Malignant Obstruction Research Articles

Treatment of choice for malignant gastric outlet obstruction: More than clearing the road

In this editorial, we comment on the in-press article in the World Journal of Gastrointestinal Endoscopy concerning the treatment of malignant gastric outlet obstruction (mGOO). The original theory of treatment involves bypassing the obstruction or reenabling the patency of the passage. Conventional surgical gastroenterostomy provides long-term relief of symptoms in selected patients, with substantial morbidity and a considerable rate of delayed gastric emptying. Endoscopic stenting was introduced as an alternative minimally invasive procedure with less procedural morbidity and rapid clinical improvement; however, it presented a high rate of long-term recurrence. Therefore, challenges remain in the treatment of mGOO patients to improve clinical outcomes. Endoscopic ultrasound-guided gastroenterostomy has recently emerged as a promising method because of the combined effects of surgery and endoscopy, whereas stomach-partitioning gastrojejunostomy has been reported as a modified surgical procedure to reduce the rate of delayed gastric emptying. In decision-making regarding the treatment of choice, it should be taken into account that mGOO might be accompanied by a variety of pathological conditions, including cancer cachexia, anorexia, malabsorption, and etc. , all of which can also lead to the characteristic symptoms and poor nutritional status of mGOO. The treatment plan should consider comprehensive aspects of patients to achieve practical improvements in prognosis and the quality of life.

Antegrade stenting for chronic malignant ureteral obstruction with the Resonance® metallic stent: a case series.

Polymeric and metallic stents are commonly used to manage patients with chronic malignant ureteric obstruction (CMUO). This paper compares the outcomes of ureteral stenting via the Resonance® metallic stent against its polymeric counterpart in published literature, as well as between antegrade and retrograde approaches. A retrospective case series was conducted whereby patients who had undergone Resonance® stent insertions via an antegrade route from June 2022 to May 2023 were reviewed through our electronic medical record system. Descriptive statistics were used to summarise patient demographics and clinical outcomes. 11 patients who presented with CMUO underwent 12 separate procedures of either unilateral or bilateral ureteral stenting. Total number of stents inserted was 16. Median age of patients was 65 (Range = 32) and 72.73% were males. 66.67% of the procedures yielded an improvement in the estimated glomerular filtration rate (eGFR) in patients as compared to before stenting. Stent failure, defined by stent removal before recommended removal date, occurred in 4 out of 16 (25%) stents. The median duration of Resonance® stent in situ at the time of data collection (4th December 2023) was 245days. We conclude that the Resonance® stent is more effective at providing long term urinary drainage for CMUO, compared to its polymeric counterpart. However, antegrade insertion of the Resonance® stent does not significantly decrease indwelling stent duration compared to retrograde insertion.

Urinary Diversion Can Improve the Chance of Implementing New Therapeutic Lines in Patients with Malignant Ureteral Obstruction: A Multicenter Study

Purpose: Malignant ureteral obstruction is generally associated with a poor disease prognosis; therefore, managing these cases is challenging. We describe our experience in treating malignant ureteral obstruction with urinary diversion and the impact of these procedures on the indication for new antineoplastic therapy and survival. Materials and Methods: We retrospectively reviewed the data of patients with advanced cancer associated with malignant ureteral obstruction who underwent urinary diversion at three tertiary institutions between January 2013 and July 2022. Results: This study included 420 patients (mean age, 58.7 years (range, 18–90 years) with a mean follow-up of 20.3 months. Cervical (36.2%) and bladder cancers (18.6%) were the most prevalent primary neo-plastic sites. The mean creatinine values measured before diversion, 30 days after surgery, and most recently were 3.45, 1.84, and 2.59 mg/dL, respectively. In total, 300 patients (71.4%) received antineoplastic treatment, 195 received palliative treatment, and 105 received curative treatment. After an average of 251.87 postoperative days, 265 (64%) patients died. The mean overall survival was 610.76 days. Patients with prostate and cervical neoplasms had the most prolonged overall survival (573.13 and 549.28 days, respectively), whereas patients with bladder and colorectal cancer had the worst overall survival (480.25 and 370.53 days, respectively). Conclusions: Urinary diversion improves kidney function and opens a therapeutic window for a new line of antineoplastic therapy that provides a cure or increases patient survival.

Self-Expanding Metal Stents in the Acute Management of Oesophageal Variceal Bleeding: A Systematic Review.

Acute variceal bleeding (AVB) continues to challenge physicians and healthcare systems. Despite significant advances in our multimodal approach to managing this problem, namely medical, endoscopic, and radiological techniques, the mortality rates for this patient cohort remain as high as 20% on the index admission. This mortality rate has remained unchanged over the past 25 years. A crucial tool in the management of AVB is the balloon tamponade technique. However, this is associated with numerous severe and potentially life-threatening adverse events. Due to the limitations of oesophageal balloon tamponade devices, there has been an increased interest in using self-expanding metal stents (SEMS) to manage refractory variceal bleeding. There is a base of experience in using SEMS derived from their use in managing malignant obstructions. This study aimed to synthesise all available evidence, for the first time, on using SEMS to manage refractory oesophageal AVB. This study was a systematic review of published papers, which is reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We identified 16 suitable studies for review. These comprised one randomised controlled trial comparing SEMS to balloon tamponade, one prospective cohort study, nine retrospective cohort studies, four case reports, and one case series. In total, 246 patients were included. An average survival rate of 49% was seen among the 11 studies that reported a six-week survival rate; this included a cohort of 225 patients. The SEMS were left in situ for an average of 7.5 days, with a maximum average of 18 days in one study. The average rate for controlling the acute bleeding episode in patients receiving a SEMS was 96%. The re-bleeding rate on the removal of SEMS was 5%, far superior to the widely reported 50% re-bleeding rate for the balloon tamponade technique. The adverse event profile for the SEMS appears superior to the balloon tamponade technique overall. The rate of stent-related adverse events in patients receiving a SEMS was 25%. The most common adverse events were technical issues related to stent functioning, namely stent migration. The most severe stent-related adverse event was compression of the left main bronchus in two cases, which required the removal of the stent. Our study has several limitations, which we have alluded to throughout the paper. The studies on this issue are of poor quality, with only one randomised controlled trial performed. As a result, we must interpret the results of our research with caution. Our study supports the use of SEMS in managing AVB as a promising area of research. We have highlighted that further well-designed randomised controlled trials are needed to assess the efficacy of this technique, ideally compared directly to the balloon tamponade technique. However, based on this systematic review, the current body of evidence would suggest that the SEMS is superior to the balloon tamponade technique in terms of adverse event profile, re-bleeding rate, and length of time the device can safely be left in situ. Current evidence suggests that SEMS are as effective at controlling acute bleeding episodes as the balloon tamponade technique.

Recurrence of malignant duodenal obstruction following duodenal stenting: successful management through EUS-guided gastrojejunostomy (with videos)

Recurrence of malignant duodenal obstruction following duodenal stenting: successful management through EUS-guided gastrojejunostomy (with videos)

Outcomes of nephrostomy and double J stent in malignant ureteral obstruction in the Palestinian practice

BackgroundMalignant ureteral obstruction (MUO) is a serious health condition in which a malignant tumor compresses the ureter. The optimal decompressive intervention in MUO remains unclear. This study was conducted to assess and compare renal function, the occurrence of ureterohydronephrosis (UHN), intraoperative, and postoperative complications among patients with MUO who underwent double J stenting (DJS) and percutaneous nephrostomy (PCN) in the Palestinian practice.MethodsThis study was conducted in retrospective design in one of the main tertiary care hospitals in the West Bank of Palestine. The data were collected from the electronic health information system of the hospital for the patients with MUO who received either DJS or PCN as a decompressive intervention from January 2018 to January 2024.ResultsIn this retrospective analysis, 62 patients who had stage 2 to stage 4 cancer and suffered MUO were included. The mean age of the patients was 60.8 ± 13.6 years. Of the patients, 40 (64.5%) were male and 22 (35.5%) were female. Of the patients, 26 (41.9%) had urinary bladder cancer. Of the patients, 23 (37.1%) had flank pain and 16 (25.8%) had lower urinary tract symptoms. Of the patients, 34 (54.8%) experienced bilateral UHN and 28 (45.2%) experienced unilateral UHN. In this study, 43 patients (69.4%) received PCN, and 19 (30.6%) received DJS as a decompressive intervention. Of the patients, 36 (58.1%) suffered postoperative complications. Stent migration/slip, UTIs, and urosepsis were the most commonly reported postoperative complications. There were no statistically significant differences in the occurrence of intraoperative complications, postoperative complications, time elapsed from receiving the decompression intervention to the diagnosis of complications, ICU admission, prognosis of UHN, serum creatinine, and serum BUN between both decompressive interventions.ConclusionDespite improvements in renal functions, creatinine and BUN levels remained abnormal even after receiving a decompressive intervention. Postoperative complications were frequently reported among patients who received DJS or PCN as decompressive interventions. Larger prospective studies are still needed to determine the optimal interventions to improve outcomes, quality of life, and survival rates of patients with DJS or PCN.

Clinical Results of Percutaneous Transhepatic Biliary Drainage With Different Hepatic Access and Methods in the Treatment of Obstructive Jaundice.

Percutaneous transhepatic biliary drainage (PTBD) is a common procedure for biliary obstruction jaundice caused by biliary tract obstruction. PTBD can be performed using external or external-internal methods, by the right or left lobe approach. However, differences in both the method used and the hepatic approach may affect success rates and complications. Therefore, this study aimed to examine the outcomes and complications of PTBD and compare them according to different methods and hepatic approaches. Patients who underwent PTBD procedures in our interventional radiology department due to benign or malignant pathologies between March 2021 and March 2024 were included in the study. The diagnoses of the patients, and total and direct bilirubin values before and after the procedure were recorded. The clinical results and the complications of PTBD were compared statistically according to the hepatic approach and method. Univariate logistic regression analysis was performed to determine significant factors associated with PTBD success and complications. Sixty patients were included in our study (32 men, 28 women; mean age: 67.14±13.61y). The most common indication was malignant bile duct obstruction (90%). The obstruction was mostly at the level of the common bile duct (46.7%). The success rate of PTBD was the highest with the left-side external biliary drainage approach (left-side external biliary drainage, 81.2%; right-side internal-external biliary drainage, 77.8%; right-side external biliary drainage, 69.2%; P=0.596). The complication rate was higher for right-side access (right side 15.9%, left side 12.5%, P=0.744). Univariate logistic regression analysis revealed that PTBD success in females was 5 times higher than in males [Exp(B): 5.000, β: 1.609, P<0.05]. Univariate logistic regression analysis revealed that methods used, entry lobes, and entry levels did not significantly affect PTBD success and complication incidence (P>0.05). All approaches and methods used during PTBD were associated with low complications and high success rates. Nevertheless, external biliary drainage with right hepatic access has the lowest clinical success rate and a higher complication rate than the left-lobe approach. We observed that left-sided external biliary drainage was the most successful method and had fewer complications.

Management of inoperable malignant bowel obstruction using the 4-step BOUNCED diet.

Malignant bowel obstruction (MBO) presents with multiple symptoms. The 4-step BOUNCED diet educates patients to self-manage oral intake according to symptoms. It includes clear fluids, thin liquids, purée and soft, sloppy foods, which are low in fibre. This mixed methods single-arm feasibility study aimed to establish if the diet could reduce MBO symptoms in patients with inoperable colorectal and gynaecological malignancies. The secondary objectives were to investigate if it was easily followed, improved quality of life (QOL) and reduced hospital admissions. Patients able to tolerate an oral diet with one or more symptoms (pain, bloating, early satiety, nausea and vomiting) were eligible. Following informed consent, an oncology dietitian took a diet history and determined which step of the diet they needed to follow using a detailed patient information leaflet. Patients remained on the trial for 28 days. Symptom and QOL data were collected on Days 1 and 28 using the Memorial Symptom Assessment Scale and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ-C30) questionnaires. Thirty patients (24 female, 6 male) aged 18-85 years consented from March 2021 to November 2022. Twenty-six participants completed the trial and 25 found the diet very easy or easy to understand. There was a significant reduction in pain from 96% on Day 1 to 63% on Day 28 (p = 0.004). The mean increase of EORTC global health status/QOL was 23.5 points, 95% CI (12.4-32.5) (p ≤ 0.001). There was a significant difference between number of admissions (p = 0.018) and bed days (p = 0.004) in the 28 days prior to consent compared to the trial period. A modified consistency low-fibre diet is easily followed, may reduce symptoms of MBO, admissions to hospital and improve QOL.

Endoscopic Ultrasound Guided Gastro-enterostomy for Malignant Gastric Outlet Obstruction: Impact of Clinical and Demographic Factors on Outcomes

Endoscopic ultrasound guided gastroenterostomy (EUS-GE) has emerged as an alternative to surgical gastrojejunostomy and endoluminal stenting for malignant gastric outlet obstruction (MGOO). Studies regarding factors associated with the EUS-GE outcomes are limited. A retrospective observational study was conducted with consecutive patients who underwent EUS-GE for MGOO at our center from January 2016 to November 2023. Primary outcomes were technical success (Establishing EUS-GE) and clinical success (Low residue diet tolerance without re-intervention at 90-day follow-up). Secondary outcomes were adverse events (AEs), reinterventions and full regular diet tolerance. Technical success and clinical success rates were 92.70% (127/137) and 88.00%, respectively, with 42.86% of the patients tolerating a regular diet. Patients with peritoneal carcinomatosis had lower odds of technical success (OR: 0.19, 95% CI: 0.04-0.93). Obstruction at the level of stomach, compared to duodenum, had lower odds of clinical success (OR: 0.06, 95% CI: 0.006-0.56). AE and reintervention rates were 14.17% and 8.66%, respectively. NGT decompression prior to EUS-GE was associated with lower AE rates in multivariable analysis (OR: 0.32, 95% CI: 0.11-0.95). Prior gastrointestinal surgery was associated with reintervention in multivariable analysis (OR: 4.09; 95% CI: 1.02-16.45, p-value: 0.047). EUS-GE has high technical and clinical success rates, with many patients tolerating regular diet. Routine NGT decompression should be considered to minimize AEs. MGOO at the level of stomach is associated with lower clinical success rates. Extra care should be taken while performing EUS-GE in patients with peritoneal carcinomatosis. Prior gastrointestinal surgery is a likely risk factor for reintervention.

A National Perspective on Palliative Interventions for Malignant Gastric Outlet Obstruction.

Approximately 15-20% of patients with duodenal or periampullary malignancies develop GOO. While small, randomized trials have reported more rapid recovery and shorter hospital stay with ES, limited studies have evaluated outcomes on a national level. The present study characterized short-term clinical and financial outcomes associated with gastrojejunostomy (GJ) versus endoscopic stenting (ES) in malignant gastric outlet obstruction (GOO). Adults with malignant GOO treated with ES or GJ were identified in the 2016-2020 Nationwide Readmissions Database. Entropy balancing was used to balance covariates between groups, and multivariable regression was used to evaluate the association between GJ or ES and in-hospital mortality, total parenteral nutrition (TPN) use, complications, length of stay (LOS), costs, and 90-day readmission. Of 8,186 GOO patients, 68.4% underwent ES and 31.6% GJ. The cohorts were similar in age, sex, and comorbidities, while GJ patients were more commonly frail. After risk adjustment, mortality, composite complications, and 90-day readmission were comparable between GJ and ES. GJ was associated with greater odds of blood transfusion (AOR 1.74 [95% CI [1.37-2.21]) and postoperative TPN use (AOR 3.76 [95% CI 2.64-5.35]). Furthermore, GJ patients experienced a significant increment of +$15,800 in costs and +6.9-day in LOS. On subgroup analysis of patients with metastatic disease, mortality, complications, and readmission remained comparable between palliation strategies. ES appears to yield comparable short-term morbidity and mortality relative to GJ with significant cost reduction. Increasing access to endoscopic technology and regionalizing care to high-volume centers may help improve outcomes for patients with malignant GOO.

Predictors of symptom recurrence and survival in patients with malignant gastric outlet obstruction treated with self-expanding metal stents.

Malignant gastric outlet obstruction (GOO) poses a substantial symptomatic burden. While various therapeutic options exist, self-expanding metal stents (SEMS) are a common palliative choice for patients who are ineligible for surgery. We studied SEMS outcomes to identify factors influencing stent dysfunction and patient survival. A multi-centre, retrospective review of 190 patients with GOO undergoing SEMS at three tertiary hospitals was performed over 2016-2022. Technical success, clinical success and adverse outcomes were recorded. Predictors of stent dysfunction and survival were evaluated using multivariate regression. Technical success was achieved in 186/190 (97.9%) and clinical success in 156/186 (83.9%), defined as post-procedural gastric outlet obstruction symptom score (GOOSS) ≥2. Eighty-two (44.1%) patients experienced an adverse event with stent occlusion the most common (23.1%). Approximately one-third (32.3%) underwent a repeat intervention. Mean stent patency time was 67 days (standard deviation=76), and median post-stent survival was 95 days (37-197). Covered and partially covered SEMS carried three times the risk of stent dysfunction compared to uncovered SEMS (odds ratio 3.06, p=0.008). Mortality predictors were Eastern Cooperative Oncology Group score ≥2 (p=0.03), extrinsic outlet obstruction (p=0.05) and presence of ascites (p=<0.001). SEMS demonstrated technical and clinical success but posed a high risk of recurrence, with stent patency time falling short of survival in our cohort. With an evolving landscape of therapeutics for GOO, appropriate patient selection is paramount. Individuals with reduced performance status, extrinsic obstruction and/or ascites may be better candidates for SEMS due to more limited life expectancy. In this setting, uncovered SEMS carry the lowest risk of reintervention.

Urogenital schistosomiasis, a leading cause of bladder squamous cell carcinoma

Abstract Introduction/Objective Schistosoma, genus of trematodes, commonly known as blood flukes are parasitic flatworms responsible for a group of infections in humans termed schistosomiasis and hundreds of millions of people are infected worldwide. In areas where Shistosoma is not endemic to the region most cases of bladder malignancy are of urothelial origin. In areas where Shistosoma is endemic bladder malignancy is more commonly squamous cell carcinoma. However, with increased travel, migration and tourism it is important to potentially consider Shistosoma infection in areas that are not typically considered endemic regions. Methods/Case Report A 62-year-old male presented to our hospital and revealed through an interpreter he has had 1.5 years hematuria with “pieces of meat or brown dirt”. Cystoscopy was performed and showed a large necrotic mass. CT scan showed an 8.2 cm exophytic bladder dome mass. TURBT was performed and a diagnosis of invasive high-grade urothelial carcinoma with squamous differentiation and with multiple Schistosoma organisms identified.The patient received Schistosoma treatment and was scheduled for radical cystectomy and ileal conduct. A few days before the scheduled procedure the patient presented to our emergency department with acute abdominal pain. He was subsequently diagnosed with progressive bladder cancer with new left malignant ureteral obstruction, which lead to hydronephrosis, DVT, abdominopelvic ascites and intraperitoneal bladder perforation. Abdominal fluid cytology showed atypical keratinizing squamous cells suspicous for malignancy and marked acute inflammation. Patient underwent cystectomy with ileal conduit and the specimen was sent to pathology for examination. Results (if a Case Study enter NA) NA Conclusion Gross examination showed an irregular perforated bladder. Microscopic examination showed a high grade urothelial carcinoma with squamous and sarcomatoid differentiation with detrusor muscle invasion. Additionally, Schistosoma organisms with a terminal spine and calcified eggs were identified. Some of the calcified egg material was engulfed by giant cells. The organisms are surrounded by a prominent eosinophilic infiltrate. Lymphovascular invasion is also noted. Schistosomiasis is associated with the development of squamous cell carcinoma of the bladder. It is important to maintain high oncological alertness for squamous cell carcinoma, particularly for patients arriving from endemic areas. Such as in our case, a patient from Somalia living in Kansas City.

A retrospective comparative study of biliary drainage using balloon endoscopy and endoscopic ultrasound for malignant obstruction in patients with surgically altered anatomy.

Endoscopic biliary drainage for malignant biliary obstruction (MBO) in patients with surgically altered anatomy is challenging, and technical difficulty could differ by the anatomy. Balloon endoscopy-assisted endoscopic retrograde cholangiopancreatography (BE-ERCP) and endoscopic ultrasonography-guided biliary drainage (EUS-BD) are both emerging procedures, and we conducted the single-center, retrospective study to compare clinical outcomes of BE-ERCP and EUS-BD for MBO. Consecutive patients with surgically altered anatomy who underwent BE-ERCP or EUS-BD for MBO were retrospectively studies. Technical and clinical success rates, adverse events (AEs), and time to recurrent biliary obstruction (TRBO) were compared. Patient characteristics were comparable between BE-ERCP (n = 118) and EUS-BD (n = 32), other than more patients with hepaticojejunostomy in the BE-ERCP group (66% vs. 44%, P = 0.03). Technical success rate was significantly higher in the EUS-BD group (70% vs. 94%, P = 0.005), but clinical success rates (84% vs. 90%, P = 0.55), early AE (14% vs. 22%, P = 0.29) and late AE rates (42% vs. 38%, P = 0.84), and RBO rates (31% vs. 34%, P = 0.67) were comparable between the groups. TRBO was 170 and 206days in the BE-ERCP and EUS-BD group (P = 0.37). In the subgroup analysis of patients with the intact papilla, the technical success rate of BE-ERCP was as low as 55%, compared to 94% in EUS-BD (P = 0.003). EUS-BD was associated with higher technical success rate than BE-ERCP for MBO in patients with surgically altered anatomy.

Malignant Small Bowel Obstruction from Hernia Mesh Invasion by Jejunal Adenocarcinoma: A Report of a Rare Case

Malignant Small Bowel Obstruction from Hernia Mesh Invasion by Jejunal Adenocarcinoma: A Report of a Rare Case

Innovative techniques using a novel thin scope for stent placement in malignant colonic obstruction with severe angulation deformity.

Innovative techniques using a novel thin scope for stent placement in malignant colonic obstruction with severe angulation deformity.

Biliary drainage in palliative and curative intent European patients with hilar cholangiocarcinoma and malignant hilar obstruction: a retrospective single center analysis

Background and aimsRelief of cholestasis in hilar cholangiocarcinoma is commonly undertaken in both curative and palliative treatment plans. There are numerous open questions with regard to the ideal biliary drainage strategy – including what constitutes clinical success (CS). In the existing data, curative patients and patients from the Western world are underrepresented.Patients and methodsWe performed a retrospective analysis of patients with complex malignant hilar obstruction (Bismuth-Corlette II and higher) due to cholangiocarcinoma who underwent biliary drainage at a German referral center between 2010 and 2020. We aimed to define CS and complication rates and directly compare outcomes in curative and palliative patients.Results56 curative and 72 palliative patients underwent biliary drainage. In patients with curative intent, CS was achieved significantly more often regardless of what definition of CS was applied (e.g., total serum bilirubin (TSB) < 2 mg/dl: 66.1% vs. 27.8%, p = < 0.001, > 75% reduction of TSB: 57.1% vs. 29.2%, p = 0.003). This observation held true only when subgroups with the same Bismuth-Corlette stage were compared. Moreover, palliative patients experienced a significantly greater percentage of adverse events (33.3% vs. 12.5%, p = 0.01). Curative intent treatment and TSB at presentation were predictive factors of CS regardless of what definition of CS was applied. The observed CS rates are comparable to published studies involving curative patients, but inferior to reported CS rates in palliative series mostly from Asia.ConclusionsBiliary drainage in complex malignant hilar obstruction due to cholangiocarcinoma is more likely to be successful and less likely to cause adverse events in curative patients compared to palliative patients.

Radiation Exposure with Self-Expandable Metallic Stent versus Transanal Decompression Tube for Malignant Colorectal Obstruction: A Post Hoc Propensity Score Matched Analysis.

Background: Although several reports have compared the outcomes of self-expandable metallic stent (SEMSs) and transanal decompression tube (TDT) placement for malignant colorectal obstruction (MCO), few studies have compared the radiation exposure (RE) associated with these two procedures. Consequently, we aimed to compare the RE of SEMS and TDT placements for MCO using propensity score matching (PSM) in a multi-center, prospective observational study. Methods: This study investigated the clinical data of 236 patients who underwent SEMS or TDT placement. The air kerma at the patient entrance reference point (Ka,r: mGy) and air kerma-area product (PKA; Gycm2) were measured and compared between SEMS and TDT groups after PSM. Results: After PSM, 61 patients were identified in each group. The median Ka,r in the SEMS group was significantly greater than that in the TDT group (77.4 vs. 55.6 mGy; p = 0.025) across the entire cohort. With respect to subgroup analyses by location, in the rectum, the median Ka, r and PKA were significantly greater in the SEMS group than in the TDT group (172.9 vs. 34.6 mGy; p = 0.001; and 46.0 vs. 18.1 Gycm2; p = 0.006, respectively). However, in the colon, the RE parameters did not significantly differ between the two groups. Conclusions: TDT might be a more suitable option for decompression in patients with malignant rectal obstruction due to its lower RE and technical advantages. Conversely, SEMS placement is recommended as the first decompression method to treat malignant colonic obstruction, in line with the current guidelines.

Palliation of Gastric Outlet Obstruction in Case of Biliary Obstruction-A Retrospective, Multicenter Study: The B-GOOD Study.

EUS-guided gastroenterostomy (EUS-GE) is a novel and effective procedure for the management of malignant gastric outlet obstruction (GOO) with more durable results when compared to enteral stenting (ES). However, data comparing EUS-GE to ES in patients already treated with EUS-guided choledocoduodenostomy (EUS-CDS) for distal malignant biliary obstruction (DMBO) are lacking. We aimed to compare outcomes of EUS-GE and ES for the palliation of GOO in this specific population of patients. A multicenter, retrospective analysis of patients with DMBO treated by EUS-CDS and subsequent GOO treated by EUS-GE or ES from 2016 to 2021 was conducted. Primary outcomes were overall AEs rate and dysfunction of the EUS-CDS after GOO treatment. Secondary outcomes included clinical success, technical success, procedure duration, length of hospital stay and relapse of GOO symptoms. A total of 77 consecutive patients were included in the study: 25 patients underwent EUS-GE and 52 underwent ES. AEs rate and patency outcomes of the EUS-CDS after GOO treatment were comparable between the two groups (12.5% vs. 17.3%; p = 0.74). No recurrence of GOO symptoms was registered in the EUS-GE group while 11.5% of ES patients had symptoms recurrence, even if not statistically significant (p = 0.16), after a mean follow-up period of 63.5 days. EUS-GE and ES are both effective and safe for the palliation of GOO in patients already treated by EUS-CDS for DMBO with no difference in the biliary stent dysfunction rate and overall AEs. EUS-GE is associated with less recurrence of GOO symptoms.

Optimizing EUS-guided choledochoduodenostomy with lumen-apposing metal stents for primary drainage of malignant distal biliary obstruction (SCORPION-IIp): a prospective pilot study

Background and AimsBiliary drainage by endoscopic retrograde cholangiography (ERCP) in patients with malignant distal bile duct obstruction (MBO) is frequently associated with complications, such as pancreatitis, hampering patient outcome. EUS-guided choledochoduodenostomy (EUS-CDS) with a lumen-apposing metal stent (LAMS) is a promising alternative in patients with MBO but is associated with a worrisome risk of stent dysfunction. Placement of a fully covered self-expandable metal stent (FCSEMS) through the LAMS, thereby changing the axis of biliary drainage towards the descending duodenum, may decrease the risk of stent dysfunction while maintaining high technical success and low adverse event rates. MethodsProspective single center pilot study in patients with a pathology confirmed MBO without gastric-outlet obstruction. Primary outcome was stent dysfunction, defined as recurrent jaundice after initial clinical success, ongoing jaundice in combination with persistent bile duct dilatation, or cholangitis. The study was registered in clinicaltrials.gov (registry number NCT05595122). ResultsOverall, 27 consecutive patients eligible for EUS-CDS were enrolled. The placement of a LAMS was successful in 24/27 patients (89%), and placement of FCSEMS through the LAMS was successful in 20/24 (83%), in the remaining 4 patients a coaxial double-pigtail plastic stent was placed. In 2 of these 20 patients there was persistent jaundice requiring stent revision (10%), leading to a clinical success rate of 90%. No patients developed stent dysfunction after initial clinical success. ConclusionsThis study showed a stent dysfunction rate of 10% following technically successful EUS-CDS with placement of a FCSEMS through the LAMS. Improving the design of LAMS may further reduce the rate of stent dysfunction.

Palliative procedures for malignant gastric outlet obstruction: a network meta-analysis.

The optimal treatment for malignant gastric outlet obstruction (GOO) remains uncertain. This systematic review aimed to comprehensively investigate the efficacy and safety of four palliative treatments for malignant GOO: gastrojejunostomy, endoscopic ultrasound-guided gastroenterostomy (EUS-GE), stomach-partitioning gastrojejunostomy (PGJ), and endoscopic stenting. We searched PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform for randomized controlled trials (RCTs) and cohort studies comparing the four treatments for malignant GOO. We included studies that reported at least one of the following clinical outcomes: clinical success, 30-day mortality, reintervention rate, or length of hospital stay. Evidence from RCTs and non-RCTs was naïve combined to perform network meta-analysis through the frequentist approach using an inverse variance model. Treatments were ranked by P score. This network meta-analysis included 3617 patients from 4 RCTs, 4 prospective cohort studies, and 32 retrospective cohort studies. PGJ was the optimal approach in terms of clinical success and reintervention (P scores: 0.95 and 0.90, respectively). EUS-GE had the highest probability of being the optimal treatment in terms of 30-day mortality and complications (P scores: 0.82 and 0.99, respectively). Cluster ranking to combine the P scores for 30-day mortality and reintervention indicated the benefits of PGJ and EUS-GE (cophenetic correlation coefficient: 0.94; PGJ and EUS-GE were in the same cluster). PGJ and EUS-GE are recommended for malignant GOO. PGJ could be the alternative choice in centers with limited resources or in patients who are unsuitable for EUS-GE.