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Su HJ, Chen CC, Kuo YT, Han ML, Tsai MC, Liu KL, Wang HP. Clinical outcomes of different types of metallic stents in malignant distal duodenum stenosis: A retrospective study. J Formos Med Assoc 2024; 123:854-859. [PMID: 38171957 DOI: 10.1016/j.jfma.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 12/06/2023] [Accepted: 12/20/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND/PURPOSE Endoscopic stenting at malignant distal duodenum stenosis (MDDS) is challenging because of the duodenal C-loop configuration, the acute angle of the duodenojejunal junction, and the limited length of the endoscope. Few studies have investigated the clinical outcomes of stenting at the distal duodenum. Therefore, this study aimed to investigate the clinical outcomes of treating MDDS with different types of metallic stents. METHODS From January 2012 to December 2020, fifty-six patients with MDDS who underwent duodenal stenting were enrolled for analysis. Thirty-five patients received uncovered self-expandable metallic stents (UC-SEMS), and twenty-one patients received partially covered self-expandable metallic stents (PC-SEMS). All patients were followed up till death or for 18 months. The clinical success rate, stent dysfunction rate, and stent patency were compared between the groups. Multivariate analysis was conducted to identify factors related to stent dysfunction. RESULTS The clinical success rates were 85.7 % in both the UC-SEMS and PC-SEMS groups. Stent dysfunction rates (UC-SEMS: 34.3 %, PC-SEMS: 38.1 %, p = 0.773) and the average stent patency (UC-SEMS: 117.2 days, PC-SEMS: 100.0 days, p = 0.576) were not statistically different between the groups. Multivariate analysis disclosed the age ≥65 years was significantly related to stent dysfunction (odds ratio: 4.78, p = 0.031). CONCLUSION Both UC-SEMS and PC-SEMS are safe and effective treatment options for MDDS. However, stent dysfunction remains a significant issue to overcome, particularly in the elderly. Further research is needed to explore novel strategies that can improve the effectiveness of stent placement and reduce the risk of stent dysfunction.
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Affiliation(s)
- Hau-Jyun Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chieh-Chang Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yu-Ting Kuo
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Endoscopy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Lun Han
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Division of Endoscopy, Department of Integrated Diagnostics and Therapeutics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chang Tsai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan; School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imaging, National Taiwan University Cancer Center, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Fugazza A, Andreozzi M, Asadzadeh Aghdaei H, Insausti A, Spadaccini M, Colombo M, Carrara S, Terrin M, De Marco A, Franchellucci G, Khalaf K, Ketabi Moghadam P, Ferrari C, Anderloni A, Capretti G, Nappo G, Zerbi A, Repici A. Management of Malignant Gastric Outlet Obstruction: A Comprehensive Review on the Old, the Classic and the Innovative Approaches. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:638. [PMID: 38674284 PMCID: PMC11052138 DOI: 10.3390/medicina60040638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/31/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
Gastrojejunostomy is the principal method of palliation for unresectable malignant gastric outlet obstructions (GOO). Gastrojejunostomy was traditionally performed as a surgical procedure with an open approach butrecently, notable progress in the development of minimally invasive procedures such as laparoscopic gastrojejunostomies have emerged. Additionally, advancements in endoscopic techniques, including endoscopic stenting (ES) and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are becoming more prominent. ES involves the placement of self-expandable metal stents (SEMS) to restore luminal patency. ES is commonly the first choice for patients deemed unfit for surgery or at high surgical risk. However, although ES leads to rapid improvement of symptoms, it carries limitations like higher stent dysfunction rates and the need for frequent re-interventions. Recently, EUS-GE has emerged as a potential alternative, combining the minimally invasive nature of the endoscopic approach with the long-lasting effects of a gastrojejunostomy. Having reviewed the advantages and disadvantages of these different techniques, this article aims to provide a comprehensive review regarding the management of unresectable malignant GOO.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Marta Andreozzi
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Hamid Asadzadeh Aghdaei
- Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Agustin Insausti
- Department of Gastroenterology and Digestive Endoscopy, Medical Association Hospital, IGEA Institute, Patricios 347, Bahia Blanca B8000, Argentina;
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Maria Terrin
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Alessandro De Marco
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Gianluca Franchellucci
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada;
| | - Pardis Ketabi Moghadam
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Chiara Ferrari
- Division of Anaesthesiology, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
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Diamantopoulos A, Choudhury SR, Irani FG, Tinto HR, Sabharwal T. CIRSE Standards of Practice on Placement of Upper Gastrointestinal Stents. Cardiovasc Intervent Radiol 2023; 46:562-572. [PMID: 36918426 PMCID: PMC10156831 DOI: 10.1007/s00270-023-03395-0] [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] [Received: 04/04/2022] [Accepted: 02/13/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Image-guided insertion of stents in the upper gastrointestinal trunk is an effective, minimally invasive treatment option to provide immediate relief of symptoms caused by upper gastrointestinal tract obstruction related to advanced-stage malignant causes or benign causes that lead to lumen narrowing. PURPOSE This document, as with all CIRSE Standards of Practice documents, is not intended to impose a standard of clinical patient care but will recommend a reasonable approach to best practices for performing stenting of the upper gastrointestinal tract, namely the oesophageal and gastroduodenal segments. Our purpose is to provide up-to-date recommendations for placement of upper gastrointestinal tract stents based on the previously published guidelines on this topic in 2005 and 2007. METHODS The writing group was established by the CIRSE Standards of Practice Committee and consisted of a group of internationally recognised experts in performing upper gastrointestinal stenting. The writing group reviewed the existing literature using PubMed to search for relevant publications in the English language up to September 2021. The final recommendations were formulated through consensus. CONCLUSION Insertion of stents in the oesophageal and gastroduodenal tracts has an established role in the successful management of malignant or benign obstructions. This Standards of Practice document provides up-to-date recommendations for the safe performance of upper gastrointestinal stent placement.
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Affiliation(s)
- Athanasios Diamantopoulos
- Department of Interventional Radiology, Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK. .,School of Biomedical Engineering & Imaging Sciences, Faculty of Life Sciences & Medicine, Kings College London, London, UK.
| | - Shuvro Roy Choudhury
- Radiology, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Farah Gillian Irani
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Singapore, Singapore
| | - Hugo Rio Tinto
- Radiology Department, Champalimaud Foundation, Lisbon, Portugal
| | - Tarun Sabharwal
- Department of Interventional Radiology, Guy's and St. Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
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Chamely EA, Hoang B, Jafri NS, Felinski MM, Bajwa KS, Walker PA, Barge J, Wilson EB, Cen P, Shah SK. Palliative Endoscopic Salvage of a Functionally Obstructed Gastrojejunostomy - Report of Technique. CRSLS : MIS CASE REPORTS FROM SLS 2022; 9:e2021.00094. [PMID: 36016812 PMCID: PMC9387390 DOI: 10.4293/crsls.2021.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Gastric outlet obstruction secondary to foregut gastrointestinal malignancies can be managed with a variety of medical, endoscopic, and surgical options. Laparoscopic gastrojejunostomy is an option for those patients who are able to tolerate an operation as a long-term palliative option. This operation may be associated with some significant postoperative technical and nontechnical complications, including delayed gastric emptying. This paper describes an incision-less, endoscopic option that we propose can be used to salvage a functionally obstructed gastrojejunostomy. CASE DESCRIPTION A 57-year old male patient had a history of pancreatic adenocarcinoma causing gastric outlet obstruction and underwent a previously created surgical gastrojejunostomy at an outside hospital. His procedure was complicated by anastomotic leak and essentially persistent obstructive symptoms secondary to delayed gastric emptying. Though his anastomosis was demonstrably patent, these symptoms were thought to be secondary to a functional obstruction at the gastrojejunostomy. After repeated workups and many failed attempts to treat these symptoms, he ultimately underwent endoscopic placement of an uncovered colonic stent into the efferent limb of his gastrojejunostomy. This allowed for preferential drainage of gastric contents down the efferent limb, and improvement of his delayed gastric emptying. CONCLUSIONS In a select group of patients with advanced foregut malignancy, and with high re-operative risks, salvage endoscopic stenting may be useful in the palliation of symptoms from a functionally obstructed gastrojejunostomy.
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Affiliation(s)
- Elias A Chamely
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan Hoang
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Nadim S Jafri
- Michael E DeBakey Institute of Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX
| | - Melissa M Felinski
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Kulvinder S Bajwa
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Peter A Walker
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Erik B Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Putao Cen
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
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Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2021. [PMID: 32390697 DOI: 10.3748/wjg.v26.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy.
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Kwon JH, Gwon DI, Kim JW, Chu HH, Kim JH, Ko GY, Yoon HK, Sung KB. Percutaneous Biliary Metallic Stent Insertion in Patients with Malignant Duodenobiliary Obstruction: Outcomes and Factors Influencing Biliary Stent Patency. Korean J Radiol 2020; 21:695-706. [PMID: 32410408 PMCID: PMC7231609 DOI: 10.3348/kjr.2019.0753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To investigate the technical and clinical efficacy of the percutaneous insertion of a biliary metallic stent, and to identify the factors associated with biliary stent dysfunction in patients with malignant duodenobiliary obstruction. MATERIALS AND METHODS The medical records of 70 patients (39 men and 31 women; mean age, 63 years; range, 38-90 years) who were treated for malignant duodenobiliary obstruction at our institution between April 2007 and December 2018, were retrospectively reviewed. Variables found significant by univariate log-rank analysis (p < 0.2) were considered as suitable candidates for a multiple Cox's proportional hazard model. RESULTS The biliary stents were successfully placed in all 70 study patients. Biliary stent insertion with subsequent duodenal stent insertion was performed in 33 patients and duodenal stent insertion with subsequent biliary stent insertion was performed in the other 37 study subjects. The median patient survival and stent patency time were 107 days (95% confidence interval [CI], 78-135 days) and 270 days (95% CI, 95-444 days), respectively. Biliary stent dysfunction was observed in 24 (34.3%) cases. Multiple Cox's proportional hazard analysis revealed that the location of the distal biliary stent was the only independent factor affecting biliary stent patency (hazard ratio, 3.771; 95% CI, 1.157-12.283). The median biliary stent patency was significantly longer in patients in whom the distal end of the biliary stent was beyond the distal end of the duodenal stent (median, 327 days; 95% CI, 249-450 days), rather than within the duodenal stent (median, 170 days; 95% CI, 115-225 days). CONCLUSION The percutaneous insertion of the biliary metallic stent appears to be a technically feasible, safe, and effective method of treating malignant duodenobiliary obstruction. In addition, a biliary stent system with a distal end located beyond the distal end of the duodenal stent will contribute towards longer stent patency in these patients.
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Affiliation(s)
- Ji Hye Kwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
| | - Jong Woo Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hee Ho Chu
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gi Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hyun Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kyu Bo Sung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Troncone E, Fugazza A, Cappello A, Blanco GDV, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2020; 26:1847-1860. [PMID: 32390697 PMCID: PMC7201143 DOI: 10.3748/wjg.v26.i16.1847] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/06/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
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Park S, Shin JH, Han K. Interventional radiology for post-gastrectomy complications. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii180020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Suyoung Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kichang Han
- Division of Interventional Radiology, Department of Radiology, Severance Hospital, Yonsei University, Seoul, Korea
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Wang Z, Park JH, Kim KY, Choi J, Hu H, Bekheet N, Yoon SH, Song HY. Fluoroscopy-Guided Peroral Placement of a Self-Expandable Metallic Stent for Malignant Jejunal Obstruction in a Non-surgically Altered Stomach. Cardiovasc Intervent Radiol 2018; 42:145-149. [PMID: 30088059 DOI: 10.1007/s00270-018-2048-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 07/28/2018] [Indexed: 11/29/2022]
Abstract
Malignant small bowel obstruction is a common and distressing complication in advanced cancer patients. Recently, stent placement was reported to be a safe and effective alternative treatment. However, there are only a few case reports associated with stent placement in malignant jejunal obstruction. Furthermore, most patients had a history of gastrectomy before stent placement, which shortens the catheterization pathway. In our case series, we present five cases of malignant proximal jejunal obstruction in a non-surgically altered stomach in the management of fluoroscopy-guided self-expandable metallic stent placement and discuss the interventional management and clinical outcomes. LEVEL OF EVIDENCE: Level 4, Case Series.
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Affiliation(s)
- Zhe Wang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Radiology, Tianjin Medical University General Hospital, Anshan Road 154, Heping District, 300052, People's Republic of China
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Kun Yung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Joonmyeong Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hongtao Hu
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea.,Department of Minimal-Invasive Intervention, The Affiliated Cancer Hospital of Zhengzhou University, 127 Dongming Road, Zhengzhou city, 450003, Henan Province, China
| | - Nader Bekheet
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea.,Gastrointestinal Endoscopy and Liver Unit, Kasr Al-Ainy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sung Hwan Yoon
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 05505, Republic of Korea. .,Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olymic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
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11
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Bekheet N, Kim MT, Park JH, Kim KY, Tsauo J, Zhe W, Lim YJ, Song HY. Fluoroscopic Gastroduodenal Stent Placement in 55 Patients with Endoscopic Stent Placement Failure. Cardiovasc Intervent Radiol 2018. [PMID: 29541839 DOI: 10.1007/s00270-018-1933-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the technical feasibility and clinical effectiveness of fluoroscopic self-expandable metal stent (SEMS) placement in malignant gastroduodenal obstructions after failed endoscopic SEMS placement. MATERIALS AND METHODS Between September 2010 and July 2017, 874 patients underwent endoscopic SEMS placement for dysphagia caused by malignant gastroduodenal obstructions. Endoscopic SEMS placement failed in 55 of 874 patients (6.3%). These patients were referred for fluoroscopic SEMS placement. In case of failed fluoroscopic SEMS placement, combined endoscopic and fluoroscopic SEMS placement was attempted at the same setting. RESULTS Fluoroscopic SEMS placement was technically successful in 40 of 55 patients (72.7%). Combined endoscopic and fluoroscopic SEMS placement was technically successful in 6 of 15 patients with fluoroscopic SEMS placement failure. Failures in the nine patients were due to complete obstruction (n = 5) and acute angulation at the stricture site (n = 4). The overall technical success rate was 83.6% (46/55). Clinical success was achieved in 95.6% of patients (44/46). Complications occurred in 7 of 46 patients (15.2%), including tumor overgrowth (n = 3), SEMS migration (n = 3), and bleeding (n = 1). The median SEMS patency and patient survival periods were 515 (95% confidence interval (CI), 266.6-761.5) and 83 (95% CI 60.6-105.4) days, respectively. CONCLUSIONS Fluoroscopic SEMS placement is technically feasible and clinically effective in cases of endoscopic SEMS placement failure. A combined endoscopic and fluoroscopic approach increases the technical success rate after failure of the endoscopic or fluoroscopic approach. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Nader Bekheet
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.,Gastrointestinal Endoscopy and Liver Unit, Kasr Al-Ainy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Min Tae Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.,Department of Radiologic Technology, Cheju Halla University, Jeju, Republic of Korea
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.,Department of Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Kun Yung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Wang Zhe
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Young Je Lim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
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12
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Bulut E, Çiftçi T, Akhan O, Akıncı D. Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches. Diagn Interv Radiol 2018; 23:211-216. [PMID: 28209556 DOI: 10.5152/dir.2016.16165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE We aimed to evaluate the safety and effectiveness of fluoroscopy-guided gastroduodenal metallic stent placement with different approaches in malignant obstruction. METHODS We retrospectively assessed 53 patients (33 men and 20 women; mean age, 58.7±15 years) who underwent stent placement between February 2004 and April 2014. All patients had unresectable tumors. The most common causes of obstruction were gastric (38%) and pancreatic cancers (36%). Uncovered self-expandable metallic stents (SEMS) were placed under fluoroscopic guidance. In addition to transoral approach in 46 patients (86.7%), transgastric and transhepatic approaches were used in six patients (11.3%) and one patient (1.8%), respectively. Gastric outlet obstruction scoring system (GOOSS) was used to evaluate oral intake before and after stenting. Patients were followed until death or the end of the study. RESULTS Technical and clinical success rates were 100% and 92%, respectively. The median stent patency was 76 days (range, 4-985 days). Mean preprocedural GOOSS score of 0.1 increased to postprocedural GOOSS score of 2.42 (P < 0.001). Afferent loop decompression was achieved in one symptomatic patient. Neither mortality nor major complications occurred due to stenting. Stent migration occurred in one patient (2%) and stent obstruction occurred in two patients (4%). Combined biliary and duodenal stenting were performed in 21 patients (40%). Post-stenting GOOSS scores were predictive of survival (P = 0.003). CONCLUSION Fluoroscopic metallic stent placement for palliation of malignant gastroduodenal obstruction is safe and effective with high technical and clinical success rates and minimal complications. High technical success rates can be achieved using different approaches.
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Affiliation(s)
- Elif Bulut
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey.
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13
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Kim KY, Tsauo J, Kim PH, Park JH, Wang Z, Kim MT, Song HY. Acute Biliary Obstruction After Gastroduodenal Covered Self-Expanding Metallic Stent Placement in Patients with Previous Biliary Stent Placement for Periampullary Cancer: Frequency and Protective Factors. Cardiovasc Intervent Radiol 2017; 41:603-609. [DOI: 10.1007/s00270-017-1823-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 10/12/2017] [Indexed: 01/08/2023]
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14
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Bektaş H, Gürbulak B, Düzköylü Y, Çolak Ş, Gürbulak EK, Çakar E, Bayrak S. Clinical Outcomes of Upper Gastrointestinal Stents and Review of Current Literature. JSLS 2017; 21:JSLS.2017.00058. [PMID: 29162972 PMCID: PMC5683815 DOI: 10.4293/jsls.2017.00058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The self-expandable metal stent (SEMS) is an alternative for several possible surgical and palliative treatments of upper gastrointestinal obstructions that occur in several disease states. The present study was performed to describe a single-center experience with upper gastrointestinal stents. METHODS All patients at a single center who had an SEMS placed for the treatment of obstruction over a 3-year period were retrospectively evaluated. Pre- and postoperative dysphagia scoring was calculated and used to evaluate postprocedure improvement in quality of life. Procedural success and early and late complication rates were investigated. RESULTS A total of 171 endoscopic procedures were performed in 73 patients. Procedural success was 95.8% (n = 69) and dilatation was performed in 80 patients. The rate of perioperative complication was 26% (n = 19). After 1 month, stents were patent in all patients (n = 73). Stent obstruction was noted in 6 patients: 2 each at 2, 7, and 10 months. CONCLUSION SEMS usage for palliative and curative purposes in benign or malignant upper gastrointestinal system obstructions is an efficient and reliable treatment method with advantages, such as shortening hospital stay, decreased pain, cost-effectiveness, and low mortality-morbidity rates when compared to surgical procedures, and a high rate of clinical success.
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Affiliation(s)
- Hasan Bektaş
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Bünyamin Gürbulak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Yiğit Düzköylü
- Department of Gastroenterological Surgery, Turkiye Yuksek Ihtisas Training and Research Hospital, Ankara, Turkey
| | - Şükrü Çolak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Esin Kabul Gürbulak
- Department of General Surgery, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ekrem Çakar
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Savaş Bayrak
- Department of General Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey
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15
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Kim GB, Park JH, Song HY, Kim N, Song HK, Kim MT, Kim KY, Tsauo J, Jun EJ, Kim DH, Lee GH. 3D-printed phantom study for investigating stent abutment during gastroduodenal stent placement for gastric outlet obstruction. 3D Print Med 2017; 3:10. [PMID: 29782574 PMCID: PMC5954787 DOI: 10.1186/s41205-017-0017-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/05/2017] [Indexed: 01/17/2023] Open
Abstract
Background Placing a self-expandable metallic stent (SEMS) is safe and effective for the palliative treatment of malignant gastroduodenal (GD) strictures. SEMS abutment in the duodenal wall is associated with increased food impaction, resulting in higher stent malfunction and shorter stent patency. The desire to evaluate the mechanism and significance of stent abutment led us to design an in vitro experiment using a flexible anthropomorphic three-dimensional (3D)-printed GD phantom model. Results A GD phantom was fabricated using 3D printer data after performing computed tomography gastrography. A partially covered (PC) or fully covered (FC) stent was placed so that its distal end abutted onto the duodenal wall in groups PC-1 and FC-1 or its distal end was sufficiently directed caudally in groups PC-2 and FC-2. The elapsed times of the inflowing of three diets (liquid, soft, and solid) were measured in the GD phantom under fluoroscopic guidance. There was no significant difference in the mean elapsed times for the liquid diet among the four groups. For the soft diet, the mean elapsed times in groups PC-1 and FC-1 were longer than those in groups PC-2 and FC-2 (P = 0.018 and P < 0.001, respectively). For the solid diet, the mean elapsed time in group PC-1 was longer than that in group PC-2 (P < 0.001). The solid diet could not pass in group FC-1 due to food impaction. The mean elapsed times were significantly longer in groups FC-1 and FC-2 than in groups PC-1 and PC-2 for soft and solid diets (all P < 0.001). Conclusions This flexible anthropomorphic 3D-printed GD phantom study revealed that stent abutment can cause prolonged passage of soft and solid diets through the stent as well as impaction of solid diets into the stent.
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Affiliation(s)
- Guk Bae Kim
- 1Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Jung-Hoon Park
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Ho-Young Song
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea.,6Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736 Republic of Korea
| | - Namkug Kim
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea.,3Department of Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea.,5Department of Radiology and Convergence Medicine, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736 Republic of Korea
| | - Hyun Kyung Song
- 1Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Min Tae Kim
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Kun Yung Kim
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Jiaywei Tsauo
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Eun Jung Jun
- 2Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Do Hoon Kim
- 4Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
| | - Gin Hyug Lee
- 4Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, Republic of Korea
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16
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Kim SH, Song HY, Park JH, Zhou WZ, Cho YC, Shin JH, Kim JH. Fluoroscopic-guided stent placement in failed tentative endoscopic approaches to malignant gastroduodenal obstructions. Acta Radiol 2017; 58:959-963. [PMID: 28084810 DOI: 10.1177/0284185116682379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background Fluoroscopic or endoscopic placement of metallic stents is used as a safe, non-surgical, palliative treatment option for malignant gastroduodenal obstructions. However, endoscopic stent placement is not always feasible, due to the tight or tortuous stricture of the obstructed area and insufficient visualization of the stomach due to remnant food material. Purpose To assess the technical feasibility and clinical outcomes of fluoroscopic-guided stent placement in malignant gastroduodenal obstructions following the technical failure of endoscopic stent placement. Material and Methods In all, 19 patients (14 men, 5 women; age range, 36-85 years) were referred due to technical failures of tentative endoscopic stent placement. Indications were failure to pass the guide wire through the obstruction (n = 13), failure to reach the stricture lesion due to short endoscope (n = 5), and acute angulation of the stricture lesion (n = 1). Data were retrospectively collected regarding the technical and clinical success of the fluoroscopy, the dysphagia score before and after stent placement, and major complications and their management. Results Fluoroscopic stent placement was technically successful in 15/19 patients (79%). Failures were due to complete obstruction (n = 3) and acute angulation of the stricture lesion (n = 1). Clinical success was achieved in all 15 patients with successful stent placement. The dysphagia score significantly improved after stent placement ( P < 0.001). Complications occurred in 4/15 patients (27%), including tumor overgrowth (n = 2), stent collapse (n = 1), and jaundice (n = 1). Conclusion Fluoroscopic stent placement in malignant gastroduodenal obstructions following a technical failure of endoscopic stent placement is technically feasible and has an acceptable clinical outcome.
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Affiliation(s)
- Soo Hwan Kim
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho-Young Song
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Hoon Park
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- 2 Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wei-Zhong Zhou
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- 3 Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Young Chul Cho
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ji Hoon Shin
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hyoung Kim
- 1 Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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17
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Significance of Stent Abutment in Gastroduodenal Stent Placement for Gastric Outlet Obstructions. J Vasc Interv Radiol 2017; 28:1147-1153. [PMID: 28291717 DOI: 10.1016/j.jvir.2017.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/11/2017] [Accepted: 01/24/2017] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To evaluate the frequency, severity, and clinical significance of stent abutment (SA) after gastroduodenal stent placement in patients with gastric outlet obstruction caused by unresectable gastric cancer. MATERIALS AND METHODS A retrospective study was conducted in a single tertiary referral university hospital to identify the incidence and clinical significance of SA in 318 patients who underwent self-expandable metallic stent placement. SA was defined as abutment of the distal end of the stent to the duodenal wall and/or superior duodenal flexure. The outcomes included technical and clinical success, complications, repeat intervention, stent patency, and survival. RESULTS A total of 318 patients, 107 with SA (33.6%) and 211 without, were included. SA occurred partially (n = 64; 59.8%) and completely (n = 43; 40.2%). The technical and clinical outcomes and survival were similar in the groups with and without SA. Food impaction and resultant repeat intervention rates were higher in the SA group than in the non-SA group (P < .001 and P < .001, respectively), and were associated with complete SA (P = .007). Stent patency rate was lower in the SA group than in the non-SA group (P = .003). CONCLUSIONS SA was associated with increased food impaction, resulting in a greater incidence of stent malfunction and shorter stent patency compared with a lack of SA. The concept of SA may be useful for the improvement of stent patency and avoidance of food impaction.
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18
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Predictors of stent dysfunction after self-expandable metal stent placement for malignant gastric outlet obstruction: tumor ingrowth in uncovered stents and migration of covered stents. Surg Endosc 2017; 31:4165-4173. [DOI: 10.1007/s00464-017-5471-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 02/15/2017] [Indexed: 10/25/2022]
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Lee CM, Choi IK, Kim JH, Park DW, Kim JS, Park SH. Is noncurative gastrectomy always a beneficial strategy for stage IV gastric cancer? Ann Surg Treat Res 2016; 92:23-27. [PMID: 28090502 PMCID: PMC5234432 DOI: 10.4174/astr.2017.92.1.23] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/18/2016] [Accepted: 09/07/2016] [Indexed: 12/11/2022] Open
Abstract
Purpose The purpose of this study is to suggest a treatment strategy for stage IV gastric cancer by investigating the behavioral difference between initially and recurrent metastatic disease. Methods We reviewed the medical records of the patients who underwent chemotherapy alone for metastatic gastric cancer between January 2006 and September 2013. Patients were divided into those who underwent chemotherapy for metastatic disease since initial diagnosis (IM group) and for metastatic recurrence after curative surgery (RM group). Survival and causes of death were compared between the 2 groups, and significant prognostic factors were also investigated. Results A total of 170 patients were enrolled in this study. Of these patients, 104 were included in the IM group and 66 in the RM group. Overall survival of the IM group did not differ from that of RM (P = 0.569). In the comparison of the causes of death, the IM group had a greater tendency to die from bleeding (P = 0.054) and pneumonia (P = 0.055). In multivariate analysis, bone metastasis (P < 0.001; HR = 2.847), carcinoma peritonei (P = 0.047; HR = 1.766), and the frequency of chemotherapy (P < 0.001; HR = 0.777) were significantly associated with overall survival of IM group. Conclusion Disease-burden mainly contributes to the prognosis of metastatic gastric cancer, although noncurative gastrectomy may be helpful in reducing the mortality of initially metastatic disease. Therefore, disease-burden should be also prioritized in determining the treatment strategies for stage IV gastric cancer.
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Affiliation(s)
- Chang Min Lee
- Department of Surgery, Korea University Medical Center, Seoul, Korea.; Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - In Keun Choi
- Department of Oncology, Korea University Medical Center, Seoul, Korea.; Department of Oncology, Korea University College of Medicine, Seoul, Korea
| | - Jong-Han Kim
- Department of Surgery, Korea University Medical Center, Seoul, Korea.; Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Da Won Park
- Department of Surgery, Korea University Medical Center, Seoul, Korea.; Department of Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jun Suk Kim
- Department of Oncology, Korea University Medical Center, Seoul, Korea.; Department of Oncology, Korea University College of Medicine, Seoul, Korea
| | - Seong-Heum Park
- Department of Surgery, Korea University Medical Center, Seoul, Korea.; Department of Surgery, Korea University College of Medicine, Seoul, Korea
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20
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Tsauo J, Yoo MW, Song HY, Hwang DW, Park JH, Ryu MH, Kim SC, Lee JH, Choi KD, Kim JH, Kim DH. Partially-covered stent placement versus surgical gastrojejunostomy for the palliation of malignant gastroduodenal obstruction secondary to pancreatic cancer. Abdom Radiol (NY) 2016; 41:2233-2240. [PMID: 27290721 DOI: 10.1007/s00261-016-0810-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE To compare the outcomes of partially covered self-expandable metallic stent (SEMS) placement with surgical gastrojejunostomy (GJ) in patients with gastroduodenal obstruction caused by pancreatic cancer. METHODS The medical records of 107 patients with gastroduodenal obstruction caused by pancreatic cancer who underwent fluoroscopic partially covered SEMS placement (n = 75) or surgical GJ (n = 32) at our institution were reviewed. RESULTS The technical (100% vs. 100%; P > 0.999) and clinical (98.7% vs. 96.9%; P = 0.511) success rates were similar between the SEMS and GJ group. The mean gastric outlet obstruction scoring system score was higher in the SEMS group at 1 week after treatment (2.3 ± 0.5 vs. 1.2 ± 0.4; P < 0.001) but was similar between the two groups at 1 month (2.7 ± 0.5 vs. 2.8 ± 0.5; P = 0.242). The median hospital stay was shorter in the SEMS group than in the GJ group (7 vs. 14 days; P < 0.001). The overall complication (22.7% vs. 28.1%; P = 0.547) and reintervention (21.3% vs. 25.0%; P = 0.677) rates were similar between the two groups. The median patency (99 vs. 138 days; P = 0.102) and survival (106 vs. 140 days; P = 0.245) were also similar between the two groups. CONCLUSION The outcomes of partially covered SEMS placement seem to be more favorable than surgical GJ in patients with gastroduodenal obstruction caused by pancreatic cancer.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Moon-Won Yoo
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea.
| | - Dae Wook Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Min-Hee Ryu
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Song Cheol Kim
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul, 138-736, Republic of Korea
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Park JH, Song HY, Yun SC, Yoo MW, Ryu MH, Kim JH, Kim DH, Lee JH, Zhou WZ, Yook JH, Jung HY. Gastroduodenal stent placement versus surgical gastrojejunostomy for the palliation of gastric outlet obstructions in patients with unresectable gastric cancer: a propensity score-matched analysis. Eur Radiol 2016; 26:2436-2445. [PMID: 26662027 DOI: 10.1007/s00330-015-4106-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/12/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To compare the outcomes between stent placement and surgical gastrojejunostomy (GJ) for the palliation of gastric outlet obstruction (GOO) in patients with unresectable gastric cancer. METHODS A retrospective study was performed in a single university hospital in 224 patients with GOO, and who were treated either by stent placement (n = 124) or surgical GJ (n = 100). The outcomes were assessed with reference to the following variables with the use of propensity-score matching: success rates; complications; dysphagia scores, albumin, and body mass index; survival; symptom-free duration; and hospitalization. RESULTS We identified a well-balanced cohort of 74 pairs of patients, matched on the basis of propensity score. The dysphagia score 7 days after treatment was significantly better in the stent group (P < 0.001). Albumin level 1 month after treatment was significantly lower in the stent group (P < 0.001). Symptom-free duration and hospitalization were significantly longer in the surgery group (P = 0.002, P < 0.001, respectively). The recurrence rate was significantly higher in the stent group (P = 0.032). CONCLUSIONS Stent placement can provide faster symptom relief and shorter hospitalization, while surgical GJ can provide longer symptom-free duration, less recurrent obstruction symptoms and better nutritional status. KEY POINTS • The two methods are equally effective in palliating gastric outlet obstruction symptoms • The stent group showed rapid and efficient palliation of symptoms • Recurrent symptoms were more frequent in the stent group • Surgical gastrojejunostomy provides a longer symptom-free duration and better nutritional status.
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Affiliation(s)
- Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olymic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olymic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
| | - Sung-Cheol Yun
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Moon-Won Yoo
- Department of General Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min-Hee Ryu
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olymic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Wei-Zhong Zhou
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olymic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jeong Hwan Yook
- Department of General Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Tsauo J, Park JH, Song HY. Development of gastroduodenal self-expandable metallic stents: 30 years of trial and error. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Laasch HU, Edwards DW, Song HY. Enteral stent construction: Current principles. GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Derek W. Edwards
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Ho-Young Song
- Department of Radiology, Asan Medical Center, Seoul, Korea
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Outcomes of endoscopically inserted self-expandable metal stents in malignancy according to the type of stent and the site of obstruction. Surg Endosc 2015. [PMID: 26715018 DOI: 10.1007/s00464-015-4712-x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2022]
Abstract
BACKGROUND/AIMS Self-expandable metal stents (SEMSs) can be used for the palliation of malignant obstruction in the upper gastrointestinal tract. This study assessed the feasibility and efficacy of endoscopically inserted SEMSs for the palliation of malignant obstruction in the stomach and duodenum. METHODS Between January 2011 and April 2014, 220 patients with gastric or duodenal obstruction due to malignancy underwent endoscopic SEMS insertion at Asan Medical Center. The associations of technical/clinical outcomes and complications with the type of stent and site of obstruction were analyzed. RESULTS The 220 patients included 125 men (56.8 %) and 95 women (43.2 %); median patient age was 63 years. Fully covered, partially covered, and uncovered SEMSs were inserted into 16, 77, and 120 patients, respectively. Obstructions were located in the gastric outlet, including the duodenal bulb, in 106 patients, and in the duodenal second and third portions in 114 patients. Technical success was achieved in 213 of 220 patients (96.8 %) and clinical success in 184 of 213 (86.4 %). Clinical success rates were similar to the type of stent, but were significantly greater for gastric outlet (95/104, 91.3 %) than for duodenal (89/109, 81.7 %) obstructions (p = 0.039). Stent migration was observed in 20 patients (9.1 %) and stent obstruction in 51 (23.2 %). Rates of stent migration were significantly higher for fully covered (6/16, 37.5 %) than for partially covered (7/77, 9.1 %) and uncovered (7/120, 5.8 %) SEMSs (p < 0.001) and were significantly higher for gastric outlet (16/104, 15.4 %) than for duodenal (4/109, 1.2 %) obstructions (p = 0.003). Rates of stent obstruction were similar for fully covered (2/16, 12.5 %), partially covered (17/77, 22.1 %), and uncovered (32/120, 26.7 %) SEMSs (p = 0.409) and in patients with gastric outlet (26/104, 25.0 %) and duodenal (25/109, 22.9 %) obstruction (p = 0.724). CONCLUSIONS SEMS selection for malignant obstruction of the upper gastrointestinal tract depends on the site of obstruction.
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Jung K, Ahn JY, Jung HY, Cho CJ, Na HK, Jung KW, Lee JH, Kim DH, Choi KD, Song HJ, Lee GH, Kim JH. Outcomes of endoscopically inserted self-expandable metal stents in malignancy according to the type of stent and the site of obstruction. Surg Endosc 2015; 30:4001-10. [DOI: 10.1007/s00464-015-4712-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 11/27/2015] [Indexed: 12/14/2022]
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26
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Zhao L, Xu H, Zhang Y. Palliation double stenting for malignant biliary and duodenal obstruction. Exp Ther Med 2015; 11:348-352. [PMID: 26889267 DOI: 10.3892/etm.2015.2875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 10/17/2014] [Indexed: 11/06/2022] Open
Abstract
The surgical management of patients with malignant biliary and duodenal obstruction is complex. Tumor excision is no longer possible in the majority of patients with malignant obstructive jaundice and duodenal obstruction. The aim of the present study was to evaluate the effectiveness of intraluminal dual stent placement in malignant biliary and duodenal obstruction. In total, 20 patients with malignant obstructive jaundice and duodenal obstruction, including 6 with pancreatic carcinoma, 11 with cholangiocarcinoma, 1 with duodenal carcinoma and 2 with abdominal lymph node metastasis, were treated with intraluminal stent placement. Bile duct obstruction with late occurrence of duodenal obstruction was observed in 16 cases, and duodenal obstruction followed by a late occurrence of bile duct obstruction was observed in 3 cases, while, in 1 case, bile duct obstruction and duodenal obstruction occurred simultaneously. After X-ray fluoroscopy revealed obstruction in the bile duct and duodenum, stents were placed into the respective lumens. Percutaneous transhepatic placement was employed for the biliary stent, while the duodenal stent was placed perioraly. The clinical outcomes, including complications associated with the procedures and patency of the stents, were evaluated. The biliary and duodenal stents were successfully implanted in 18 patients and the technical success rate was 90% (18/20). A total of 39 stents were implanted in 20 patients. In 2 cases, duodenal stent placement failed following biliary stent placement. Duodenal obstruction remitted in 15 patients, and 1 patient succumbed to aspiration pneumonia 5 days after the procedure. No severe complications were observed in any other patient. The survival time of the 18 patients was 5-21 months (median, 9.6 months), and 6 of those patients survived for >12 months. The present study suggests that X-ray fluoroscopy-guided intraluminal stent implantation is an effective procedure for the treatment of malignant biliary and duodenal obstruction.
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Affiliation(s)
- Liang Zhao
- Department of Hepatopancreatobiliary Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang 150040, P.R. China
| | - Haitao Xu
- Department of Hepatopancreatobiliary Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang 150040, P.R. China
| | - Yubao Zhang
- Department of Hepatopancreatobiliary Surgery, Harbin Medical University Cancer Hospital, Harbin, Heilongjiang 150040, P.R. China
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Lee H, Min BH, Lee JH, Shin CM, Kim Y, Chung H, Lee SH. Covered metallic stents with an anti-migration design vs. uncovered stents for the palliation of malignant gastric outlet obstruction: a multicenter, randomized trial. Am J Gastroenterol 2015; 110:1440-9. [PMID: 26372507 PMCID: PMC4697131 DOI: 10.1038/ajg.2015.286] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/01/2015] [Accepted: 06/03/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Previous studies reported comparable stent patency between covered self-expandable metallic stents (SEMS) and uncovered SEMS (UCS) for palliation of malignant gastric outlet obstruction (GOO). The aim of this study was to evaluate the efficacy and safety of the newly developed WAVE-covered SEMS (WCS), which has an anti-migration design, compared with UCS in gastric cancer patients with symptomatic GOO. METHODS A total of 102 inoperable gastric cancer patients with symptomatic GOO were prospectively enrolled from five referral centers and randomized to undergo UCS or WCS placement. Stent patency and recurrence of obstructive symptoms were assessed at 8 weeks and 16 weeks after stent placement. RESULTS At the 8-week follow-up, both stent patency rates (72.5% vs. 62.7%) and re-intervention rates (19.6% vs. 19.6%) were comparable between the WCS and the UCS groups. Both stent stenosis (2.4% vs. 8.1%) and migration rates (9.5% vs. 5.4%) were comparable between WCS and UCS groups. At the 16-week follow-up, however, the WCS group had a significantly higher stent patency rate than the UCS group (68.6% vs. 41.2%). Re-intervention rates in the WCS and UCS groups were 23.5% and 39.2%, respectively. Compared with the UCS group, the WCS group had a significantly lower stent restenosis rate (7.1% vs. 37.8%) and a comparable migration rate (9.5% vs. 5.4%). Overall stent patency was significantly longer in the WCS group than in the UCS group. No stent-associated significant adverse events occurred in either the WCS or UCS groups. In the multivariate analysis, WCS placement and chemotherapy were identified as independent predictors of 16-week stent patency. CONCLUSIONS WCS group showed comparable migration rate and significantly more durable long-term stent patency compared with UCS group for the palliation of GOO in patients with inoperable gastric cancer.
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Affiliation(s)
- Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Younjoo Kim
- Division of Gastroenterology, Department of Internal Medicine, Korea Cancer Center Hospital, Korea Institute of Radiological and Medical Sciences, Seoul, Republic of Korea
| | - Hyunsoo Chung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Hyub Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea,Department of Internal Medicine and Liver Research Institute, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea. E-mail:
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Oh D, Lee SS, Song TJ, Choi JH, Park DH, Seo DW, Lee SK, Kim MH. Efficacy and safety of a partially covered duodenal stent for malignant gastroduodenal obstruction: a pilot study. Gastrointest Endosc 2015; 82:32-36.e1. [PMID: 25771068 DOI: 10.1016/j.gie.2014.11.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 11/21/2014] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Dongwook Oh
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Tae Jun Song
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Do Hyun Park
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Dong-Wan Seo
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Sung Koo Lee
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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29
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Cha RR, Lee SS, Kim H, Kim HJ, Kim TH, Jung WT, Lee OJ, Bae KS, Jeong SH, Ha CY. Management of post-gastrectomy anastomosis site obstruction with a self-expandable metallic stent. World J Gastroenterol 2015; 21:5110-5114. [PMID: 25945029 PMCID: PMC4408488 DOI: 10.3748/wjg.v21.i16.5110] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/13/2014] [Accepted: 02/05/2015] [Indexed: 02/06/2023] Open
Abstract
Post-gastrectomy anastomosis site obstruction is a relatively rare complication after a subtotal gastrectomy. We present a case of a 75-year-old man who underwent a truncal vagotomy, omental patch, gastrojejunostomy, and Braun anastomosis for duodenal ulcer perforation and a gastric outlet obstruction. Following the 10(th) postoperative day, the patient complained of abdominal discomfort and vomiting. We diagnosed post-gastrectomy anastomosis site obstruction by an upper gastrointestinal series and an upper endoscopic examination. We inserted a self-expandable metallic stent (SEMS) at the anastomosis site. The stent was fully expanded after deployment. On the day following the stent insertion, the patient began to eat, and his abdominal discomfort was resolved. This paper describes the successful management of post-gastrectomy anastomosis site obstruction with temporary placement of a SEMS.
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30
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Poincloux L, Goutorbe F, Rouquette O, Mulliez A, Goutte M, Bommelaer G, Abergel A. Biliary stenting is not a prerequisite to endoscopic placement of duodenal covered self-expandable metal stents. Surg Endosc 2015; 30:437-445. [PMID: 25894447 DOI: 10.1007/s00464-015-4216-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 04/06/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Duodenal covered self-expandable metal stent (cSEMS) can be used in malignant or benign gastroduodenal obstruction. The need for biliary stenting in patients with no concomitant biliary stricture, before duodenal cSEMS placement, remains unknown. The aim of this study was to determine whether cSEMS placement is responsible for biliary obstruction. METHODS This is a single-center, retrospective, case-controlled study, including 106 patients with symptomatic gastric outlet obstruction or duodenal fistula who received a covered nitinol duodenal stent by using through-the-scope/over-the-wire placement procedure. The main outcome measurement was the occurrence comparison of jaundice and bilirubin level, between patients with previous or concomitant biliary stenting (cSEMS + BS group), and patients with no biliary stent (cSEMS group) during an observational period of 90 days. RESULTS Hundred and six patients underwent cSEMS placement between June 2005 and March 2014: 53 in the cSEMS group (58% male, mean age 66.4 ± 13.3 years) and 53 in cSEMS + BS group (60% male, mean age 70.4 ± 11.6 years). The obstruction was due to cancer in 45% in cSEMS group and 87% in cSEMS + BS group. No case of jaundice was reported in the cSEMS group or in the cSEMS + BS group. In cSEMS group, the mean bilirubin level (μmol/L ± SD) was 8.0 ± 4 at baseline and 8.5 ± 4.6 at day 10, while in the cSEMS + BS group it was 91.4 ± 108 at baseline and 35.3 ± 39 at day 10 (p < 0.01). Patients from the two groups were matched on age, gender and bilirubin level at baseline. Evolution of bilirubinemia was +0.98 ± 2.76 µmol/L in experimental group and +0.39 ± 522 µmol/L in the control group (p = 0.34). No significant difference was observed between the two groups in term of technical success, clinical effectiveness, migration and other complications. CONCLUSIONS Previous biliary stenting is not required before endoscopic covered duodenal stent placement in patients with no associated biliary obstruction. Prospective studies are needed.
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Affiliation(s)
- L Poincloux
- Digestive Diseases Department, NHE University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France. .,ISIT (Image Sciences for Innovations Techniques), UMR Auvergne University/CNRS 6284, Clermont-Ferrand, France.
| | - F Goutorbe
- Digestive Diseases Department, NHE University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - O Rouquette
- Digestive Diseases Department, NHE University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - A Mulliez
- Biostatistics Unit, DRCI, Gabriel Montpied University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - M Goutte
- Clinical Research Unit, NHE University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - G Bommelaer
- Digestive Diseases Department, NHE University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France
| | - A Abergel
- Digestive Diseases Department, NHE University Hospital of Clermont-Ferrand, 63003, Clermont-Ferrand, France.,ISIT (Image Sciences for Innovations Techniques), UMR Auvergne University/CNRS 6284, Clermont-Ferrand, France
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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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A Multicenter Randomized Controlled Trial of Malignant Gastric Outlet Obstruction: Tailored Partially Covered Stents (Placed Fluoroscopically) versus Standard Uncovered Stents (Placed Endoscopically). Gastroenterol Res Pract 2014; 2014:309797. [PMID: 25610459 PMCID: PMC4290140 DOI: 10.1155/2014/309797] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/24/2014] [Accepted: 11/30/2014] [Indexed: 12/27/2022] Open
Abstract
The aim of our study is to compare the efficacy and safety of “outlet-shape” tailored stents with standard stents for the management of distal gastric cancer causing gastric outlet obstructions (GOOs) with varying gastric cavity shapes and sizes. To determine the shape and size of the GOOs, stomach opacifications were performed using contrast media before stenting. Two basic shapes of the residual cavity of the proximal GOO were observed: cup shaped or approximately cup shaped and funnel shaped or approximately funnel shaped. Other shapes were not found. In the GOO tailored group, the size and shape of the proximal ends of the tailored stent were suited for the residual cavity of the proximal GOO. The tailored stents included large cup-shaped stents and large funnel-shaped stents. GOO tailored covered stents led to less restenosis and reintervention rates compared to standard uncovered stents but with the same survival.
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33
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Enteral Stents are Safe and Effective to Relieve Malignant Gastric Outlet Obstruction in the Elderly. J Gastrointest Cancer 2014; 46:42-7. [DOI: 10.1007/s12029-014-9675-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Zhou WZ, Yang ZQ. Stenting for malignant gastric outlet obstruction: Current status. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Oh SJ, Song HY, Nam DH, Ko HK, Park JH, Na HK, Lee JJ, Kang MK. Bleeding after expandable nitinol stent placement in patients with esophageal and upper gastrointestinal obstruction: incidence, management, and predictors. Acta Radiol 2014; 55:1069-75. [PMID: 24226292 DOI: 10.1177/0284185113511080] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Placement of self-expandable nitinol stents is useful for the treatment of esophageal and upper gastrointestinal (GI) obstruction. However, complications such as stent migration, tumor overgrowth, and bleeding occur. Although stent migration and tumor overgrowth are well documented in previous studies, the occurrence of bleeding has not been fully evaluated. PURPOSE To evaluate the incidence, management strategies, and predictors of bleeding after placement of self-expandable nitinol stents in patients with esophageal and upper GI obstruction. MATERIAL AND METHODS We retrospectively reviewed the medical records and results of computed tomography and endoscopy of 1485 consecutive patients with esophageal and upper GI obstructions who underwent fluoroscopically guided stent placement. RESULTS Bleeding occurred in 25 of 1485 (1.7%) patients 0 to 348 days after stent placement. Early stent-related bleeding occurred in 10 patients (40%) and angiographic embolization was used for 5/10. Late bleeding occurred in 15 patients (60%) and endoscopic hemostasis was used for 7/15. Twenty-two of 25 (88%) patients with bleeding had received prior radiotherapy and/or chemotherapy. CONCLUSION Bleeding is a rare complication after placement of expandable nitinol stents in patients with esophageal and upper GI obstruction, but patients with early bleeding may require embolization for control. Care must be exercised on placing stents in patients who have received prior radiotherapy or chemotherapy.
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Affiliation(s)
- Se Jin Oh
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho-Young Song
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deok Ho Nam
- Department of Radiology, Kyung Hee University Hospital at Gangdong, School of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Heung Kyu Ko
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Hoon Park
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Han Kyu Na
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong Jin Lee
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Kyoung Kang
- Departments of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Reynolds I, Healy P, Mcnamara DA. Malignant tumours of the small intestine. Surgeon 2014; 12:263-70. [PMID: 24637026 DOI: 10.1016/j.surge.2014.02.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Accepted: 02/16/2014] [Indexed: 02/06/2023]
Abstract
Adenocarcinoma, neuroendocrine tumours, sarcomas and lymphomas are the four most common malignant tumours arising in the small intestine, although over forty different histological subtypes are described. Collectively these account for only 2% of cancers of the digestive system. The incidence of small bowel cancer has increased in recent decades with a four-fold increase in carcinoid tumours. Risk factors for small bowel tumours include coeliac disease, inflammatory bowel disease and a number of genetic abnormalities. The non-specific nature of their symptoms and the difficulty in visualising these tumours with normal endoscopic techniques often results in late diagnosis. Furthermore the paucity of literature on this topic has made it difficult to standardise management. There has however been marked improvement in imaging methods resulting in earlier diagnosis in many cases. As expected, early detection of localised, well differentiated tumours followed by surgical resection with negative margins offers the best chance of long term survival. Better adjuvant treatment, notably for gastrointestinal stromal tumours, has improved 5-year survival rates significantly. Development of surveillance guidelines for at risk populations may be a valuable way of improving early diagnosis of this challenging group of conditions.
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Affiliation(s)
- Ian Reynolds
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
| | - Paul Healy
- Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland
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Jeon HH, Park CH, Park JC, Shim CN, Kim S, Lee HJ, Lee H, Shin SK, Lee SK, Lee YC. Carcinomatosis matters: clinical outcomes and prognostic factors for clinical success of stent placement in malignant gastric outlet obstruction. Surg Endosc 2014; 28:988-95. [PMID: 24185750 DOI: 10.1007/s00464-013-3268-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Accepted: 10/06/2013] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although carcinomatosis is not a contraindication to stenting in selected patients with malignant gastric outlet obstruction (GOO), associate factors for clinical success rate of self-expandable metallic stent (SEMS) placement in GOO patients with carcinomatosis have not been fully characterized. METHODS We analyzed a total 228 patients who were scheduled for SEMS placement for malignant GOO in tertiary-care academic medical center. All patients were treated with an uncovered or covered SEMS by using the over-the-wire placement procedure. We retrospectively evaluated clinical outcomes of SEMS placement. RESULTS Technical success was achieved in all patients. Patients were categorized into two groups according to the presence of carcinomatosis. Clinical success rates of patients without carcinomatosis group and with carcinomatosis group were 93.9 % (92 of 98) and 80.8 % (105 of 130), respectively (P = 0.004). In subgroup analysis of patients with carcinomatosis, the clinical success rate was lower in patients with ascites (64.8 %) than in those without ascites (92.1 %, P < 0.001). Multivariate logistic regression model revealed that carcinomatosis without ascites did not decrease clinical success rate compared with absence of carcinomatosis; meanwhile, carcinomatosis with ascites showed lower clinical success rates compared with absence of carcinomatosis (adjusted odds ratio 0.163, 95 % confidence interval 0.058-0.461). In addition, poor performance status [Eastern Cooperative Oncology Group (ECOG) status ≥ 3, adjusted odds ratio 0.178, 95 % confidence interval 0.078-0.409] was also an independent poor predictive factor for clinical success of SEMS placement. CONCLUSIONS In palliation for malignant GOO, the status of carcinomatosis with ascites and poor performance status (ECOG status ≥ 3) are significant predictive factors for poor clinical success of SEMS placement.
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Affiliation(s)
- Han Ho Jeon
- Division of Gastroenterology, Department of Internal Medicine, Yonsei Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Maetani I, Mizumoto Y, Shigoka H, Omuta S, Saito M, Tokuhisa J, Morizane T. Placement of a triple-layered covered versus uncovered metallic stent for palliation of malignant gastric outlet obstruction: a multicenter randomized trial. Dig Endosc 2014; 26:192-9. [PMID: 23621572 DOI: 10.1111/den.12117] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 03/18/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Usually, uncovered self-expandable metallic stents (SEMS) are used for palliation of malignant gastric outlet obstruction (GOO). A triple-layered covered SEMS is reported to be efficacious, but its performance has not been compared with uncovered SEMS. The present study is the first to compare the efficacy and safety of a triple-layered covered versus uncovered SEMS. PATIENTS AND METHODS A multicenter randomized study was conducted in two tertiary referral centers, with 62 eligible patients with symptomatic GOO to receive covered (n = 31) or uncovered SEMS (n = 31). The primary endpoint was SEMS patency, and secondary endpoints were success rate and adverse events after complete follow up. RESULTS Both groups had a technical success rate of 100% and comparable clinical success rates (P = 0.67). There was nostatistically significant difference in stent patency and adverse events between the two groups (P = 0.52 and P = 0.38, respectively). Although the occurrence rate of persistent obstructive symptoms was comparable (P = 0.42), that of recurrent obstructive symptoms was higher in the uncovered group (29% vs 3.6%, P = 0.0125). Patient survival did not differ between groups (P = 0.34). CONCLUSION There was no statistically significant difference in stent patency, but use of a triple-layered covered SEMS was associated with less frequent stent dysfunction more than 4 weeks after stenting, despite similar short-term outcomes.
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Affiliation(s)
- Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center
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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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Individualization of metal stents for management of gastric outlet obstruction caused by distal stomach cancer: a prospective study. Gastrointest Endosc 2013; 78:277-84. [PMID: 23528652 DOI: 10.1016/j.gie.2013.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 02/04/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of various kinds of metal stents has emerged as an effective palliative treatment for malignant gastric outlet obstruction (GOO). However, most of these metal stents were designed for use in the esophagus or intestine and have a high incidence of stent obstruction and stent migration when used elsewhere. OBJECTIVE To evaluate the efficacy and safety of individualized stents (designed according to the shape and size of the GOO) in order to determine whether such stents could reduce the incidence of stent obstruction and migration. DESIGN Multicenter, prospective, clinical trial. SETTING Two tertiary-care referral centers. PATIENTS Thirty-seven patients who presented with symptomatic unresectable malignant GOO caused by distal gastric cancer between April 2005 and June 2009. INTERVENTION Placement of the individualized metal stents. MAIN OUTCOME MEASUREMENTS The primary endpoint was to optimize stent resolution of proximal obstruction as determined by a GOO scoring system. Secondary endpoints were success rates, survival rates, and adverse events. RESULTS Technical and clinical success was achieved in 97.3% and 94.4% of patients, respectively. The rate of resolution of proximal obstruction by a proximal stent was 97.3%. There were no procedure-related perforations or deaths. No stent migration or obstruction by tumor growth were found. The mean survival time was 232 days (range 28-387 days). LIMITATIONS A single-arm study in tertiary-care centers. CONCLUSION Placement of individualized stents is a safe and effective modality for the palliation of malignant GOO caused by distal stomach cancer and can help reduce tumor ingrowth and stent migration.
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Mansoor H, Yusuf MA. Outcomes of endoscopic pyloric stenting in malignant gastric outlet obstruction: a retrospective study. BMC Res Notes 2013; 6:280. [PMID: 23870091 PMCID: PMC3720273 DOI: 10.1186/1756-0500-6-280] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 07/16/2013] [Indexed: 12/14/2022] Open
Abstract
Background Up to 30% of patients with pancreatic cancer and more than 50% of patients with gastric cancer already have incurable disease, with distressing symptoms of gastric outlet obstruction at the time of presentation which require effective palliation. We decided to test the clinical outcomes of endoscopic stent placement in malignant gastric outlet obstruction. Methods In a retrospective single institution-based study, the charts of patients who had self-expandable metal stents placed to alleviate malignant gastric outlet obstruction were reviewed. Charts were reviewed to assess improvement in oral intake according to the Gastric Outlet Obstruction Scoring System (GOOSS), and in order to also evaluate technical success and complications of the procedure. Results 69 patients with successful stent placement were retrospectively evaluated. Within 7 and 28 days after stent placement respectively, 85.5% and 80% benefited from stent insertion, with an increase in the GOOSS score of > 1. Resumption of soft or low residue diet (GOOSS 2-3) was achieved in 53.6% at day 7 and in 62% of patients at day 28, respectively. Of the patients achieving a GOOSS score of 2-3, 17.3% remained on a soft or low residue diet at 24 weeks or at last follow up, while 46% died. Stent related adverse events occurred in 10 patients (14%), including stent blockade in 7 and stent migration in 3 patients. Conclusion Endoscopic enteral stenting promptly increases oral intake in the majority of patients with malignant gastric outlet obstruction and is a safe procedure with a low rate of serious complications.
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Neely D, Ong J, Patterson J, Kirkpatrick D, Skelly R. Small intestinal adenocarcinoma: rarely considered, often missed? Postgrad Med J 2013; 89:197-201. [PMID: 23412393 DOI: 10.1136/postgradmedj-2012-131323] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Adenocarcinoma of the small intestine is rare in comparison with other gastrointestinal malignancies but its incidence is rising. It often presents at an advanced stage due to the non-specific symptomatology. More recent advances in small intestinal visualisation including video capsule endoscopy and double balloon enteroscopy may facilitate diagnosis in patients with suspected small intestinal neoplasia. At present aggressive surgical resection provides the best chance of cure of small intestinal adenocarcinoma. Despite apparent curative resection the long-term outlook remains poor. The role of adjuvant chemotherapy is not well defined due to the rarity of the disease and lack of randomised controlled trials; however, there appears to be a survival benefit in advanced disease with the use of oxaliplatin and 5-fluorouracil. We reviewed the clinical aspects of this aggressive condition focusing on the pathological associations, available diagnostic modalities and current management options. Three cases are included to illustrate the review.
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Affiliation(s)
- David Neely
- Department of Surgery, Northern Health and Social Care Trust, Causeway Hospital, Newbridge Road, Coleraine, UK.
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Çaglar E, Dobrucali A. Self-expandable metallic stent placement in the palliative treatment of malignant obstruction of gastric outlet and duodenum. Clin Endosc 2013; 46:59-64. [PMID: 23423384 PMCID: PMC3572353 DOI: 10.5946/ce.2013.46.1.59] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 07/09/2012] [Accepted: 07/09/2012] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND/AIMS To asses the usefulness of flexible metallic stents in the palliation of malignant obstruction of gastric outlet and duodenum. METHODS Retrospective review was performed between January 2006 and December 2011 in 30 patients. Thirty consecutive patients with obstruction of the gastric outlet underwent palliative treatment with self-expandable flexible metallic stents. Complications and clinical outcomes were assessed. RESULTS Twenty-four patients had advanced gastric carcinoma at the antrum and/or pylorus, four patients had obstruction at the pylorus due to pancreas tumours and one patient had duodedum and one patient had gall bladder tumour. Symptoms improved in 82.7% of the patients after the procedure. The improvement in ability to eat using the score system was statistically significant (p<0.001). Tumor ingrowth and/or overgrowth were seen in four patients (13.3%), and a second stent was inserted in these patients. The mean stent patency was 100 days (range, 5 to 410). The mean survival was 120.76±38.96 days. CONCLUSIONS Endoscopic placement of self-expendable metallic stents under fluoroscopy is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach or pancreas cancer.
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Affiliation(s)
- Erkan Çaglar
- Department of Gastroenterology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Ahmet Dobrucali
- Department of Gastroenterology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
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Han K, Song HY, Kim JH, Park JH, Nam DH, Ryu MH, Yook JH. Afferent loop syndrome: treatment by means of the placement of dual stents. AJR Am J Roentgenol 2012; 199:W761-W766. [PMID: 23169750 DOI: 10.2214/ajr.12.8575] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2025]
Abstract
OBJECTIVE The purpose of this article is to assess the technical feasibility and clinical effectiveness of the placement of partially covered self-expandable dual stents in patients with afferent loop syndrome. MATERIALS AND METHODS Data from 13 consecutive patients who had undergone partially covered dual stent placement for afferent loop syndrome after various types of surgery were retrospectively analyzed. Nine patients underwent stent placement via the percutaneous transhepatic biliary drainage tract, and four patients underwent placement via the peroral route. A total of 16 stents were used in this study (i.e., 15 dual stents and one fully covered esophageal stent). RESULTS The route of stent insertion was determined on the basis of each patient's general condition, the site of obstruction, anatomic variations, and associated symptoms. Stent placement was technically successful in all patients. After stent placement, 12 of 13 patients experienced normalization of their abnormal biliary laboratory findings and decompression of the dilated bowel loop, whereas the remaining patient showed no change. This patient had to undergo the additional treatment of surgical jejunojejunostomy. No procedure-related complications occurred in any patients enrolled in this study. CONCLUSION Placement of partially covered dual stents appears to be a promising technique that may offer successful palliation for patients who develop afferent loop syndrome after various types of surgery.
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Affiliation(s)
- Kichang Han
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
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Lee YJ, Kim JH, Song HY, Park JH, Na HK, Kim PH, Fan Y. Hepatocellular carcinoma complicated by gastroduodenal obstruction: palliative treatment with metallic stent placement. Cardiovasc Intervent Radiol 2012; 35:1129-1135. [PMID: 21882080 DOI: 10.1007/s00270-011-0262-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Accepted: 08/14/2011] [Indexed: 01/14/2023]
Abstract
PURPOSE To evaluate the clinical effectiveness of self-expandable metallic stents in seven patients with malignant gastroduodenal obstruction caused by inoperable hepatocellular carcinoma (HCC). METHODS Seven patients with gastroduodenal obstruction caused by advanced HCC underwent metallic stent placement from 2003 to 2010. These patients had total dysphagia (n = 5) or were able to eat only liquids (n = 2) before stent placement. Patients had Eastern Cooperative Oncology Group performance scores of 2 or 3, and Child-Pugh classification B or C. RESULTS Stent placement was technically successful in all seven patients (100%) and clinically successful in six (86%). Five patients could eat a soft diet, and one patient tolerated regular diet after stent placement. Stent-related obstructive jaundice occurred in one patient. One patient had hematemesis 11 days after stent placement. Overall mean survival was 51 days (range, 10-119 days). Stent patency was preserved in six patients with clinical success until death. CONCLUSION Placement of a covered self-expandable metallic stent may offer good palliation in patients with gastroduodenal obstruction due to advanced HCC.
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Affiliation(s)
- Ye Jin Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Oral intake throughout the patients' lives after palliative metallic stent placement for malignant gastroduodenal obstruction: a retrospective multicentre study. Eur J Gastroenterol Hepatol 2012; 24:747-55. [PMID: 22522142 DOI: 10.1097/meg.0b013e328353d9d3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Patients with inoperable malignant gastric outlet obstruction (GOO) have been managed with self-expandable metal stents to improve oral intake. Recent studies have shown conflicting results on the capacity of self-expandable metal stents to restore food intake in the long term. This study evaluated the clinical effectiveness of enteral stent placement for GOO throughout the patients' lives. METHODS This was a multicentre, retrospective study with a long-term follow-up of 74 patients who underwent enteral stenting for symptomatic GOO. Data were collected to analyse improvements in oral intake for the patients' entire lives as assessed by the GOO scoring system (GOOSS), technical success, stent patency, complications, the need for reintervention, survival and the prognostic factors associated with stent patency. RESULTS Technical and clinical success was achieved in 100 and 97.2% of the patients, respectively. A total of 71/74 patients (95.9%) continued oral intake for the rest of their lives and 58/74 patients (78.4%) needed no further intervention until death. Solid food intake (GOOSS 2-3) continued until death in 47/74 patients (63.5%). The GOOSS score improved (P<0.001) during the follow-up compared with the baseline. The median survival and the mean stent patency were 8 and 76.6 weeks, respectively. The complication rate was 18.9%. Malignant stent reobstruction was observed in 7/74 patients (9.5%). A Cox multivariate analysis showed that duodenal location of the obstruction was the only independent factor associated with stent patency (hazard ratio=5.28; 95% confidence interval=1.14-24.45; P=0.033). CONCLUSION Enteral stenting in patients with unresectable GOO is safe and clinically effective. Ninety-five per cent of patients are able to resume oral intake for the rest of their lives, and the great majority remain free from further intervention. In approximately two-thirds of patients, solid food intake continues until death.
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Isayama H, Sasaki T, Nakai Y, Togawa O, Kogure H, Sasahira N, Yashima Y, Kawakubo K, Ito Y, Hirano K, Tsujino T, Toda N, Tada M, Omata M, Koike K. Management of malignant gastric outlet obstruction with a modified triple-layer covered metal stent. Gastrointest Endosc 2012; 75:757-763. [PMID: 22284092 DOI: 10.1016/j.gie.2011.11.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Accepted: 11/29/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND A high incidence of migration with covered metal stents has been reported in malignant gastric outlet obstruction (GOO). A newly modified, partially covered, triple-layer nitinol stent was developed that has a longer uncovered portion (5-15 mm) to prevent stent migration. OBJECTIVE To estimate the efficacy and safety of the modified covered, triple-layer metal stent. DESIGN Multicenter, prospective cohort study. SETTING Three tertiary referral centers. PATIENTS Fifty consecutive patients (26 with pancreatic carcinoma, 14 with gastric carcinoma, 9 with cholangiocarcinoma, 1 with a metastatic node) who presented with symptomatic unresectable malignant GOO between April 2007 and March 2010. INTERVENTIONS Endoscopic placement of the modified covered, triple-layer metal stent. MAIN OUTCOME MEASUREMENTS The primary endpoint was to improve the GOO scoring system (GOOSS) score. Secondary endpoints were success rate, patency, and complications. RESULTS The median GOOSS score improved significantly (P < .0001) after stenting (from 0 to 3). The technical and clinical success rates were 100% and 90%, respectively. Stent occlusion by tumor overgrowth or ingrowth at the uncovered portion developed in 5 patients (10%). Asymptomatic stent migration occurred in 3 patients (6%) receiving chemotherapy at 95, 230, and 553 days after stent placement, but these patients tolerated solid food 68, 260, and 142 days after stent migration, respectively. Other complications occurred in 1 patient with insufficient expansion, cholangitis, and pancreatitis. No procedure-related deaths occurred. LIMITATIONS A single-arm study in tertiary-care centers. CONCLUSIONS The modified covered, triple-layer metal stent was effective and safe for managing malignant GOO and can prevent tumor ingrowth and stent migration. ( CLINICAL TRIAL REGISTRATION NUMBER UMIN000004566.).
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Affiliation(s)
- Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Chou SQH, Song HY, Kim JH, Park JH, Fan Y, Lee H, Yoon YS, Kim JC. Dual-design expandable colorectal stent for a malignant colorectal obstruction: preliminary prospective study using new 20-mm diameter stents. Korean J Radiol 2012; 13:66-72. [PMID: 22247638 PMCID: PMC3253405 DOI: 10.3348/kjr.2012.13.1.66] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2011] [Accepted: 09/01/2011] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the safety and effectiveness of a 20-mm diameter dual-design expandable colorectal stent for malignant colorectal obstruction. MATERIALS AND METHODS The study series included 34 patients with malignant colorectal obstruction who underwent implantation of a 20-mm dual-design expandable colorectal stent in our department between March 2009 and June 2010. The 20-mm dual-design expandable colorectal stent was placed by using a 3.8-mm delivery system that had 28-mm diameter proximal and distal ends. Among the 34 patients, stent placement for palliation was performed in 20 patients, while stent placement for bridge to surgery was performed in 14 patients. RESULTS A 97% (33 of 34) success rate was achieved for the stent placement. The perforation rate in the bridge to surgery group was 7% (1 of 14), compared to 0% (0 of 19) in palliative group. Migration occurred in one of 33 patients (3%) at 30 days after stent placement. CONCLUSION The placement of a 20-mm diameter dual-design stent appears to be clinically safe and effective for the management of colorectal obstruction, with low perforation and migration rates.
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Affiliation(s)
- Sandas Qi Hua Chou
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
- Department of Radiology & Imaging, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Yong Fan
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Heuiran Lee
- Department of Microbiology, Bio-Medical Institute Technology, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Yong Sik Yoon
- Department of Colorectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
| | - Jin Cheon Kim
- Department of Colorectal Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, Korea
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Lee PHU, Moore R, Raizada A, Grotz R. Small bowel perforation after duodenal stent migration: An interesting case of a rare complication. World J Radiol 2011; 3:152-4. [PMID: 21860709 PMCID: PMC3158882 DOI: 10.4329/wjr.v3.i6.152] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Revised: 04/10/2011] [Accepted: 04/17/2011] [Indexed: 02/06/2023] Open
Abstract
Duodenal stents are frequently used for palliating malignant gastric outlet obstruction. Successful stent placement relieves obstructive symptoms, is cost effective, and has a relatively low complication rate. However, enteral stents have the potential of migrating distally and rarely, even lead to bowel perforation. We present a rare case of a duodenal stent placed as a palliative measure for gastric outlet obstruction due to unresectable pancreatic cancer that migrated distally after a gastrojejunostomy resulting in small bowel perforation.
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Jang JK, Song HY, Kim JH, Song M, Park JH, Kim EY. Tumor overgrowth after expandable metallic stent placement: experience in 583 patients with malignant gastroduodenal obstruction. AJR Am J Roentgenol 2011; 196:W831-W836. [PMID: 21606277 DOI: 10.2214/ajr.10.5861] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of our study was to assess the incidence, predictive factors, and treatment of tumor overgrowth after placement of expandable metallic dual stents in patients with malignant gastroduodenal obstruction. MATERIALS AND METHODS Expandable metallic dual stents were inserted under fluoroscopic guidance in 583 patients with symptomatic malignant gastroduodenal obstruction. We retrospectively reviewed prospectively collected patient records to determine the incidence and treatment of tumor overgrowth after stent placement and used multivariate analysis to determine factors predicting tumor overgrowth. RESULTS Tumor overgrowth occurred after stent placement in 22 of 583 patients (3.8%) (range, 41-634 days; mean, 179.0 days). Duodenal lesions (odds ratio [OR], 4.505; p = 0.002), longer survival time (OR, 1.003; p = 0.001), and length of obstruction (OR, 0.783; p = 0.035) were independent predictors of tumor overgrowth. Twenty of the 22 patients were successfully treated by placement of a second dual stent, whereas the other two patients refused placement of a second stent or other further treatment. Overall, 19 of 20 patients (95%) showed improvement in symptoms after second stent placement. Duodenal perforation occurred in one of the 20 patients 125 days after placement of a second stent and was treated surgically. CONCLUSION Tumor overgrowth seems to be an uncommon complication of expandable metallic dual stent placement in patients with malignant gastroduodenal obstruction. Tumor overgrowth is associated with duodenal lesions, longer survival time, and shorter stricture length. Tumor overgrowth can be successfully managed by coaxial insertion of a second dual-expandable metallic stent into the obstructed first stent.
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Affiliation(s)
- Jong Keon Jang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 388-1, Poongnap 2-dong, Songpa-gu, Seoul 138-736, Republic of Korea
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