 2013; 27:2068-75. [PMID: 23299137 DOI: 10.1007/s00464-012-2712-7] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 11/06/2012] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Mouen Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, 1830 E. Monument Street, Room 424, Baltimore, MD 21205, USA.
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Ryu CB, Chen YK. Endoscopic Therapy for Gastric Neoplasms. CLINICAL GASTROINTESTINAL ENDOSCOPY 2012:425-447. [DOI: 10.1016/b978-1-4377-1529-3.00033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Varadarajulu S, Banerjee S, Barth B, Desilets D, Kaul V, Kethu S, Pedrosa M, Pfau P, Tokar J, Wang A, Song LMWK, Rodriguez S. Enteral stents. Gastrointest Endosc 2011; 74:455-64. [PMID: 21762904 DOI: 10.1016/j.gie.2011.04.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 02/08/2023]
Abstract
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.
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Brimhall B, Adler DG. Enteral stents for malignant gastric outlet obstruction. Gastrointest Endosc Clin N Am 2011; 21:389-403, vii-viii. [PMID: 21684461 DOI: 10.1016/j.giec.2011.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malignant gastric outlet obstruction (GOO) is a commonly encountered entity, defined as the inability of the stomach to empty because of mechanical obstruction at the level of either the stomach or the proximal small bowel. In this article, current literature on GOO is reviewed with a focus on enteral stents to include symptoms and diagnosis, stent and nonstent treatment, types of enteral stents, indications and contraindications to stent placement, and technical and clinical success rates. In comparison with gastrojejunostomy, enteral stent placement is better suited for patients with a shorter life expectancy and/or those who are poor surgical candidates.
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Affiliation(s)
- Bryan Brimhall
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84132, USA
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Rudolph HU, Post S, Schlüter M, Seitz U, Soehendra N, Kähler G. Malignant gastroduodenal obstruction: retrospective comparison of endoscopic and surgical palliative therapy. Scand J Gastroenterol 2011; 46:583-90. [PMID: 21366507 DOI: 10.3109/00365521.2010.545831] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Endoscopic stenting (ES) is a minimally invasive alternative to surgical gastroenterostomy (GE) for palliation of malignant gastroduodenal obstructions. This consecutive, retrospective analysis compares the clinical outcome of all patients undergoing ES or GE in the same period. METHODS ES was performed at the Endoscopy Department, University Hospital Mannheim or at the Interdisciplinary Endoscopy Department, University Hospital Hamburg-Eppendorf. GE was performed at the Surgical Department, University Hospital Mannheim. All palliative ES or GE on patients with malignant gastroduodenal obstruction without earlier gastric resections between January 2001 and April 2007 were evaluated. Main outcome measurements were ability of solid food intake (gastric outlet obstruction score), persistence of nausea and vomiting (gut function score), length of hospital stay, morbidity, mortality and re-interventions. RESULTS A total of 44 ES and 43 GE were performed. Nausea and vomiting--measured by means of the gut function score--persisted in significantly more patients in the GE group than in those who underwent stent placement (p = 0.0102). The gastric outlet obstruction score at discharge from the hospital revealed no significant difference in the ability of solid food intake between the groups. The hospital stay was significantly longer in the GE group (p = 0.0003). There was no significant difference in mortality and the rates of complications and re-interventions. CONCLUSION In this study, ES is a generally equivalent--and in several points superior--alternative to GE for palliation of malignant gastroduodenal obstruction. ES seems to be the less invasive alternative for symptomatic patients. GE has good results in patients with longer survival and can be practiced within abdominal explorations.
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Sequential or simultaneous placement of self-expandable metallic stents for palliation of malignant biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. Surg Laparosc Endosc Percutan Tech 2011; 20:410-5. [PMID: 21150420 DOI: 10.1097/sle.0b013e3182001f26] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pancreatic cancer is generally not amenable to curative resection, and self-expanding metallic stents have been used to relieve obstruction of bile duct and duodenum in patients with unresectable pancreatic cancer. However, both relative experience with sequential or simultaneous endoscopic stents placement in biliary and duodenal stricture and long-term efficacy of these stents are limited. The aim of this study was to present our experience on the effectiveness of this form of endoscopic treatment. PATIENTS AND METHODS We performed a retrospective review of all patients undergoing sequential or simultaneous biliary and duodenal stent placement for biliary and symptomatic duodenal obstruction due to unresectable pancreatic head carcinomas in 4 tertiary endoscopic centers. Data were collected from endoscopy and outpatient clinic reports, x-rays, and telephone calls. All patients were followed until their death. Endpoints included technical and clinical success, stent long-term patency, and survival. RESULTS Thirty-nine patients with unresectable pancreatic head cancer were included. Biliary or duodenal stenting was unsuccessful in 7 patients (17.9%). The remaining 32 patients (median age: 77 y; range: 52 to 82 y), with locally advanced (n=21) or metastatic disease (n=11), were studied. Twenty-one patients (65.6%) received at least first-line chemotherapy. Overall median survival was 9 months (range: 2 to 22 mo), being higher in locally advanced (median survival: 11.5 mo, range: 4 to 22 mo) than metastatic disease (median survival: 3 mo, range: 2 to 5.5 mo) (P<0.001). Median duodenal and biliary patency was 3 months (range: 1 to 12 mo) and 9 months (range: 2 to 22 mo), respectively (P<0.05). Nine of 32 patients (28.1%) required reintervention for recurrent symptoms. No major complications or death occurred in relation to endoscopic treatment. CONCLUSIONS Placement of self-expandable metal stents is a safe and efficacious palliation method for biliary and duodenal obstruction due to unresectable pancreatic head carcinoma. The majority of patients do not require reintervention and those who require can usually be managed nonoperatively.
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Lee KM, Choi SJ, Shin SJ, Hwang JC, Lim SG, Jung JY, Yoo BM, Cho SW, Kim JH. Palliative treatment of malignant gastroduodenal obstruction with metallic stent: prospective comparison of covered and uncovered stents. Scand J Gastroenterol 2010; 44:846-52. [PMID: 19462336 DOI: 10.1080/00365520902929849] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The placement of self-expandable metallic stents (SEMS) is known to be effective palliative treatment of malignant gastroduodenal obstruction. There are two types of SEMS--covered and uncovered--each with its own advantages and disadvantages. This study was conducted to compare between the clinical outcomes of covered and uncovered stents in patients with malignant gastroduodenal obstruction. PATIENTS AND METHODS The study was conducted prospectively from January 1998 to June 2007 and 154 patients were included. All had symptomatic gastroduodenal obstruction and were not candidates for curative operation. Seventy patients received covered SEMS, while the other 84 received uncovered SEMS. We compared technical and clinical success rates, tumour ingrowth rate, stent migration rate, stent patency time and patient survival in both SEMS groups. RESULTS The technical and clinical success rates of the covered and uncovered stent groups did not differ. Stent migration was more frequent in the covered stent group than in the uncovered group (17.1% versus 0%; p=0.0001). Tumour ingrowth was more frequent in the uncovered stent group than in the covered group (16.6% versus 2.9%; p=0.0066). Stent re-intervention rate, stent patency time and patient survival did not differ between groups. CONCLUSION Covered and uncovered stent insertions are technically feasible and effective palliative treatment of malignant gastroduodenal obstruction. Covered stents can reduce the risk of tumour ingrowth, whereas uncovered stents are effective in preventing stent migration. However, covered stents did not differ from uncovered stents in regard to other clinical outcomes.
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Affiliation(s)
- Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Abstract
Advances in stent design have led to a substantial increase in the use of stents for a variety of malignant and benign strictures in the gastrointestinal tract and biliary system. Whereas early stents were mostly composed of plastic, the majority of contemporary stents are self-expanding metal stents that are composed of either nitinol or stainless steel. These stents are able to exert an adequate expansile force and, at the same time, are highly flexible and biocompatible. Covered stents have been introduced to minimize tumor ingrowth through the metal mesh but are associated with higher rates for spontaneous migration. This has led to the development of covered stents with uncovered ends and stents with both covered and uncovered layers. Drug-eluting and biodegradable stents are also likely to become available in the near future. Although stents appear to be the preferred form of palliation for some patients with advanced cancer, many patients will benefit from a multidisciplinary approach that usually includes surgeons and oncologists.
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Affiliation(s)
- Hoon Jai Chun
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Havemann MC, Adamsen S, Wøjdemann M. Malignant gastric outlet obstruction managed by endoscopic stenting: a prospective single-centre study. Scand J Gastroenterol 2009; 44:248-51. [PMID: 19016077 DOI: 10.1080/00365520802530820] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic stenting for malignant gastric outlet obstruction was chosen as the primary strategy by which to palliate this complication, which is dominated by weight loss and anorexia. Advanced upper gastrointestinal tract cancers present late and life expectancy is limited. Only smaller multicentre studies point to endoscopic stenting as superior to surgery in terms of clinical outcome and cost. MATERIAL AND METHODS Forty-five consecutive patients with gastric outlet obstruction as a result of advanced upper GI-tract malignancy were enrolled in accordance with the intention-to-treat principle. All patients were offered endoscopic stenting. Oral intake before and after stenting was assessed using the gastric outlet obstruction score system (GOOSS). Various lengths of duodenal Hanaro self-expanding nitinol stents were delivered through a therapeutic endoscope. Outcome criteria were successful deployment, clinical effect, length of stay in hospital, survival, need for re-intervention and complications. RESULTS Forty-one patients (91%) were successfully stented. The mean pre-procedure GOOSS improved significantly from 0.39 (95% CI 0.22-0.56) to 2.29 (95% CI 2.01-2.58) after stenting (p<0.0001). Twenty-six patients (63%) improved GOOSS at least one point, whereas 5 patients (12%) did not change GOOSS at all. Mean length of hospital stay was 13 days (95% CI 9-17 days). Mean survival was 121 days (95% CI 62-181 days). Two patients (4%; numbers 6 and 19) sustained perforation without fatalities. Three patients (7%) had stent migration. Procedure-related mortality was zero. CONCLUSIONS Palliative stenting for advanced malignant upper GI-tract tumours at a tertiary Hepato-Pancreato-Biliary Unit is a safe, feasible and effective alternative to surgical bypass with a short hospital stay and prompt improvement of food intake.
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Affiliation(s)
- Maria Cecilie Havemann
- Department of Surgical Gastroenterology, HPB-Unit, Copenhagen University Hospital Herlev, Herlev, Denmark
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Larssen L, Medhus AW, Hauge T. Treatment of malignant gastric outlet obstruction with stents: an evaluation of the reported variables for clinical outcome. BMC Gastroenterol 2009; 9:45. [PMID: 19534803 PMCID: PMC2708180 DOI: 10.1186/1471-230x-9-45] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 06/17/2009] [Indexed: 12/19/2022] Open
Abstract
Background Malignant gastric outlet obstruction (GOO) is commonly seen in patients with advanced gastric-, pancreatic-, duodenal, hepatobiliary or metastatic malignancies. Ten to 25% of patients with pancreatic cancer will develop duodenal obstruction during the course of the disease. Duodenal stenting with self-expandable metal stents is an alternative treatment to surgical bypass procedures. Our aim was to review the published literature regarding treatment of malignant GOO with stents to reveal whether the information provided is sufficient to evaluate the clinical effects of this treatment Methods A literature search from 2000 – 2007 was conducted in Pub Med, Embase, and Cochrane library, combining the following search terms: duodenal stent, malignant duodenal obstruction, gastric outlet obstruction, SEMS, and gastroenteroanastomosis. All publications presenting data with ≥ 15 patients and only articles written in English were included and a review focusing on the following parameters were conducted: 1) The use of graded scoring systems evaluating clinical success; 2) Assessment of Quality of life (QoL) before and after treatment; 3) Information on stent-patency; 4) The use of objective criteria to evaluate the stent effect. Results 41 original papers in English were found; no RCT's. 16 out of 41 studies used some sort of graded scoring system. No studies had objectively evaluated QoL before or after stent treatment, using standardized QoL-questionnaires, 32/41 studies reported on stent patency and 9/41 performed an oral contrast examination after stent placement. Objective quantitative tests of gastric emptying had not been performed. Conclusion Available reports do not provide sufficient relevant information of the clinical outcome of duodenal stenting. In future studies, these relevant issues should be addressed to allow improved evaluation of the effect of stent treatment.
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Affiliation(s)
- Lene Larssen
- Department of Gastroenterology, Oslo University Hospital, Ullevaal, Department of Gastroenterology, Kirkeveien 166, N-0407 Oslo, Norway.
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19
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Schmidt C, Gerdes H, Hawkins W, Zucker E, Zhou Q, Riedel E, Jaques D, Markowitz A, Coit D, Schattner M. A prospective observational study examining quality of life in patients with malignant gastric outlet obstruction. Am J Surg 2009; 198:92-9. [PMID: 19482259 DOI: 10.1016/j.amjsurg.2008.09.030] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Revised: 09/29/2008] [Accepted: 09/30/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastric outlet obstruction (GOO) often complicates advanced malignancy. Palliative options include surgical bypass, endoscopic stent, percutaneous gastrostomy (PEG), or percutaneous jejunostomy (PEJ). METHODS We enrolled 50 patients with GOO secondary to unresectable primary or metastatic cancer in a study examining palliative interventions. Validated instruments assessed quality of life (QOL) at baseline, 1 month, and 3 months following intervention. RESULTS Median overall survival was 64 days. A shorter hospital stay and trend to lower mortality were observed after stent placement; solid food intake and rates of secondary intervention were comparable. Both stent and surgical bypass were associated with acceptable QOL outcomes. Fifteen patients refused participation at 1 month and 28 died of disease before 3 months, so 10 patients completed all surveys. CONCLUSIONS Although malignant GOO is associated with poor survival, there are reasonable alternatives for palliation. QOL studies are difficult to complete in this population due to severity of illness and short life expectancy.
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Affiliation(s)
- Carl Schmidt
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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20
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Abstract
Self expanding metal stents (SEMS) play an important role in the management of malignant obstructing lesions in the gastrointestinal tract. Traditionally, they have been used for palliation in malignant gastric outlet and colonic obstruction and esophageal malignancy. The development of the polyflex stent, which is a removable self expanding plastic stent, allows temporary stent insertion for benign esophageal disease and possibly for patients undergoing neoadjuvant chemotherapy prior to esophagectomy. Potential complications of SEMS insertion include perforation, tumour overgrowth or ingrowth, and stent migration. Newer stents are being developed with the aim of increasing technical and clinical success rates, while reducing complication rates. Other areas of development include biodegradable stents for benign disease and radioactive or drug-eluting stents for malignant disease. It is hoped that, in the future, newer stents will improve our management of these difficult conditions and, possibly, provide prognostic as well as symptomatic benefit in the setting of malignant obstruction.
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21
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Abstract
The application of stents in the GI tract has expanded tremendously. Stent placement is the most frequently used treatment modality for palliating dysphagia from esophageal or gastric cardia cancer. Newly designed esophageal stents, including the Polyflex stent and the Niti-S double stent, have been introduced to reduce recurrent dysphagia owing to migration or nontumoral or tumor overgrowth. Stents are also the treatment of choice for esophagorespiratory fistulas, for proximal malignant lesions near the upper esophageal sphincter, for recurrent carcinoma after esophagectomy or gastrectomy and for sealing traumatic or iatrogenic nonmalignant ruptures, such as Boerhaave's syndrome and leakages following surgery. Stents in the latter patient group should be removed within 4-8 weeks after placement to prevent the formation of granulation tissue or hyperplasia at the stent ends. For gastric outlet obstruction, many case series have been published. Only two, small, randomized controlled trials have compared stent placement with gastrojejunostomy to date, and a large, randomized trial is currently being conducted in The Netherlands. Obstructive jaundice caused by a malignancy in the common bile duct can be treated effectively with plastic or metal stent placement. However, a prognostic score needs to be developed that guides a treatment decision towards using either of these stents. Finally, colonic stents are applied successfully for acute malignant obstruction as a 'bridge to surgery' in patients with tumors that are deemed to be resectable, or as a palliative treatment for patients with locally advanced or metastatic disease.
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Affiliation(s)
- Marjolein Y V Homs
- University Medical Center Utrecht, Dept of Internal Medicine, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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22
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Surgical Emergencies. Oncology 2007. [DOI: 10.1007/0-387-31056-8_73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Lee SM, Kang DH, Kim GH, Park WI, Kim HW, Park JH. Self-expanding metallic stents for gastric outlet obstruction resulting from stomach cancer: a preliminary study with a newly designed double-layered pyloric stent. Gastrointest Endosc 2007; 66:1206-1210. [PMID: 18028923 DOI: 10.1016/j.gie.2007.06.021] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 06/13/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND Although endoscopic stent placement is now generally accepted as a palliative treatment for gastric outlet obstruction resulting from gastric cancer, it carries potential limitations such as tumor ingrowth or migration. OBJECTIVE Our purpose was to evaluate the technical and clinical efficacy of endoscopic placement of a newly designed double-layered combination pyloric stent. DESIGN Prospective, uncontrolled, single-center. SETTING Tertiary referral university hospital. PATIENTS Eleven patients with gastric outlet obstruction by unresectable stomach cancer. INTERVENTIONS Eleven patients received a double-layered combination pyloric stent (an outer uncovered stent to reduce migration and an inner polytetrafluoroethylene-covered stent to prevent tumor ingrowth). MAIN OUTCOME MEASUREMENT To evaluate technical success, clinical success, and complications, especially tumor ingrowth and migration. RESULTS Technical success was achieved in 11 of 11 (100%) patients. Among 11 patients in whom endoscopic stenting was placed successfully, clinical success was 90.9%, tumor ingrowth 0%, migration 9.1%, and tumor overgrowth 9.1%. Median stent patency period was 121 days. LIMITATIONS Small number of patients, uncontrolled study, short-term follow-up period. CONCLUSIONS We have described a technique for endoscopic metal stent placement by using the newly designed double-layered combination stent for gastric outlet obstruction by stomach cancer. This stent seems to be effective and looks promising for technical efficacy, clinical outcome, and preventing tumor ingrowth and migration.
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Affiliation(s)
- Sun Mi Lee
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
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24
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Abstract
Advanced gastric cancer and its palliative treatment have a long and interesting history. Today, gastric adenocarcinoma is the second leading cause of cancer death worldwide. Unfortunately, many cases are not diagnosed until late stages of disease, which underscores the importance of the palliative treatment of gastric cancer. Palliative care is best defined as the active total care of patients whose disease is not responsive to curative treatment. Although endoscopy is the most useful method for securing the diagnosis of gastric adenocarcinoma, computed tomography may be useful to assess local and distant disease. The main indication for the institution of palliative care is the presence of advanced gastric cancer for which curative treatment is deemed inappropriate. The primary goal of palliative therapy of gastric cancer patients is to improve quality, not necessarily length, of life. Four main modalities of palliative therapy for advanced gastric cancer are discussed: resection, bypass, stenting, and chemotherapy. The choice of modality depends on a variety of factors, including individual patient prognosis and goals, and should be made on case-by-case basis. Future directions include the discovery and development of serum or stool tumor markers aimed at prevention, improving prognostication and stratification, and increasing awareness and education.
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Affiliation(s)
- Steven C Cunningham
- Department of Oncology, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA
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25
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Chopita N, Landoni N, Ross A, Villaverde A. Malignant gastroenteric obstruction: therapeutic options. Gastrointest Endosc Clin N Am 2007; 17:533-44, vi-vii. [PMID: 17640581 DOI: 10.1016/j.giec.2007.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Malignant gastric outlet obstruction is a complication of advanced pancreatic cancer, manifesting endoscopically or radiographically as a stricture of the proximal duodenum. Until recently, management consisted of surgical gastroenteric bypass with or without associated biliary bypass. Over the past decade, the endoscopic deployment of self-expanding metal stents (SEMS) emerged as a new option for restoration of enteric patency. Compared with surgical bypass, SEMS placement is less invasive with good clinical outcomes. Aside from SEMS placement and surgical bypass, recent reports of magnetic gastroenteric anastamosis have emerged. This article critically examines each of the different therapeutic options for malignant gastric outlet obstruction, defines their clinical utility, and provides the exact recommendations as to how they may be usefully employed.
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Affiliation(s)
- Néstor Chopita
- San Martin Hospital, La Plata and University of La Plata, calle 62 n 370, 1900 La Plata, Buenos Aires, Argentina
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26
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Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol 2007; 7:18. [PMID: 17559659 PMCID: PMC1904222 DOI: 10.1186/1471-230x-7-18] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 06/08/2007] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gastrojejunostomy (GJJ) is the most commonly used palliative treatment modality for malignant gastric outlet obstruction. Recently, stent placement has been introduced as an alternative treatment. We reviewed the available literature on stent placement and GJJ for gastric outlet obstruction, with regard to medical effects and costs. METHODS A systematic review of the literature was performed by searching PubMed for the period January 1996 and January 2006. A total of 44 publications on GJJ and stents was identified and reported results on medical effects and costs were pooled and evaluated. Results from randomized and comparative studies were used for calculating odds ratios (OR) to compare differences between the two treatment modalities. RESULTS In 2 randomized trials, stent placement was compared with GJJ (with 27 and 18 patients in each trial). In 6 comparative studies, stent placement was compared with GJJ. Thirty-six series evaluated either stent placement or GJJ. A total of 1046 patients received a duodenal stent and 297 patients underwent GJJ. No differences between stent placement and gastrojejunostomy were found in technical success (96% vs. 100%), early and late major complications 7% vs. 6% and 18% vs. 17%, respectively) and persisting symptoms (8% vs. 9%). Initial clinical success was higher after stent placement (89% vs. 72%). Minor complications were less frequently seen after stent placement in the patient series (9% vs. 33%), however the pooled analysis showed no differences (OR: 0.75, p = 0.8). Recurrent obstructive symptoms were more common after stent placement (18% vs. 1%). Hospital stay was prolonged after GJJ compared to stent placement (13 days vs. 7 days). The mean survival was 105 days after stent placement and 164 days after GJJ. CONCLUSION These results suggest that stent placement may be associated with more favorable results in patients with a relatively short life expectancy, while GJJ is preferable in patients with a more prolonged prognosis. The paucity of evidence from large randomized trials may however have influenced the results and therefore a trial of sufficient size is needed to determine which palliative treatment modality is optimal in (sub)groups of patients with malignant gastric outlet obstruction.
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Sanders M, Papachristou GI, McGrath KM, Slivka A. Endoscopic palliation of pancreatic cancer. Gastroenterol Clin North Am 2007; 36:455-76, xi. [PMID: 17533090 DOI: 10.1016/j.gtc.2007.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic approaches have revolutionized the palliation of advanced pancreatic cancer. The ideal management consists of a multidisciplinary approach involving surgeons, endoscopists, radiologists, and oncologists. Concurrent advances in the fields of interventional radiology and laparoscopic surgical oncology should be readdressed and directly compared with endoscopic approaches in randomized controlled trials. Exciting novel endoscopic techniques are being developed and evaluated; however, these approaches require further validation with randomized clinical trials to determine the safety and efficacy when compared with more traditional approaches.
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Affiliation(s)
- Michael Sanders
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Pittsburgh Medical Center, Mezzanine Level, C-Wing, UPMC Presbyterian, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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28
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Lowe AS, Beckett CG, Jowett S, May J, Stephenson S, Scally A, Tam E, Kay CL. Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol 2007; 62:738-44. [PMID: 17604761 DOI: 10.1016/j.crad.2007.01.021] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Revised: 01/11/2007] [Accepted: 01/31/2007] [Indexed: 12/13/2022]
Abstract
AIM To assess the technical success rate, and evaluate the clinical outcome, length of hospital stay, and cost of palliative gastro-duodenal stenting in a single-centre. MATERIALS AND METHODS Eight-seven patients referred for insertion of a gastroduodenal stent between April 1999 and April 2004 were recruited to a non-randomized, before and after intervention study performed in a single centre. Demographic data, diagnosis and symptoms along with clinical and technical outcomes were recorded. RESULTS The technical success rate was 84/87 (96.6%), with inability to traverse the stricture in three patients. No immediate complications were demonstrated. There was marked improvement after stent placement with resolution of symptoms and commencement of dietary intake in 76 patients (87%). Stenting resulted in improved quality of life as reflected by an increase in Karnofsky score from 44/100, to 63/100 post-procedure. Late complications included perforation (n=1), migration (n=1) and stent occlusions due to tumour ingrowth/overgrowth (n=7; mean 165 days). Mean survival was 107 days (range 0-411 days). Median hospital stay post-stent placement was 5.5 days, (range 1-55 days) with a majority of patients (75%) discharged home. The mean cost of each treatment episode was 4146 pounds ($7132 $US, 6,028 EUROS). CONCLUSION The present series confirms that combined endoscopic and radiological gastroduodenal stenting is a highly favourable treatment for patients with inoperable malignant gastric outlet obstruction. The results suggest that this minimally invasive procedure has a very high technical success rate, whilst at the same time providing excellent palliation of symptoms with improved quality of life in the majority of patients.
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Affiliation(s)
- A S Lowe
- Department of Clinical Radiology, Bradford Royal Infirmary, Bradford, UK.
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29
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Song GA, Kang DH, Kim TO, Heo J, Kim GH, Cho M, Heo JH, Kim JY, Lee JS, Jeoung YJ, Jeon TY, Kim DH, Sim MS. Endoscopic stenting in patients with recurrent malignant obstruction after gastric surgery: uncovered versus simultaneously deployed uncovered and covered (double) self-expandable metal stents. Gastrointest Endosc 2007; 65:782-7. [PMID: 17324410 DOI: 10.1016/j.gie.2006.08.030] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Accepted: 08/22/2006] [Indexed: 01/19/2023]
Abstract
BACKGROUND Uncovered, rather than covered, metal stents are commonly used for palliation of malignant gastric outlet obstruction because of the low risk of stent migration, but tumor ingrowth risk is a major drawback. Few reports address malignant obstruction after gastric surgery. OBJECTIVE Our purpose was to compare the technical feasibility and clinical outcome of using an endoscopic uncovered self-expandable metal stent (SEMS) and simultaneous use of uncovered and covered SEMS (double SEMS) in patients with recurrent malignant obstruction after gastric surgery. DESIGN Retrospective study. SETTING Tertiary care, academic medical center, from August 2000 to June 2005. PATIENTS Twenty patients were included in the study. All patients had symptomatic obstruction with nausea, vomiting, and decreased oral intake. INTERVENTION Ten patients received uncovered SEMS; the other 10 received double SEMS. MAIN OUTCOME MEASUREMENTS To compare tumor ingrowth and stent patency between the uncovered and the double-SEMS groups. RESULTS Technical and clinical successes were 10 of 10 and 8 of 10, respectively, in the uncovered SEMS group and 10 of 10 and 10 of 10, respectively, in the double SEMS group. Six of 10 patients (60%) with uncovered SEMS had tumor ingrowth compared with 1 of 10 patients with double SEMS, P = .057. Five of 10 patients (50%) with uncovered SEMS had very early restenosis, but no patients had early restenosis in the double SEMS group, P = .033. Stent patency was a median of 21.5 days (range, 7-217 days) in the uncovered SEMS group and 150 days (range 29-263 days) in the double SEMS group, P = .037. Survival duration was 109.5 days (range 29-280 days) and 150 days (range 29-263 days), respectively. LIMITATIONS This was a small retrospective study. CONCLUSION Simultaneous double stent placement seems to be technically feasible and effective for palliative treatment of recurrent malignant obstruction after gastric surgery. Double stent placement is important in preventing tumor ingrowth, especially very early restenosis, and prolongs stent patency. We suggest that this procedure be considered rather than uncovered stent alone as the primary choice for palliation of obstruction in such patients.
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Affiliation(s)
- Geun Am Song
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Pusan National University College of Medicine, Busan, Korea
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Kim TO, Kang DH, Kim GH, Heo J, Song GA, Cho M, Kim DH, Sim MS. Self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction caused by stomach cancer. World J Gastroenterol 2007; 13:916-920. [PMID: 17352023 PMCID: PMC4065929 DOI: 10.3748/wjg.v13.i6.916] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2006] [Revised: 12/05/2006] [Accepted: 01/05/2007] [Indexed: 02/06/2023] Open
Abstract
AIM To ascertain clinical outcome and complications of self-expandable metal stents for endoscopic palliation of patients with malignant obstruction of the gastrointestinal (GI) tract. METHODS A retrospective review was performed throughout August 2000 to June 2005 of 53 patients with gastric outlet obstruction caused by stomach cancer. All patients had symptomatic obstruction including nausea, vomiting, and decreased oral intake. All received self-expandable metallic stents. RESULTS Stent implantation was successful in all 53 (100%) patients. Relief of obstructive symptoms was achieved in 43 (81.1%) patients. No immediate stent-related complications were noted. Seventeen patients had recurrent obstruction (tumor ingrowth in 14 patients, tumor overgrowth in 1 patient, and partial distal stent migration in 2 patients). The mean survival was 145 d. Median stent patency time was 187 d. CONCLUSION Endoscopic placement of self-expandable metallic stents is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach cancer.
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Affiliation(s)
- Tae Oh Kim
- Department of Internal Medicine, Pusan National University College of Medicine, 1-10 Ami-dong, Soe-gu, Busan 602-739, Korea
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31
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Kiely JM, Dua KS, Graewin SJ, Nakeeb A, Erickson BA, Ritch PS, Wilson SD, Pitt HA. Palliative stenting for late malignant gastric outlet obstruction. J Gastrointest Surg 2007; 11:107-13. [PMID: 17390196 DOI: 10.1007/s11605-006-0060-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Malignant gastric outlet obstruction (MGO) is a late complication of pancreatobiliary and gastric cancers. Although surgical gastrojejunostomy provides good palliation, many of these patients may be nonoperative candidates or underwent previous extensive resection such as a Whipple procedure. Recently, endoscopically placed self-expanding metallic stents (SEMS) have been used to palliate MGO. The aim of this study was to evaluate the efficacy of SEMS for palliation of late MGO. Medical records of patients with endoscopic placement of SEMS for palliation of MGO were reviewed. Results showed that 30 patients with MGO had SEMS placed for late gastroduodenal (n = 20) or jejunal (n = 10) obstruction. Twenty-one patients (70%) had previous surgery. Return to oral feeding was observed in 90% of patients who presented with recurrent obstruction after prior bypass surgery and in 88% of nonoperative patients in whom SEMS were placed as the primary therapy for obstruction. No major complications were observed, and median survival after SEMS was 4.1 months (0.1 to 10.5 months). SEMS also did not interfere with biliary drainage. In conclusion, endoscopically placed SEMS are safe and provide good palliation for late malignant gastroduodenal and jejunal strictures and are an excellent complement to recurrent obstruction after surgical gastrojejunostomy.
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Affiliation(s)
- James M Kiely
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226-3596, USA
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32
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Kaltenbach T, Crockett S, Triadafilopoulos G. Interventional upper endoscopy: the adult perspective. Curr Gastroenterol Rep 2006; 8:443-9. [PMID: 17105681 DOI: 10.1007/s11894-006-0033-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Advances in interventional endoscopic technology and techniques are paving the way for the increased application of minimally invasive methods to treat various upper gastrointestinal conditions, both benign and malignant. Through the description of enteral stenting for palliation of malignant obstruction, expanded techniques of enteral feeding tube placement, mucosectomy of early gastric cancer, and snare ampullectomy for benign ampullary lesions, this review focuses on recent progress in therapeutic endoscopy of the stomach and duodenum and highlights the importance of continued research and development.
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Affiliation(s)
- Tonya Kaltenbach
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building M-211, Stanford, CA 94305, USA.
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Tierney W, Chuttani R, Croffie J, DiSario J, Liu J, Mishkin DS, Shah R, Somogyi L, Petersen BT. Enteral stents. Gastrointest Endosc 2006; 63:920-6. [PMID: 16733104 DOI: 10.1016/j.gie.2006.01.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Maire F, Hammel P, Ponsot P, Aubert A, O'Toole D, Hentic O, Levy P, Ruszniewski P. Long-term outcome of biliary and duodenal stents in palliative treatment of patients with unresectable adenocarcinoma of the head of pancreas. Am J Gastroenterol 2006; 101:735-42. [PMID: 16635221 DOI: 10.1111/j.1572-0241.2006.00559.x] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Life expectancy in patients with unresectable pancreatic cancer has improved by using new chemotherapeutic regimens. Biliary and digestive stenoses can be endoscopically treated in most cases. However, long-term efficacy of these stenting procedures remains unknown. AIM To evaluate the incidence of biliary and duodenal stenoses as well as technical success and short- and long-term patency of endoscopically deployed stents in patients with unresectable pancreatic cancer. PATIENTS AND METHODS All consecutive patients with unresectable cancer of the pancreatic head seen between January 1999 and September 2003 in our center were retrospectively studied. Patients with biliary and/or duodenal stenoses underwent endoscopic stent insertion as first intention therapy. Outcomes included technical and clinical success, stent patency, and survival. RESULTS One hundred patients, median age 65 yr (32-85), with locally advanced (62%) or metastatic (38%) pancreatic cancer were studied. Eighty-three percent received at least one line of chemotherapy. The actuarial median survival was 11 months (0.7-29.3). Biliary and duodenal stenoses occurred in 81 and 25 patients, respectively. A biliary stent was successfully placed in 74 patients (91%). When a self-expandable metallic stent was first introduced (N = 59), a single stent was sufficient in 41 patients (69%) (median duration of stent patency 7 months (0.4-21.1)). Duodenal stenting was successful in 24 patients (96%); among them, 96% required a single stent (median duration of stent patency 6 months [0.5-15.7]). In the 23 patients who developed both biliary and duodenal stenoses, combined stenting was successful in 91% of cases. No major complication or death occurred related to endoscopic treatment. CONCLUSION Endoscopic palliative treatment of both biliary and duodenal stenoses is safe and effective in the long term, including in patients with combined obstructions. Use of such palliative management is justified as repeat procedures are rarely required even in patients who have a long survival.
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Affiliation(s)
- Frédérique Maire
- Pôle des Maladies de l'Appareil Digestif, Hôpital Beaujon, AP-HP, Clichy, France
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35
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He X, Shin JH, Kim HC, Woo CW, Woo SH, Choi WC, Kim JG, Lim JO, Kim TH, Yoon CJ, Kang W, Song HY. Balloon sheaths for gastrointestinal guidance and access: a preliminary phantom study. Korean J Radiol 2006; 6:167-72. [PMID: 16145292 PMCID: PMC2685040 DOI: 10.3348/kjr.2005.6.3.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective We wanted to evaluate the feasibility and usefulness of a newly designed balloon sheath for gastrointestinal guidance and access by conducting a phantom study. Materials and Methods The newly designed balloon sheath consisted of an introducer sheath and a supporting balloon. A coil catheter was advanced over a guide wire into two gastroduodenal phantoms (one was with stricture and one was without stricture); group I was without a balloon sheath, group ll was with a deflated balloon sheath, and groups III and IV were with an inflated balloon and with the balloon in the fundus and body, respectively. Each test was performed for 2 minutes and it was repeated 10 times in each group by two researchers, and the positions reached by the catheter tip were recorded. Results Both researchers had better performances with both phantoms in order of group IV, III, II and I. In group IV, both researchers advanced the catheter tip through the fourth duodenal segment in both the phantoms. In group I, however, the catheter tip never reached the third duodenal segment in both the phantoms by both the researchers. The numeric values for the four study groups were significantly different for both the phantoms (p < 0.001). A significant difference was also found between group III and IV for both phantoms (p < 0.001). Conclusion The balloon sheath seems to be feasible for clinical use, and it has good clinical potential for gastrointestinal guidance and access, particularly when the inflated balloon is placed in the gastric body.
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Affiliation(s)
- Xu He
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, Korea
| | - Ji Hoon Shin
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Hyo-Cheol Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Cheol Woong Woo
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Sung Ha Woo
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Won-Chan Choi
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jong-Gyu Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jin-Oh Lim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Tae-Hyung Kim
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Chang Jin Yoon
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Weechang Kang
- Department of Information and Statistics, Daejeon University, Korea
| | - Ho-Young Song
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Korea
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36
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Abstract
PURPOSE OF REVIEW This review is an update of key issues in gastric interventional endoscopy. It focuses on the areas of patient preparation, endoscopic mucosal resection, gastroduodenal stenting, and endoscopic placement of enteric feeding tubes. RECENT FINDINGS Clopidogel (Plavix), a newer antiplatelet agent, can increase the risk of bleeding. Therefore, in selected cases, it should be held for 7-10 days prior to interventional procedures. In experienced hands, endoscopic mucosal resection (success rate, 76-100%; complication rate, 4-28%) and gastroduodenal stenting (success rate, 81-92%; complication rate, 1-17%) seem to be safe and effective techniques. SUMMARY The field of interventional endoscopy continues to advance and to conquer new frontiers. These advances create new problems that need to be addressed and studied by researchers, however. It is only through these types of reviews that our state of knowledge can be updated to help provide the latest information for clinicians in the field and to challenge researchers with future problems that need to be studied.
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Affiliation(s)
- Wahid Wassef
- University of Massachusetts Medical School, UMass Memorial Health Care, Worcester, 01655, USA.
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37
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Tsukada K. Metallic stent placement or gastroenterostomy for gastric outlet obstruction caused by gastric cancer? J Gastroenterol 2005; 40:1007-8. [PMID: 16261444 DOI: 10.1007/s00535-005-1700-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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38
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Abstract
Placement of self-expandable metal stents (SEMS) is an effective mode of palliative treatment for patients with malignant gastrointestinal obstruction. Gastrointestinal mucosal bleeding complicates about 5% of placement of SEMS but is not well described. We report three cases of gastrointestinal bleeding post-SEMS placement and suggest that bleeding is caused by direct mucosal infringement by the sharp edges of the ends of the stents.
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Affiliation(s)
- Chun-Tao Wai
- Department of Medicine, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore
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39
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Hayashi K, Okayama Y, Gotoh K, Ohara H, Sano H, Nakazawa T, Nakao H, Joh T, Itoh M. CLINICAL EVALUATION OF METALLIC STENTING FOR MALIGNANT DUODENAL OBSTRUCTION USING COVERED SELF-EXPANDABLE METALLIC STENT. Dig Endosc 2005. [DOI: 10.1111/j.1443-1661.2005.00509.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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40
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Morrison CP, Court FG, Teague BD, Metcalfe MS, Wemyss-Holden SA, Texler M, Dennison AR, Maddern GJ. Endoscopic perductal electrolytic ablation of the pancreas: experimental studies of morbidity and mortality. Dig Dis 2005; 23:83-91. [PMID: 15920329 DOI: 10.1159/000084730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Palliation of pancreatic cancer remains the only option for the majority of patients. Palliative techniques such as surgical bypass and endoscopic retrograde cholangiopancreatography (ERCP) with stenting are not ideal. The 'ideal' palliative technique would combine the efficacy of surgery with the minimal complications of an endoscopic procedure. Endoscopically delivered perductal electrolytic ablation of pancreatic lesions has the potential to meet these criteria. METHODS Fifteen pigs were used. The pancreatic duct was cannulated with an electrolysis catheter. Animals were randomised to either: controls, treatment 2-week survivor or treatment 8-week survivor. An electrolytic dose was administered to the treatment animals. Post-operatively, serum amylase and leucocyte count were assessed. Pancreata were histologically examined to detect evidence of acute pancreatitis. RESULTS Electrolysis was well tolerated. There was no difference in post-operative hyperamylasaemia and leucocyte count between the groups. Histological examination showed inflammation at the ablation site at 2 weeks, by 8 weeks this was replaced by scarring. CONCLUSION The results of this study suggest that endoscopic perductal electrolytic ablation of the pancreas is feasible and safe. Biochemical and histological findings indicate self-limiting localised inflammation of the pancreas. This technique may have a role in the palliation of pancreatic cancer and warrants further investigation.
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Affiliation(s)
- C P Morrison
- University of Adelaide, Department of Surgery, The Queen Elizabeth Hospital, Adelaide, SA, Australia
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41
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Telford JJ, Carr-Locke DL, Baron TH, Tringali A, Parsons WG, Gabbrielli A, Costamagna G. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study. Gastrointest Endosc 2004; 60:916-20. [PMID: 15605006 DOI: 10.1016/s0016-5107(04)02228-x] [Citation(s) in RCA: 151] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Endoscopic placement of self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction is safe and feasible. METHODS Patients with malignant gastric outlet obstruction undergoing enteral stent insertion were identified from endoscopy databases. Duration of oral intake after stent insertion was calculated by using the log-rank test. Factors associated with duration of oral intake were assessed by using Cox multivariable regression analysis. RESULTS A total of 176 patients (mean age 65 [14] years) treated at 4 centers from 1996 to 2003 were identified. Obstruction was caused by cancer of the pancreas in 84, the stomach in 20, the bile duct in 15, the major duodenal papilla in 8, another primary site in 16, and metastases in 33. The site of obstruction was the duodenum in 125, the distal stomach in 17, the stomach and the duodenum in 18, and surgical anastomosis in 16 patients. Stent deployment was technically successful in 173. Complications occurred in 14 patients. Seventeen patients were lost to follow-up. Of the remaining 159 patients, 133 resumed oral intake for a median time of 146 days: 95% CI [65, 202]. On regression analysis, chemotherapy after stent placement was associated with prolonged duration of oral intake (hazard ratio 0.41: 95% CI [0.23, 0.72]). CONCLUSIONS After enteral stent insertion for malignant gastric outlet obstruction, 84% of patients resumed oral intake for a median time of 146 days. Chemotherapy after enteral stent insertion was independently associated with prolongation of oral intake.
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Affiliation(s)
- Jennifer J Telford
- Endoscopy Center, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA
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42
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Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 2004; 60:1010-7. [PMID: 15605026 DOI: 10.1016/s0016-5107(04)02276-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroduodenal obstruction is a common preterminal event for patients with gastric and pancreatic cancer who often undergo palliative surgical bypass. Endoscopic palliation with self-expanding metallic stents has emerged as a safe and an effective alternative to surgery, but experience with the technique remains limited. METHODS Twenty-eight patients hospitalized with GI obstruction because of incurable gastric or pancreatic cancer were recruited for a prospective study of palliation with self-expanding metallic stents. Complications and clinical outcomes were assessed. OBSERVATIONS Stent insertion was technically successful in 26 patients. Thereafter, 24 patients resumed an adequate liquid or semisolid diet. Stent insertion facilitated hospital discharge for 20 patients. Occlusion of the stent because of tumor ingrowth occurred in 3 patients, but there was no complication related to stent insertion or the stent itself. CONCLUSIONS Endoscopic placement of a self-expanding metallic stent is a simple, effective means of palliation for patients with malignant gastroduodenal obstruction.
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Affiliation(s)
- Andrew P Holt
- Liver Transplant and Hepato-biliary Unit, Queen Elizabeth Hospital, Birmingham, UK
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43
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Solt J, Grexa E. Treatment of recurrent malignant obstruction with a flexible covered metal stent after gastric surgery. Gastrointest Endosc 2004; 60:813-7. [PMID: 15557967 DOI: 10.1016/s0016-5107(04)02195-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The management of gastric outlet obstruction with expandable metallic stents is difficult and frequently is associated with late complications. A new, flexible, covered metal stent has been developed, which may be suitable for treatment of patients with recurrent malignant strictures after gastric surgery. METHODS The stainless-steel stent is covered by a polyethylene membrane. It has a proximal funnel attached to an expanded antimigratory segment 29 mm in diameter. The flexible covering membrane connects isolated distal segments that are 20 mm in diameter. The stent is preloaded in a 6.7-mm-diameter introducer system. The structural features and the increased flexibility of this new prosthesis are intended to reduce the risk of migration and the frequency of late complications, and to broaden the range of applications. RESULTS This stent was used to successfully treat two patients with recurrent tortuous malignant strictures after partial or complete gastrectomy. CONCLUSIONS This new flexible, polyethylene-covered stent potentially is a new alternative for the palliation of patients with recurrent, inoperable gastric malignant strictures.
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Affiliation(s)
- Jeno Solt
- Department of Medicine I, Baranya County Hospital, Pécs, Hungary
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44
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Johnsson E, Thune A, Liedman B. Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation. World J Surg 2004; 28:812-7. [PMID: 15457364 DOI: 10.1007/s00268-004-7329-0] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.
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Affiliation(s)
- Erik Johnsson
- Department of Surgery and Transplantation, Sahlgrenska University Hospital/Sahlgrenska, 413 45, Göteborg, Sweden
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45
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Maetani I, Ikeda M, Shimura JI, Ukita T, Sakai Y. CURRENT STATE OF SELF-EXPANDABLE METALLIC STENT PLACEMENT FOR GASTRIC OUTLET OBSTRUCTION. Dig Endosc 2004. [DOI: 10.1111/j.1443-1661.2004.00364.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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46
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Abstract
BACKGROUND Patients with unresectable distal gastric cancer causing obstruction have classically undergone palliative gastrojejunostomy, but high mortality rates and delayed return of gastric emptying have been reported. The aim of the present study was to compare gastrojejunostomy and proximal gastric exclusion in patients with unresectable distal gastric cancer. METHODS Until 1996, patients with unresectable obstructing distal gastric cancer underwent antecolic gastrojejunostomy, but since 1997 we have performed proximal gastric exclusion for these patients. Mortality, morbidity, time taken to resume oral fluids and normal diet, length of palliation and survival were compared. RESULTS There was no mortality in either the gastrojejunostomy group (n = 4) or the exclusion group (n = 6). A single patient in the gastrojejunostomy group developed a sacral sore and another patient had recurrent vomiting following gastrojejunostomy. Exclusion resulted in a quicker return to diet and a slightly longer survival, although these were not statistically significant. CONCLUSION Proximal gastric exclusion offers a safe, quick and life-enduring palliation for unresectable malignant gastric outlet obstruction.
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Affiliation(s)
- Kevin Dolan
- Department of Surgery, The General Infirmary at Leeds, Leeds, United Kingdom.
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47
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N/A, 官 泳. N/A. Shijie Huaren Xiaohua Zazhi 2004; 12:199-201. [DOI: 10.11569/wcjd.v12.i1.199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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48
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Affiliation(s)
- Todd H Baron
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Foundation, Rochester, Minnesota, USA
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49
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Wassef W. Interventional endoscopy. Curr Opin Gastroenterol 2002; 18:669-77. [PMID: 17033346 DOI: 10.1097/00001574-200211000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Technologic milestones have been achieved in the field of interventional endoscopy. These have resulted in improved hemostasis, more accurate cancer staging, safer and less invasive methods of removing gastric neoplasms, and endoscopic palliation of malignant gastric outlet obstruction via stenting. However, just as these milestones are achieved, new challenges emerge: (1) How much sedation can one use safely? (2) What is the risk of transmitting infection and how can that be prevented? (3) Can scopes be made smaller and more comfortable? (4) Can optics be improved? (5) Can endoscopic repair of gastric perforations be safely performed? In this section, we review some of these issues. First, we will provide an update on the most recent concepts in the field of light sedation and infection control. Then, a review of the most commonly used interventional endoscopy procedures, including hemostasis, endosonography, endoscopic mucosal resection, stenting, and percutaneous gastrostomy tube placements. Finally, an overview of the ongoing research and development in the field of interventional endoscopy and how it can improve patient comfort, diagnostic accuracy, therapeutic efficacy, and training in the future.
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Affiliation(s)
- Wahid Wassef
- Division of Gastroenterology, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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50
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Abstract
Stents represent an exciting development in the field of gastroenterology. Their use to maintain luminal patency in the pancreatobiliary system has been well established. Stents have also found a place in maintaining the patency of the esophagus. Recent developments have led to an increasing role for their use to decompress both the small and large intestine. In the small intestine they are often placed to palliate proximal obstruction in the duodenum or the very proximal jejunum resulting from various malignancies. Self-expandable metal stents are an attractive alternative to surgery, especially in patients with compromised performance status, and can be done safely as outpatient procedures. However, one should be aware of the associated risks and complications. With a proper understanding of the principles involved in stent placement one can safely undertake this procedure.
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Affiliation(s)
- Sandeep Singh
- Division of Gastrointestinal Medicine and Nutrition, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 436, Houston, TX 77030, USA
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