Gastroduodenal Obstruction Research Articles

Successful Management of Upper Gastrointestinal Obstruction With Primary Advanced Ovarian Cancer.

Upper gastrointestinal obstruction is an extremely rare complication of primary ovarian cancer. We present a case of primary advanced ovarian cancer with gastroduodenal obstruction successfully managed with neoadjuvant chemotherapy (NAC) and conservative treatment. A 60-year-old woman was referred to our hospital for advanced ovarian cancer with upper gastrointestinal obstruction. Computed tomography and endoscopy revealed severe duodenal obstruction caused by dissemination. NAC was initiated with conservative management using a nasogastric tube and total parenteral nutrition (TPN). She was able to eat and TPN was stopped after three months. Complete resection was achieved with interval debulking surgery (IDS) not involving pancreatoduodenectomy, which would have been necessary for primary debulking surgery. There were no serious postoperative complications. NAC with conservative management can improve upper gastrointestinal obstruction in patients with primary advanced ovarian cancer. Furthermore, IDS is expected to allow complete resection, avoiding highly invasive surgeries.

Frequency of loco-regional complications and their IMPACT on hospitalization outcomes in patients with pancreatic cancer.

e16278 Background: Despite advances in medicine, pancreatic cancer continues to have a grim prognosis. It is not well studied if certain loco-regional complications pose higher prognostic risk than others and thus may be useful in estimating longevity and targeting care. Methods: National Inpatient Sample (NIS) was queried to identify adult patients with underlying pancreatic cancer between 2016-2018. Relative frequency and diagnosis of locoregional complications as principal diagnosis in these patients were identified and top 5 loco-regional complications were studied and compared for all-cause mortality, mean length of stay (LOS), mean total hospital charges (THC). Statistics were performed using the t-test, univariate and multinomial logistic regression. Results: There were 112,230 adult hospitalizations for pancreatic cancer. Top 5 loco-regional complications were cancer pain (8.6%), upper GI bleeding (UGIB) (8.4%), gastroduodenal obstruction (5.7%), failure to thrive (5%) and acute liver failure (2.8%). Mortality rate of all pancreatic cancer admissions was 7% and all loco-regional complications studied were associated with significant increased odds of mortality, the highest in patients with acute liver failure (AOR- 5.33, p < 0.001). All Loco-regional complications studied were associated with statistically significant increased LOS with the highest among patients admitted with UGIB (p < 0.001). UGIB was also associated with the highest THC whiles cancer pain admissions had a lower charge (p < 0.001). Conclusions: Among Loco-regional complications in pancreatic cancer that were studied, cancer associated pain was the most frequent while acute liver failure was the most fatal (5x higher odds of mortality). UGIB was associated with the longest hospital LOS (6 more days) and the highest THC (over $100,000 extra per admission) whereas cancer associated pain was associated with the shortest length of stay and lowest total charge. Further efforts are needed to improve outpatient pain management in pancreatic cancer patients to prevent these admissions.[Table: see text]

Pyloroduodenojejunostomy

Background: Gastric outlet obstruction is a common condition due to various malignant and benign etiologies. Benign gastric outlet obstruction has been managed surgically by gastric resection or drainage procedures. Pyloroduodenojejunostomy (PDJ) is an old surgical procedure with very few descriptions in the literature and is rarely performed now. We present our experience of six cases of Roux-en-Y PDJ performed for benign gastroduodenal strictures causing gastric outlet obstruction.Materials and Methods: Prospective study of patients who underwent Roux-en-Y PDJ for benign gastroduodenal obstruction in the department of Surgical Gastroenterology in a teaching hospital in Northern India from January 2017 to December 2019. Side-to-side pyloroduodenojejunostomy was done with a Roux-en-Y limb of jejunum along with side-to-side jejunojejunostomy. A feeding jejunostomy was added in patients who were nutritionally poor. No vagotomy was performed.Results: Four male and two female patients with median (range) age of 42 (37–61) years underwent PDJ. There were no major postoperative complications in the study group. Etiology of benign strictures was tuberculosis in two patients and peptic in four. On mean (standard deviation [SD]) follow-up of 19.5 (5.12) months, all the patients were symptom-free. The mean (SD) weight gain was 10 (3.40) kg.Conclusion: Roux-en-Y PDJ is a useful alternative in the management of surgically difficult cases of benign gastroduodenal strictures with low morbidity and good outcome.

70-Year-Old Man With Chronic Nausea and Vomiting

70-Year-Old Man With Chronic Nausea and Vomiting

Squamous gastric ulceration complicated by gastric stenosis in a foal

SummaryA 2‐month‐old Warmblood colt presented with recurrent colic and regurgitation. Gastroscopy, performed on several occasions, and barium‐contrast radiography revealed severe squamous gastric ulceration and stenosis at the level of the margo plicatus. Treatment with omeprazole reduced the extent and severity of the gastric ulcers but did not affect the stenosis. The foal was euthanised because of a poor prognosis, and post‐mortem examination confirmed the clinical diagnosis. Severe squamous gastric ulceration, granulation tissue formation and cicatrisation of deep gastric lesions were considered to have caused the stenosis. Gastroduodenal outflow obstruction is a recognised disorder in foals, but stenosis at the level of the margo plicatus has not been reported in foals or adult horses. To the authors' knowledge, this is the first case of severe squamous gastric ulceration, complicated by stenosis at the level of the margo plicatus, in a foal. Although rare, gastric stenosis should be considered in foals suffering recurrent colic and regurgitation.

Clear cap-assisted luminal stenting may improve technical success in gastroduodenal and colonic obstruction.

Background Luminal stenting is safe, effective, and at times the preferred method for relieving gastrointestinal obstruction. However, stent placement is not technically feasible when lesions cannot be traversed with a guidewire, resulting in the need for more invasive methods of palliation and urgent/emergent surgical intervention. In this series, we report our experience with cap-assisted stenting to improve lumen visualization in obstructed segments of the gastrointestinal tract and salvage cases that may have otherwise resulted in technical failure. Methods A clear cap (i. e. distal attachment) was affixed to the scope tip to facilitate visualization and stenting in two cases of gastroduodenal obstruction and three cases of colonic obstruction. Indications for stent placement included malignant obstruction, diverticulitis-associated obstruction, and Crohn’s disease-associated stricture. Results In this report, we demonstrate that use of a clear cap facilitated endoscopic stenting in challenging cases of malignant and benign gastroduodenal and colonic obstruction. Conclusions A clear cap for endoscopic stenting can be used in cases in which standard techniques are unsuccessful or those anticipated to be technically difficult at the outset. Cases with tortuous anatomy or particularly tight, friable, or exophytic obstructive lesions may benefit most from this novel technical modification.

Su1337 DIRECT ENDOSCOPIC ULTRASOUND-GUIDED GASTROENTEROSTOMY WITH LUMEN-APPOSING METAL STENTS: ARETROSPECTIVE BICENTER STUDY ON TECHNICAL FEASIBILITY AND CLINICAL OUTCOME

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with lumen apposing metal stents (LAMS) appears to be a promising intervention in the management of gastroduodenal obstruction as a less invasive alternative to surgery. The aim of this study was to evaluate the feasibility, safety and clinical outcome of direct EUS-GE in patients of surgical high-risk or in a palliative setting. This retrospective study included all patients who received direct EUS-GE with LAMS between April 2017 and November 2019 at two tertiary referral hospitals investigating feasibility, technical success (correctly placed LAMS), clinical outcome (successful oral food intake) and procedure-associated complications. Direct EUS-GE was performed using the Hot-Axios-Stent® (Boston Scientific, Marlboroug, MA.) For this, the intestinal target loop was filled with fluids and subsequently directly punctured with the stent delivery system followed by stent release under endosonographic control. A total of 24 patients (50% women; mean age 67.2 years) underwent direct EUS-GE for gastroduodenal obstruction of malignant (n=21), benign (n=2) or unknown (n=1) etiology. A 20/10 mm LAMS was used in the majority of cases (n= 18), five patients received a 15/10 LAMS and one patient a 10/10 LAMS respectively. The technical success rate of correctly placed LAMS was 100% (24/24). However, in 17 % of patients (4/24) the distal flange of the stent was unintendedly released in the peritoneal cavity due to loss of contact to the target loop while performing the first puncture but correct stent placement succeeded in a second attempt. 92% of patients (22/24) benefited from the intervention by showing reduced nausea and vomiting and the ability of oral food intake. Direct EUS-GE with LAMS has a favorable risk-benefit-profile for patients with gastroduodenal obstruction showing high technical success rates, manageable complications and rapid symptom relief.

Endoscopic stenting for gastroduodenal outlet obstruction of a malignant origin, real life experience in a single center.

to evaluate the safety and effectiveness of self-expandable metal stent placement for malignant gastric outlet obstruction (GOO). a retrospective, analytic cohort study at a single, tertiary-care center. thirty-six patients that underwent stent placement for GOO of malignant origin were identified during the study period. Technical success was achieved in 36 (100 %) patients and clinical success was achieved in 31 patients (86.1 %). Before the procedure, 17 (54.8 %) patients had a gastric outlet obstruction score (GOOSS) of 0, which is a complete inability of oral intake. Twenty-three patients were alive 30 days after the procedure, two (8.6 %) patients had a GOOSS of 1, ten (43.3 %) had a GOOSS of 2 and eleven (47.9 %) had a GOOSS of 3. Abdominal pain was present in all 31 patients before the procedure and only seven (22.6 %) patients continued with abdominal pain 24 hours after the procedure. During follow-up, ten (30.3 %) patients developed complications related to the stents and none of them was fatal. Additional therapy due to partial occlusion of the stent was necessary in three patients. The stents functional duration had a median of 72 days (IQR 25-75 15-105 days) and was closely related to overall survival. palliative stenting for gastroduodenal obstruction is a safe, feasible and effective therapy to treat patients with malignant gastric outlet obstruction.

Percutaneous Transgastric Stent Placement for Malignant Gastroduodenal Obstruction

목적수술이 불가능한 악성 위십이지장 협착 환자에서 구강 경유 스텐트 설치술 실패 시 경피적 위 경유 스텐트 설치술의 기술적 타당성과 임상적 효용성에 대해 알아보았다.대상과 방법이 연구는 2008년 10월부터 2016년 4월까지 악성 위십이지장 협착이 있는 환자 중, 구강 경유 스텐트 설치술이 어렵거나 실패하여 위 경유 스텐트 설치술을 시행한 9명의 환자를 대상으로 하였다. 환자는 췌장암 5명, 위암 2명, 전이암 2명이었다. 경피적 위루술(percutaneous gastrostomy) 후, 이 경로를 통해 이중 팽창성 스텐트를 협착 부위에 설치하였다. 기술적, 임상적 성공률과 합병증에 대해 조사하였다.결과기술적 성공률은 8명의 환자에서 성공적으로 설치되어 88%였다. 1명의 환자에서는 협착 부위로 유도 철사가 통과되지 않아 실패하였다. 스텐트 설치 후, 7명의 환자에서 증상의 호전을 보여 임상적 성공률은 87.5%였다. 위루관은 9~20일 후(평균 12일) 제거되었다. 시술과 관련된 주요 합병증은 발생하지 않았다. 평균 추적관찰 기간은 136일(범위, 3~387일)이었고, 1명의 환자에서 스텐트 원위부에 종양의 과성장에 의한 재협착이 발생하였다.결론수술이 불가능한 악성 위십이지장 협착 환자에서 구강 경유 스텐트 설치술에 실패한 경우 경피적 위 경유 스텐트 설치술은 기술적으로 어렵지 않고 임상적으로 효과적인 치료 방법으로 생각된다.

1852 Acute Gastroparesis Syndrome After Percutaneous Atrial Fibrillation Ablation

INTRODUCTION: Percutaneous radiofrequency ablation (RFA) is now a common minimally invasive procedure for the maintenance of sinus rhythm in drug-resistant atrial fibrillation. We present a rare case of acute delayed gastric emptying after an RFA procedure. CASE DESCRIPTION/METHODS: 57-year-old male with a history significant only for paroxysmal atrial fibrillation, who presented for a planned RFA procedure. He has no other medical or surgical history. The patient tolerated the procedure well and was discharged the same day. That evening, 1-2 hours after he ate dinner, he experienced severe nausea, vomiting, and abdominal pain. He was hemodynamically stable on presentation to the emergency department with labs significant only for a mild leukocytosis. Computed tomography showed a severely dilated stomach and proximal duodenum, with a transition point identified at the third portion of the duodenum. The patient was managed conservatively as a case of proximal small bowel obstruction. As he had mild improvement in symptoms after five days, the decision was made for an exploratory laparotomy. An intra-operative push enteroscopy demonstrated large amounts of retained food in the stomach, but no gastroduodenal outlet obstruction. A diagnosis of acute gastroparesis syndrome was made, and surgical exploration was not done. The patient was discharged, managed conservatively, and on follow-up 4 weeks later his symptoms had significantly improved. DISCUSSION: Acute gastroparesis syndrome is a rare complication of RFA for atrial fibrillation, that occurs due to thermal injury to the peri-esophageal vagal nerves during ablation. Symptoms of nausea, bloating, vomiting, gastric pain occur within 72 hours after the procedure. Most patients fully recover within 1-2 months after the procedure with conservative management. However, a few reported cases with persistent symptoms required eventual esophagojejunal anastomosis or intra-pyloric botulinum injection. Due to wide variation in vagal plexus anatomy around the lower esophagus, and lack of visualization of the nervous system, nerve injury is hard to avoid. Higher BMI was noted to be a protective. Minimizing RF ablative power around the esophagus and/or esophageal temperature monitoring may be a strategy to lower the risk. As RFA ablation for atrial fibrillation becomes more common, gastroenterologists should be aware of this complication.

1406 “Windsock” Duodenal Diverticulum Resulted in Recurrent Pancreatitis and Gastric Outlet Obstruction

INTRODUCTION: “Windsock” or intraluminal duodenal diverticulum (IDD) is a rare congenital abnormality caused by an improper luminal recanalization of the foregut during embryological development. Most patients are asymptomatic. We present a case of recurrent pancreatitis and gastric outlet obstruction (GOO) caused by IDD in a young man with chronic alcohol use. CASE DESCRIPTION/METHODS: A 30-year-old man presented with severe nausea, vomiting and abdominal pain and found to have a third episode of acute pancreatitis in one month. Medical history was notable for alcohol abuse. However the patient stated that his last drink was more than a month ago. Lipase on admission was 130 U/L and he was found to have acute kidney injury (AKI) with creatinine 4.1 mg/dL. Magnetic resonance imaging without contrast revealed severe gastroduodenal obstruction and acute pancreatitis with pancreatic head pseudocysts. Esophagogastroduodenoscopy revealed nearly complete obstruction of the second portion of duodenum that the scope could not traverse. The patient was managed for acute pancreatitis, resulting most likely from paraduodenal pancreatitis causing GOO. After 10 days of aggressive treatment, the patient's pancreatitis has clinically much improved with better relief of the abdominal pain and resolution of the AKI. However he remained obstructed as large volume was drained from the nasogastric tube. A subsequent abdomen and pelvis computed tomography (CT) revealed interval decrease of the cluster pseudocysts previously seen by the pancreatic head but showed a “windsock” duodenal diverticulum. With conservative management, parental nutrition, intravenous fluids and pain control, the patient was able to tolerate frequent small portions of regular diet on hospital day 23. He was then discharged for elective surgery and resection of the IDD. DISCUSSION: Patients with IDD may present with chronic non-specific symptoms such as epigastric pain, nausea, vomiting, post-prandial fullness or rarely acute complications such as obstruction, hemorrhage, or pancreatitis. Radiologic diagnosis by CT or upper gastrointestinal series shows a typical “windsock” appearance hence the name. Endoscopic diagnosis may be challenging as the diverticulum can collapse and be unnoticed, or be mistaken for a polyp or a mass. Surgery has been the mainstay of treatment. However endoscopic techniques have been described in recent literature. IDD should be considered in the context of unexplained duodenal obstruction or recurrent pancreatitis.

Outcomes of duodenal stenting: Experience in a French tertiary center with 220 cases

IntroductionEndoscopic stenting for malignant gastroduodenal outlet obstruction (MGOO) is described as ineffective and not long-lasting despite a few favorable studies. This study aimed to evaluate the clinical outcomes of a large series of patients in a tertiary center. MethodsA single-center retrospective study was performed using data collected from all patients who received palliative duodenal self-expandable metal stents between January 2011 and December 2016. The primary endpoints were patient diet after the first duodenal procedure (Gastric Outlet Obstruction Scoring System, GOOSS) and clinical success. The secondary endpoints were the median patency duration (calculated according to the Kaplan–Meier method) and the cumulative incidence of reintervention. ResultsTwo-hundred twenty patients were included. The increase in the GOOSS score was significant (p < 0.001), and the clinical success rate was 86.3%. The median estimated patency duration was 9.0 months [6.5–29.1]. Patients with pancreatic adenocarcinoma had significantly longer patency durations (p = 0.02). The estimated cumulative probability of a second duodenal procedure after 4 months was 13%. ConclusionsIn this large series of patients who underwent duodenal stenting for MGOO, we observed significant changes in GOOSS scores, a relatively long patency duration compared to findings in previous series, and a low probability of subsequent duodenal procedures, primarily due to a low median overall survival time (4 months).

Bouveret Syndrome: A Systematic Review of Endoscopic Therapy and a Novel Predictive Tool to Aid in Management.

Bouveret syndrome is characterized by gastroduodenal obstruction caused by an impacted gallstone. Current literature recommends endoscopic therapy as the first line of intervention despite significantly lower success rates compared with surgery. The lack of treatment efficacy studies and the paucity of clinical guidelines contribute to current practices being arbitrary. The aim of this systematic review was to identify factors that predict outcomes of endoscopic therapy. Subsequently, a predictive tool was devised to predict the success of endoscopic therapy and recommendations were proposed to improve current management strategies of impacted gallstones in the upper gastrointestinal tract. A systematic search of PubMed, Medline, Cochrane, and Scopus was performed for articles that contained the terms "Bouveret syndrome," "Bouveret's syndrome," "gallstone" AND "gastric obstruction" and "gallstone" AND "duodenal obstruction" that were published between January 1, 1950 to April 15, 2018. Articles were reviewed by 3 reviewers and raw data collated. χ and Kolmogorov-Smirnov tests were used to test associations between predictors and endoscopic outcomes. A logistic regression model was then used to create a predictive tool which was cross validated. Failure of endoscopic therapy is associated with increasing gallstone length (P<0.0001) and impaction in the distal duodenum (P<0.05). Using multiple endoscopic modalities is associated with better success rates (P<0.05). The novel predictive tool predicted success of endoscopic therapy with an area under the receiver operating characteristic score of 0.86 (95% confidence interval: 0.79-0.94). In Bouveret syndrome, a selective approach to endoscopic therapy can expedite definitive treatment and improve current management strategies.

A retrospective, multicenter analysis of incidents associated with Axios™ lumen-apposing stents.

there is controversy with regard to the risks associated with lumen-apposing metal stents (LAMSs), with significant variations between available reports. to describe the types and proportions of complications that arise during the permanence time and removal of Axios™ LAMS. Furthermore, the relationship between patency time, therapeutic target and the presence of complications was also described. a retrospective, multicenter case series study was performed of all patients with an implanted LAMS to access extra-luminal structures during 2017. Only technically successful cases were recorded. a total of 179 patients from seven sites (range, 4-68 cases/site) were included in the study, with a mean age of 64.3 years (SD: 15.8; range: 24.6-98.8 years) and 122 (68.2%) were male. Most common indications included encapsulated necrosis (58, 32.4%), pseudocysts (31, 17.3%) and gallbladder drains (26, 14.5%). Complications during LAMS stay were reported in 19 patients (10.9%); stent lumen or gastroduodenal obstruction (8, 4.5%) and bleeding (7, 3.9%) were the most common. LAMS were not removed in 86 (48%) patients due to the following reasons: a permanent stent was used (46, 53.5%), loss to follow-up (18, 20.9%), patient demise (16, 18.6%) and stent migration (6, 7%). Five (5.4%) complications were reported during stent removal, which were three bleeds and two perforations. No association was found between stent duration and complications (p = 0.67). complications secondary to LAMS insertion are uncommon but may be serious. This study found no association between complications and stent duration.

Palliation of malignant gastroduodenal obstruction with self-expandable metal stent using side- and forward-viewing endoscope: Feasibility and outcome.

BackgroundThe endoscopic placement of a self‐expandable metal stent (SEMS), an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction (GOO), is commonly performed using a forward‐viewing endoscope with a wide therapeutic channel; however, due to limited availability, most Indian centers use a side‐viewing duodenoscope. We studied the feasibility and outcome of SEMS placement using side‐ and forward‐viewing endoscopes.MethodData of patients undergoing SEMS placement using side‐ and forward‐viewing endoscopes with a therapeutic channel for the palliation of malignant GOO presenting during a 5‐year period were analyzed retrospectively. Follow‐up data were obtained from records and telephonic interviews, and technical and clinical success, complications, and survival were evaluated.ResultsOf 114 patients (age 56.5 ± 11.6 years, 59 [52%] female), 90 (79%) and 24 (21%) underwent SEMS placement using side‐ and forward‐viewing endoscopes, respectively. Technical (89, 98.9% vs. 24, 100%, P = ns) and clinical success (84, 93.3% vs. 23, 95.8%, P = ns) and complication rate (3, 3.3% vs. 0, P = ns) between side‐ and forward‐viewing endoscopes were comparable. However, SEMS could be placed in a shorter time using a forward‐ rather than side‐viewing endoscope (21 min [inter‐quartile range 19.5–35] vs. 34 min [25–45], P = < 0.001). SEMS could be deployed successfully with a forward‐viewing endoscope in two patients in whom an initial attempt using side‐viewing endoscope failed. Gastric outlet obstruction scoring system (GOOSS) improved following stent placement (median 0, range 0–2 vs. 2, 0–3, P = 0.0001). The survival of patients undergoing SEMS placement using side‐ and forward‐viewing endoscopes was comparable.ConclusionAlthough side‐ and forward‐viewing endoscopes are equally effective for antroduodenal SEMS placement, the procedure can be performed faster using the latter.

Spontaneous Rupture of a Pancreatic Pseudocyst: A Fatal Complication

Pancreatic pseudocyst is one of the complications of acute pancreatitis, most commonly due to alcohol use and typically resolves with conservative management. Presentation can range from abdominal pain to biliary and gastro-duodenal obstruction, pancreatic ascites and pleural effusion to serious complications such as intracystic hemorrhage or spontaneous rupture. Pseudocyst rupture is a potentially fatal complication and requires emergent surgical intervention. Fortunately, this is an extremely rare occurrence with very few reports in the literature We present a case of a 59-year-old male with a medical history of alcohol abuse, gastroesophageal reflux disease and gastrointestinal bleed who presented with acute left lower quadrant abdominal pain associated with back pain and nausea. On admission, he was hypotensive and tachycardic with tensely distended and diffusely tender abdomen along with involuntary guarding concerning for peritonitis. Laboratory values revealed leukocytosis (13,300),lactic acidosis (2.2), elevated serum amylase (291 U/L) and lipase (475 U/L).CT scan of the abdomen and pelvis revealed ascites and a large abdominal fluid collection with a thick enhancing wall posterior to the stomach measuring 11.4x7.6x10.5 cm and communicating with the pancreas consistent with rupture of a pancreatic pseudocyst Emergent exploratory laparotomy was performed which revealed 5 liters of turbid ascitic fluid. A large decompressed pseudocyst was noted with a small lateral perforation draining contents into the peritoneal cavity. The defect was closed to prevent further leakage. Gastrotomy was performed through the anterior stomach wall and a surgical cystogastrostomy was constructed to allow internal drainage of the pseudocyst into the gastric lumen. The skin was left open and the wound was managed with a negative pressure wound dressing [VAC&#x0099;]. Post-operatively, patient received antibiotics and octreotide. Repeat CT scan on post-operative day (POD) 5 revealing interval decrease of the pseudocyst to 10.1x6.5 cm as well as decrease in ascitic fluid. The patient improved clinically an6d was discharged home on POD 11 While spontaneous rupture of a pancreatic pseudocyst is a rare event, it is a surgical emergency. Patients should be treated urgently with surgical intervention to minimize the complications associated with spillage of pseudocyst content into the peritoneal cavity. This strategy can be a life-saving intervention, as was the case in our patient

Temporary self-expandable metallic stent placement in post-gastrectomy complications.

Self-expandable metallic stents in the upper gastrointestinal tract are used for treating malignant esophageal or gastroduodenal outlet obstructions and fistulas. Recently, self-expandable metallic stent use has been expanded to benign esophageal or gastroduodenal strictures and post-operative complications. However, there is scarce data available regarding efficacy, long-term complications, and outcomes with the use of self-expandable metallic stent in benign disease, especially post-gastrectomy complications. Data of 57 patients who underwent upper gastrointestinal tract self-expandable metallic stent insertion for post-operative complications between March 2009 and June 2017 were analyzed. All patients underwent a curative gastrectomy for gastric cancer. Data collected included patient demographics, indication for procedure, type of stent used, complications, and patient outcomes. Self-expandable metallic stent placement was technically successful in all patients. Of the 57 patients, 33 had self-expandable metallic stent placement for anastomosis site leakage, 12 for anastomosis site refractory stricture, and 12 for obstruction due to angulation. After self-expandable metallic stent placement, symptomatic improvement was achieved in 56 patients (98.2%), among which, three patients (5.4%) had recurrent symptoms, two underwent repeated stent insertion, and one underwent balloon dilatation. After self-expandable metallic stent placement, median time to initiating dietary intake was 6days (range 1-30days), and median duration of hospitalization was 13days (range 3-135days). At the follow-up (mean 24.6months), migration was the most commonly reported complication, which developed in 15 (26.3%) patients. Self-expandable metallic stent placement is an effective and safe treatment for post-gastrectomy anastomosis site leakage, stricture, and obstruction, which can decrease the risk of reoperation related mortality and modalities.

Fluoroscopic Gastroduodenal Stent Placement in 55 Patients with Endoscopic Stent Placement Failure.

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. 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. 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. 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 IV.

Outcomes of endoscopic biliary drainage in pancreatic cancer patients with an indwelling gastroduodenal stent: a multicenter cohort study in West Japan

Gastroduodenal and biliary obstruction may occur synchronously or asynchronously in advanced pancreatic cancer, and endoscopic double stent placement may be required. EUS-guided biliary drainage (EUS-BD) often is performed after unsuccessful placement of an endoscopic transpapillary stent (ETS), and EUS-BD may be beneficial in double stent placement. This retrospective multicenter cohort study compared the outcomes of ETS placement and EUS-BD in patients with an indwelling gastroduodenal stent (GDS). We recorded the clinical outcomes of patients at 5 tertiary-care medical centers who required biliary drainage after GDS placement between March 2009 and March2014. Thirty-nine patients were included in this study. Patients' mean age was 68.5 years; 23 (59.0%) were men. The GDS overlay the papilla in 23 patients (59.0%). The overall technical success rate was significantly higher with EUS-BD (95.2%) than with ETS placement (56.0%; P< .01). Furthermore, the technical success rate was significantly higher with EUS-BD (93.3%) than with ETS placement (22.2%; P< .01) when the GDS overlies the papilla. The overall clinical success rate of EUS-BD also was significantly higher than for ETS placement (90.5% vs 52.0%, respectively; P= .01), and there was no significant difference in the incidence of adverse events (ETS, 32.0% vs EUS-BD, 42.9%; P= .65). Endoscopic double stent placement with EUS-BD is technically and clinically superior to ETS placement in patients with an indwelling GDS. EUS-BD should be considered the first-line treatment option for patients with an indwelling GDS that overlies the papilla. ETS placement remains a reasonable alternative when the papilla is not covered by the GDS.

Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches.

We aimed to evaluate the safety and effectiveness of fluoroscopy-guided gastroduodenal metallic stent placement with different approaches in malignant obstruction. 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. 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). 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.