Novel Treatment of Malignant Gastric Outlet Obstruction With a Stent-Within-Stent Approach Secured With Apollo OverStitchTM

Abstract

Uncovered self-expandable metal stents (UCSEMS) are commonly used for palliative treatment of malignant tumors resulting in gastric outlet obstruction (GOO). Tumor ingrowth is a frequent complication leading to stent restenosis and treatment failure requiring the need for additional intervention. Placement of a fully covered self expandable metal stent (FCSEMS) within an UCSEMS has been reported with successful alleviation of re-obstruction caused by stent ingrowth. While this technique can provide relief, it can be further complicated by stent migration of the fully covered stent. Placement of clips at the proximal ends of secondary stents has been shown to decrease stent migration rates. To our knowledge, no other stent-in-stent securing methods have been evaluated. We describe the successful treatment of recurrent GOO with a duodenal stent-within-stent secured in place with Apollo OverStitch (Apollo Endosurgery, Texas). A 56-year-old male with metastatic cholangiocarcinoma presented with worsening nausea and vomiting. Prior to presentation, the patient underwent placement of an UCSEMS through the pylorus and duodenum for GOO from tumor burden. The patient subsequently developed a repeat duodenal obstruction from tissue ingrowth and had a second UCSEMS deployed within the first stent 6 months after the original stent placement. At our evaluation, 4 months after the 2nd stent placement, it was noted that there was yet another stricture from further tissue ingrowth. Gastrojejunostomy tube placement was offered to the patient, but he declined. The decision was made to place a 3rd stent for symptom palliation. On endoscopy, a tight stricture was noted within the existing stents. Under endoscopic and fluoroscopic guidance, a wire was placed distally into the duodenum and a 100mm x 18mm FCSEMS was placed within the previous stents. Using Apollo OverStitch, the proximal edge of the stent was sutured into the antral gastric mucosa, and the lateral side of the stent was sutured into the proximal edge of the original stents. The patient tolerated the procedure well. The patient's symptoms of nausea and reflux resolved and follow-up at 6 months revealed continued resolution of obstructive symptoms. The Apollo OverStitch has shown a high technical success rate of securing stents in benign gastrointestinal conditions. Novel use of the OverStitch for stent fixation, particularly stent-within-stent fixation, is promising.