Gastrointestinal Stenting Research Articles

Managing radiation safety and protection in gastroenterology in Japan: insights from the REX-GI study.

Fluoroscopy-guided gastrointestinal procedures, including gastrointestinal stenting, balloon-assisted endoscopy (BAE), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS), are essential for diagnosis and treatment in gastroenterology. Such procedures involve radiation exposure that necessitates strict safety measures to protect patients, doctors, and medical staff. The April 2020 update to Japan's Ionizing Radiation Injury Prevention Regulations for occupational exposure reduced the lens exposure dose limit to approximately one-seventh of its previous level. This change highlights the need for improved safety protocols. Without adaptation, the sustainability of fluoroscopy-based endoscopic techniques could be at risk due to the potential to exceed these new limits. This review examines the current state of medical radiation exposure in the field of gastroenterology in Japan and discusses the findings of the REX-GI study.

X-ray Planning and Control in Gastrointestinal Stenting

Background. Self-expandable metal stents (SEMS) are widely used in gastrointestinal (GI) tract obstructive lesions. Planning and stent placement control can be performed with using roentgenological, endoscopic or combined method. The choice of the method depends on doctor’s preferences and clinic’s traditions, but endoscopic one is used more often. Comparison of the above methods efficacy in a single-institution material was not found in the literature. Objective: to compare clinical and roentgenological results of GI stenting depending on the method used. Material and methods. In 2016–2021, 267 cases of GI stenting were performed in Botkin Municipal Clinical Hospital. In 70 (26%) of them an endoscopic method was used, in 97 (36%) – a roentgenological one, and in 100 (37%) – a combined one. All patients underwent X-ray control postop. Results were analyzed statistically. Results. The implementation of X-ray diagnostics solo or in combination with endoscopy in GI SEMS planning and placement provided better results in comparison with endoscopic method only. Total SEMS expansion was achieved in 99% of cases versus 79% after only endoscopic procedures, correct stent placement – in 98% and 75%, respectively, evacuation was restored in 98% and 70%, respectively. All differences were statistically significant (p < 0.001). It is evident that X-ray methods are not useful for preliminary marking in decompensated patients with GI stenosis. But after elimination of such cases from analysis, the difference between the groups remained statistically significant (p < 0.05). Conclusion. The data obtained substitute expediency of X-ray method solo or with endoscopic one. Significant improvement of the results can be referred to more exact preoperative selection of SEMS type and size with X-ray method.

CIRSE Standards of Practice on Oesophageal and Gastroduodenal Stenting

BackgroundImage-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.PurposeThis 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.MethodsThe 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.ConclusionInsertion 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.

Analysis of digestive endoscopic results during COVID-19

ObjectiveThis study aims to explore the necessity and safety of digestive endoscopy during the epidemic of coronavirus disease 2019.MethodsA retrospective cohort study method was used to collect patients’ data from the endoscopy center of the Civil Aviation General Hospital of China from February 1 to May 31, 2020, as the observation group. The patients’ data of endoscopic diagnosis and treatment during the same period in 2019 were used as a control group, to compare the differences in the number of diagnosis and treatment and the detection rate of gastrointestinal diseases in the two groups. At the same time, patients and related staff were followed up for the situation of new infection.ResultsDuring the epidemic, our endoscopy center conducted a total of 1,808 cases of endoscopic operations and 5,903 cases in the control group. The amount of endoscopic work during the epidemic period was 30.63% in the same period last year. During the epidemic, 26 patients underwent endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) treatment, 26 patients underwent ERCP, and 18 patients underwent gastrointestinal stent implantation. In the control group, 273 patients underwent EMR/ESD, 17 underwent ERCP, and 16 underwent gastrointestinal stenting. During COVID-19, compared with the same period last year, the detection rates of peptic ulcer, esophageal cancer, gastric cancer, colon cancer, and rectal cancer were significantly higher (χ2 = 4.482, P = 0.034; χ2 = 5.223, P = 0.006; χ2 = 2.329, P = 0.041; χ2 = 8.755, P = 0.003; and χ2 = 5.136, P = 0.023). Through telephone follow-up, novel coronavirus nucleic acid detection and blood antibody detection, no patients or medical staff were infected with the novel coronavirus.ConclusionDuring COVID-19, the number of digestive endoscopic operations decreased significantly compared with the same period last year, but the detection rate of various diseases of the digestive tract increased significantly. On the basis of strict prevention and control, orderly recovery of endoscopic work is essential.

Upper gastrointestinal stenting during the SARS-CoV-2 outbreak: impact of mitigation measures and risk of contamination for patients and staff.

Background and study aims The impact of COVID-19 mitigation measures on stent placement procedures has not yet been reported. The aim of this study was to assess the impact of COVID-19 mitigation measures on upper stenting during SARS-CoV-2 outbreak, as well as the use of personal protection equipment (PPE) and risk of contamination for patients and staff. Patients and methods This was a multicenter, retrospective study of consecutive patients who underwent stent placement for upper gastrointestinal obstruction during the second half of SARS-CoV-2 outbreak period in comparison to same period one year before. Results A total of 29 stents were placed for upper gastrointestinal obstruction during the study period, corresponding to an increase of 241 % comparing to the same period in 2019 (n = 12). No significant major differences were found between the two time periods regarding patients’ baseline characteristics, post-stenting management and number of staff involved in stent placement. Fellows’ involvement was significantly lower in 2020 compared to 2019 (21 % vs 67 %; P = 0.01). The majority of procedures were performed using FFP2 /FFP3 mask (76 %), protective eyewear (86 %), two pairs of gloves (65 %), hairnet (76 %) and full disposable gowns (90 %). One patient tested positive for SARS-CoV-2 after the procedure. None of the medical staff involved in stenting procedures developed COVID-19 14 days after procedure. Conclusion Upper gastrointestinal stenting increased during the SARS-CoV-2 outbreak period, which could be related to yearly variation on the number of procedures or reflect a change of oncologic treatment practice during COVID times.

Design of Continuum Robot With Variable Stiffness for Gastrointestinal Stenting Using Conformability Factor

Stent placement in the gastrointestinal tract has emerged as an effective method of therapy for intestinal obstruction. In fluoroscopic guided stenting, clinicians first insert a hyper-elastic guidewire, and a stent introducer loaded with a compressed stent is passed along the guidewire to the desired deployment site. However, the high bending stiffness of the loaded stent introducer tends to straighten the inserted guidewire at the tortuous region. To overcome this issue, tubes of various stiffnesses are repeatedly inserted and removed. To optimize the mechanical properties of the devices for successful GI stenting, the interaction between the device and the environment should be considered as a key factor. In this study, conformability factor, a new index that abstracts the physical interaction for GI stenting was proposed. Based on the conformability factor, we proposed design requirements for variable stiffness continuum robots for GI stenting. The in vitro stent deployment experiment result shows that the proposed instrument can successfully deploy the loaded stent introducer without exchanging multiple tubes.

Self-expandable metal stent of esophagogastric junction versus pyloric area obstruction in advanced gastric cancer patients

Upper gastrointestinal stenting is a palliative treatment for relieving symptoms such as nausea, vomiting, and dietary intake in patients with obstruction due to inoperable advanced stomach cancer. Self-expandable metal stent (SEMS) implantation for malignant obstruction has recently become more effective, safer, and less expensive than operative modality. It also has better short-term outcomes, particularly a shorter hospital stay and a more rapid return to oral intake, than surgical treatment. However, there is no comparative analysis regarding the efficacy, side effects, and survival rate of stenting between the esophagogastric junction (EGJ) and pyloric obstructions.To compare the prognoses and complications after SEMS implantation between EGJ and pyloric obstructions in advanced gastric cancer.Among advanced gastric cancer patients with gastrointestinal obstruction diagnosed from January 2008 to December 2017 at the Gastroenterology Department of Chungnam National University Hospital, 42 and 76 patients presented with EGJ (EGJ obstruction group) and gastric pyloric obstructions (pyloric obstruction group), respectively. We retrospectively reviewed the survival period, changes in food intake, and complications of these patients before and after SEMS placement.The prevalences of aspiration pneumonia were 11.9% (5/42) and 2.6% (2/76) in the EGJ and pyloric obstruction groups, respectively, before SEMS placement (P value: .041). Other symptoms associated with gastric malignant obstruction were not statistically different between the groups. Success rate and adverse events did not significantly differ between the EGJ and pyloric obstruction groups. There was no difference in frequency of stent reinsertion procedures performed owing to reobstruction, but the reprocedure average period was statistically significantly longer in the EGJ obstruction group [EGJ obstruction: 158.3 days (±42.4); pyloric obstruction: 86.0 days (±29.1)] (P value: .022). As an index of improved dietary status, the Gastric Outlet Obstruction Scoring System score was not significantly different between the groups before and after SEMS placement.The EGJ and pyloric obstruction groups did not significantly differ in prognosis or complication rates. However, EGJ stent was more stable than pyloric stent when reobstruction was considered.

Use of Fully Covered Biliary Stents in Management of Extra-Biliary Gastrointestinal Disorders

Introduction: Gastrointestinal stenting is an excellent therapeutic modality for palliation of malignancy and management of benign disorders with immediate symptomatic relief. Fully covered biliary self-expandable metal stent (b-SEMS) are commonly used for treatment of benign biliary conditions including strictures, leaks and hemorrhage. The aim of this study was to evaluate the safety and efficacy of b-SEMS for extra-biliary gastrointestinal stenosis. Methods: A retrospective analysis was performed for patients who underwent bSEMS (Viabil) stent placement between January 2011 and December 2016 for various indications throughout the gastrointestinal tract. Primary outcomes were initial clinical success in both benign and malignant presentations and symptom relief. Secondary outcomes were stent migration, rate of re-intervention, and adverse events. Results: 47 patients underwent b-SEMS placement (12 female, 35 male, median age 58.1 years). Treatment of benign stenosis was the indication in the majority of patients (30/47, 63.8%) followed by malignant stenosis (21.3%). Interventions were primarily indicated in the upper gastrointestinal tract ( 32/47, 68.1%) with esophageal stenting being the most common (21/47, 44.6%). Of interventions for the lower gastrointestinal tract, ileal stenting was the most common (8/47, 17%). All b-SEMS were endoscopically placed with technical success. Patient initial clinical success was observed in 46 (97.8?%) patients. Complications included stent migration in 6 (12.8%) patients and 2 (4.3%) patients had persistent symptoms requiring emergent surgery. Conclusion: Biliary SEMS were successful for the management of extrabiliary gastrointestinal symptoms, particularly stenoses with good technical and initial clinical success rates. Despite of their small diameter, they served as a feasible, safe, and effective treatment for benign or malignant strictures. Few complications and low migration rates makes them an excellent alternative to conventional stents.

Enteral stents in the management of post–bariatric surgery leaks

A post–bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon’s nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post–bariatric surgery leaks.

E‐Poster Presentations ‐ C) Endoscopy

E‐Poster Presentations ‐ C) Endoscopy

Successful Non-Surgical Intervention for Massive Gastric Distention due to Malignant Duodenal Obstruction

Gastroduodenal obstruction in pancreatic cancer is common and sometimes challenging to treat. A 35-year-old man with advanced pancreatic cancer receiving palliative chemotherapy presented with worsening abdominal pain, nausea, vomiting and increased abdominal girth. Computed tomography scan of the abdomen revealed signifi cant malignant duodenal obstruction with massive gastric distention. A non-surgical endoscopic intervention with placement of a self-expanding metallic duodenal stent successfully relieved the obstruction and ameliorated symptoms. The patient was able to resume eating normally again. Gastrointestinal stenting is a less invasive and eff ective alternative to surgical gastrojejunostomy. Stent placement as a palliative treatment for patients with malignant duodenal obstruction and massive gastric distention may be considered as a first line treatment for such patients.

Gastrointestinal stenting: Current status and imaging features.

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Recent Advances in Gastrointestinal Stent Development.

Endoscopic stenting is increasingly being used in the management of gastrointestinal luminal obstruction, and has become the current treatment of choice for the palliation of blockage caused by malignant or benign growths. A variety of stents have been developed to enhance the efficacy of the procedure, and improvements are ongoing. In this article, we review the history of, and recent advances in, gastrointestinal stenting. We describe the rationale behind the design as well as the resulting outcome for each stent type.

Endoscopic ultrasound-guided treatments: are we getting evidence based--a systematic review.

The continued need to develop less invasive alternatives to surgical and radiologic interventions has driven the development of endoscopic ultrasound (EUS)-guided treatments. These include EUS-guided drainage of pancreatic fluid collections, EUS-guided necrosectomy, EUS-guided cholangiography and biliary drainage, EUS-guided pancreatography and pancreatic duct drainage, EUS-guided gallbladder drainage, EUS-guided drainage of abdominal and pelvic fluid collections, EUS-guided celiac plexus block and celiac plexus neurolysis, EUS-guided pancreatic cyst ablation, EUS-guided vascular interventions, EUS-guided delivery of antitumoral agents and EUS-guided fiducial placement and brachytherapy. However these procedures are technically challenging and require expertise in both EUS and interventional endoscopy, such as endoscopic retrograde cholangiopancreatography and gastrointestinal stenting. We undertook a systematic review to record the entire body of literature accumulated over the past 2 decades on EUS-guided interventions with the objective of performing a critical appraisal of published articles, based on the classification of studies according to levels of evidence, in order to assess the scientific progress made in this field.

Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study.

BackgroundThe clinical effect of stent treatment has been evaluated by mainly physicians; only a limited number of prospective studies have used patient-reported outcomes for this purpose. The aim of this work was to study the clinical effect of self-expanding metal stents in treatment of malignant gastrointestinal obstructions, as evaluated by patient-reported outcomes, and compare the rating of the treatment effect by patients and physicians.MethodsBetween November 2006 and April 2008, 273 patients treated with SEMS for malignant GI and biliary obstructions were recruited from nine Norwegian hospitals. Patients and physicians assessed symptoms independently at the time of treatment and after 2 weeks using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire supplemented with specific questions related to obstruction.ResultsA total of 162 patients (99 males; median age = 72 years) completed both assessments and were included in the study. A significant improvement in the mean global health score was observed after 2 weeks (from 9 to 18 on a 0–100 scale, P < 0.03) for all stent locations. Both patients and physicians reported a significant reduction in all obstruction-related symptoms (>20 on the 0–100 scale, P < 0.006) after SEMS treatment. The physicians reported a larger mean improvement in symptoms than did the patients, mainly because they reported more severe symptoms before treatment.ConclusionSEMS treatment is effective in relieving symptoms of malignant GI and biliary obstruction, as reported by patients and physicians. The physicians, however, reported a larger reduction in obstructive symptoms than did the patients. A prospective assessment of patient-reported outcomes is important in evaluating SEMS treatment.

Endoscopy-Assisted Placement of a Metallic Stent in a Patient with Crohnʼs Disease Presenting with Recurrent Benign Intestinal Strictures

Fibrotic (non-inflammatory) stricture occurrence is common in Crohn's Disease (CD). Endoscopic placement of metallic stents has been tried as an alternative to surgery. However, the available literature and experience with this technique is limited. This report illustrates a patient with recurrent, post-surgical symptomatic strictures secondary to CD who underwent an endoscopic placement of a metallic stent. The patient is a 51-year-old Caucasian male with history of CD who underwent previous resections for recurrent distal small bowel strictures. Despite medical therapy, strictureplasty was necessary to relieve recurrent obstructive symptoms that developed as a result of a new stenosis at the site of the ileocolonic anastomosis. Failure of that therapy led to repeated endoscopy-assisted balloon dilations all of which were ineffective. The patient ultimately underwent endoscopy-assisted placement of a metallic stent, which has proved successful in preventing recurrence of his symptoms over the last 36 months. Although active inflammatory strictures in CD can be treated medically, fibrotic stenosis still occurs. Intestinal resection or surgical strictureplasty are often needed. Surgical strictureplasty preserves intestinal length but does not reduce the number of surgical procedures. Endoscopy-assisted balloon dilatation has been tried as a non-surgical alternative, but the outcome, as also observed in our patient, is often transient and requires repeated procedures. Gastrointestinal stenting, already widely used in the treatment of malignant strictures and fistulas, represents a new modality to treat benign fibrotic strictures. Preliminary reports have shown that endoscopy-assisted placement of metallic stents is a safe procedure with minimal complications and lasting effects. After the endoscopic placement of the stent, our patient has experienced complete resolution of his obstructive symptoms. This report along with others supports the use of metallic stents in selected patients with medically refractory CD associated intestinal strictures with minimal side effects and maximal benefit.

INSERTION OF METALLIC STENTS FOR MALIGNANT GASTRIC OUTLET AND DUODENAL STENOSES

ABSTRACTRecently, an indication of gastrointestinal stenting is not only esophageal stenosis but it extends from the esophagus to the gastric outlet and duodenum. However, there are some problems such as shortness of the device for esophageal stenting, angulations of stenotic sites, and so on, when we perform the stenting for stenoses of the gastric outlet and duodenum. Until now, some refinements of stent insertion technique have been attempted to solve these problems. In this paper, we report three cases in which self‐expanding metallic stents were placed for stenoses of the gastric outlet and duodenum with refinements of stent insertion technique. Our attempts in these patients were an extension of stenting device to insert stents easily, and placement of covered metallic stent inside non‐covered metallic stent or a fixation of covered metallic stent to the gastrointestinal wall by means of endoclips to avoid dislocation of stents. Stents were inserted successfully in all patients, and the nutrition of these patients was improved after the placement of stents. Further refinements of stents and stent insertion technique are expected to achieve easy manipulation.