Palliation Of Malignant Gastroduodenal Obstruction Research Articles

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.

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.

Conformable covered versus uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction: A randomized prospective study

A conformable self-expandable metallic stent was developed to overcome the limitation of previous self-expandable metallic stents. The aim of this study was to evaluate outcomes after placement of conformable covered and uncovered self-expandable metallic stents for palliation of malignant gastroduodenal obstruction. A single-blind, randomized, parallel-group, prospective study were conducted in 4 medical centres between March 2009 and July 2012. 134 patients with unresectable malignant gastroduodenal obstruction were assigned to a covered double-layered (n=66) or uncovered unfixed-cell braided (n=68) stent placement group. Primary analysis was performed to compare re-intervention rates between two groups. 120 patients were analysed (59 in the covered group and 61 in the uncovered group). Overall rates of re-intervention were not significantly different between the two groups: 13/59 (22.0%) in the covered group vs. 13/61 (21.3%) in the uncovered group, p=0.999. Stent migration was more frequent in the covered group than in the uncovered group (p=0.003). The tumour ingrowth rate was higher in the uncovered group than in the covered group (p=0.016). The rates of re-intervention did not significantly differ between the two stents. Conformable covered double-layered and uncovered unfixed-cell braided stents were associated with different patterns of stent malfunction.

Treatment of malignant gastroduodenal obstruction with a nitinol self-expanding metal stent: An international prospective multicentre registry

Background Duodenal stenting has become a broadly accepted first line of treatment for patients with advanced malignant gastroduodenal obstruction as these patients are difficult to treat and are poor surgical candidates. Aims To document duodenal stent performance for palliative management of malignant gastroduodenal obstruction. Methods Multicentre, single arm, prospective registry documenting peroral endoscopic duodenal stenting procedures in 202 patients. Results Technical success achieved in 98% (CI, 95%, 99%) of stent placements. Increase of Gastric Outlet Obstruction Score by at least 1 point compared to baseline was achieved in 91% (CI, 86%, 95%) of patients persisting for a median of 184 days (CI, 109, 266). By day 5 (CI, 4, 6) after stent placement, 50% of patients experienced a score increase of at least 1 point. Improvement from 14% of patients at baseline tolerating soft solids or low residue/normal diet to 84% at 15 days, 86% at 30 days, 81% at 90 days, 79% at 180 days, and 70% at 270 days. Complications included stent ingrowth and/or overgrowth (12.4%), transient periprocedural symptoms (3%), bleeding (3%), stent migration (1.5%), and perforation (0.5%). Conclusions Safety and effectiveness of duodenal stenting for palliation of malignant gastroduodenal obstruction was confirmed in the largest international prospective series to date.

Malignant gastroduodenal obstruction: Retrospective comparison of endoscopic and surgical palliative therapy

Introduction. Endoscopic stenting (ES) is a minimally invasive alternative to surgical gastroenterostomy (GE) for palliation of malignant gastroduodenal obstructions. This consecutive, retrospective analysis compares the clinical outcome of all patients undergoing ES or GE in the same period. Methods. ES was performed at the Endoscopy Department, University Hospital Mannheim or at the Interdisciplinary Endoscopy Department, University Hospital Hamburg-Eppendorf. GE was performed at the Surgical Department, University Hospital Mannheim. All palliative ES or GE on patients with malignant gastroduodenal obstruction without earlier gastric resections between January 2001 and April 2007 were evaluated. Main outcome measurements were ability of solid food intake (gastric outlet obstruction score), persistence of nausea and vomiting (gut function score), length of hospital stay, morbidity, mortality and re-interventions. Results. A total of 44 ES and 43 GE were performed. Nausea and vomiting – measured by means of the gut function score – persisted in significantly more patients in the GE group than in those who underwent stent placement (p = 0.0102). The gastric outlet obstruction score at discharge from the hospital revealed no significant difference in the ability of solid food intake between the groups. The hospital stay was significantly longer in the GE group (p = 0.0003). There was no significant difference in mortality and the rates of complications and re-interventions. Conclusion. In this study, ES is a generally equivalent – and in several points superior – alternative to GE for palliation of malignant gastroduodenal obstruction. ES seems to be the less invasive alternative for symptomatic patients. GE has good results in patients with longer survival and can be practiced within abdominal explorations.

A Double-Layered (Comvi) Self-Expandable Metal Stent for Malignant Gastroduodenal Obstruction: A Prospective Multicenter Study

A self-expandable metal stent (SEMS) has emerged as an effective palliative treatment for malignant gastroduodenal obstruction resulting from gastric or periampullary malignancy. Despite the stent's effectiveness, tumor ingrowth and stent migration remain complications requiring reintervention. The purpose of this study was to evaluate the efficacy and safety of a double-layered SEMS (Comvi). We performed a prospective multicenter study in two university hospitals and two referral hospitals. In fifty consecutive patients with malignant gastroduodenal obstructions, placement of double-layered SEMS, comprising an outer uncovered stent and an inner covered stent that overlap each other, was performed. Palliation, efficacy, and incidence of complications were evaluated. Technical and clinical success was achieved in 100 and 88% of patients, respectively. There were no procedure-related complications. Five patients experienced stent migration (10%). For four of five patients' stent migration occurred within two weeks of stent placement. Stent collapse occurred in five patients after one month. Reintervention for stent migration, collapse, or tumor overgrowth was required for 14 (28%) patients. Endoscopic placement of a double-layered stent is a safe and effective modality for the palliation of malignant gastroduodenal obstruction. However, considering reintervention, this stent does not seem to add any clear advantage compared with preexisting uncovered stents. Migration, especially within the first two weeks, and stent collapse are still unresolved problems. The device should be fixed or the design modified to reduce these problems.

Improved Oral Intake After Palliative Duodenal Stenting for Malignant Obstruction: A Prospective Multicenter Clinical Trial

We sought to test the hypothesis that placement of a new nitinol duodenal self-expandable metallic stent (SEMS) for palliation of malignant gastroduodenal obstruction is effective and safe in allowing patients to tolerate an oral diet. In a prospective multicenter study, SEMSs (Duodenal WallFlex, Boston Scientific) were placed to alleviate gastroduodenal obstruction in inoperable patients without the ability to tolerate solid food. The primary study end point was improvement in oral intake monitored according to the 4-point Gastric Outlet Obstruction Scoring System (GOOSS) up to 24 weeks after stent placement. Forty-three patients received SEMSs, which were successfully deployed on the first attempt in 41 cases (95%) and the second attempt in two (5%). Within 1 day and 7 days after SEMS placement, 52% and 75% of patients, respectively, benefited from a GOOSS increase > or =1. Resumption of solid food intake (GOOSS 2-3) was attained by 56% of patients within 7 days and 80% by 28 days. Of the patients attaining GOOSS 2-3, 48% remained on solid food until death or last follow-up. Device-related adverse events included stent occlusion/malfunction in 9% of patients and perforation in 5% of patients. Duodenal WallFlex stent placement promptly improves oral intake in a majority of inoperable patients with malignant gastroduodenal obstruction. In approximately half the patients achieving GOOSS 2-3, the capacity for solid food intake endures until death or last follow-up.

M1995 The Usefulness of 18F-FDG PET/CT in the Evaluation of Recurrence After Curative Gastrectomy Due to Gastric Cancer

Aim: to assess the efficacy of enteric prostheses for the treatment of gastroduodenal obstruction caused by non-surgical neoplasms, their effect on quality of life and survival, and to determine the factors related to efficacy and complications. Patients: enteric prosthesis insertion was indicated in 77 patients. In 6 of these patients insertion was attempted but not achieved, and thus they were not included in the analysis. The remaining 71 patients (31 male, 40 female) had a mean age of 73,10±12,4 years. The intention of of prosthesis insertion was: permanent, 63,4%; adjuvant to chemotherapy, 35,2%; and as a bridge to surgery, 1,4%. Mean Karnofsky index was 64,86±12,9. Methods: the prostheses used were: Wallflex (76,1%), Wallstent (16,9%), Ultraflex (7%) (all of them metallic, expandable, uncoated, produced by Boston Scientific). Insertion was monitored with combined endoscopic-radiologic control (50,7%) or endoscopic control only (49,3%). Efficacy of the prostheses was assessed with the GOOSS clinical index, and quality of life was assessed with EuroQol-5D questionnaire. Results: obstruction location was: gastric 25,4%, duodenal 53,5%, and surgical anastomosis 21,1%. The time required to insert the prosthesis was 20,49±8,6 min. The length of hospital admission was 3,3±3,4 days. Symptoms of gastroduodenal obstruction, measured by GOOSS, improved at least 2 points in 57 patients (p<0,001). Quality of life index (EuroQol-5D questionnaire) before and after prosthesis insertion was 10,17±2,07 and 10,04±2,65, respectively. Antral-gastric location of the lesion was significantly related to a worse prosthetic function (p<0,002). Patients in which radiologic control was not used did not have more complications or a longer prosthesis insertion time, but required more forced dilations of the stenotic lesion for prosthesis insertion (p<0,005). Mean survival was 116,52±119,0 days (range 9-552 days). Complications were: bleeding 7,0%, tumoral obstruction requiring surgery 2,8%, perforation 2,8%, and severe pain 2,8%. Tumoral growth with prosthesis obstruction requiring insertion of a second prosthesis occurred in 14.1% of cases. Conclusions: Enteric prostheses are useful for palliation of malignant gastroduodenal obstruction, but do not improve quality of life. Antral-gastric location of the stenotic lesion is related to worse results. Prosthesis insertion without radiologic control yields similar results regarding prosthesis function and complications, but requires a larger number of dilations for insertion.

Endoscopic Stenting Versus Surgical Gastrojejunostomy for Palliation of Malignat Gastroduodenal Obstruction

Objective: Palliative treatment of malignant gastroduodenal obstruction has been performed traditionally with gastrojejunostomy. Palliation with autoexpandable metal prostheses has also shown to be effective and to improve the quality of life of patients. We compared the effectiveness of conventional gastrojejunostomy with the application of an autoexpandable metal stent developed locally, for palliation of malignant gastroduodenal obstruction by evaluating clinical success, morbidity, mortality and length of hospital stay. Materials and Methods: Medical records from 80 patients with malignant gastroduodenal obstruction were reviewed: 40 patients had received treatment with the autoexpandable metal stent and 40 with gastrojejunostomy. Patients who underwent prophylactic gastrojejunostomy were excluded. Results: Gastroduodenal stents were successfully placed in 39 of 40 (97%) patients (21 males) and gastrojejunostomy was performed in 40 patients (23 men) with obstructive tumors of the gastroduodenal tract. The gastroduodenal obstruction was secondary to gastric, gallbladder or biliary tract, pancreatic and ampullary tumors or metastatic disease. These malignancies were considered unresectable in all patients. There were no statistical differences in the origin of the obstruction, hospital mortality or survival between the treatment groups. However, time to resume oral feeding (1.6 vs 7 days) and length of hospital stay (3 vs 14 days) were significantly shorter in the group receiving the stents (p < 0.01). Furthermore, morbidity was significantly lower in the stent group (15% vs 38%, p < 0,01). There was a trend in a higher activity index in the stent group (p = 0.08). Conclusions: The placement of autoexpandable metal stents was more beneficial in terms of length of hospital stay, time to resume oral feeding and morbidity than open gastrojejunostomy for the palliation of malignant gastroduodenal obstruction.

Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre

To assess the technical success rate, and evaluate the clinical outcome, length of hospital stay, and cost of palliative gastro-duodenal stenting in a single-centre. Eight-seven patients referred for insertion of a gastroduodenal stent between April 1999 and April 2004 were recruited to a non-randomized, before and after intervention study performed in a single centre. Demographic data, diagnosis and symptoms along with clinical and technical outcomes were recorded. The technical success rate was 84/87 (96.6%), with inability to traverse the stricture in three patients. No immediate complications were demonstrated. There was marked improvement after stent placement with resolution of symptoms and commencement of dietary intake in 76 patients (87%). Stenting resulted in improved quality of life as reflected by an increase in Karnofsky score from 44/100, to 63/100 post-procedure. Late complications included perforation (n=1), migration (n=1) and stent occlusions due to tumour ingrowth/overgrowth (n=7; mean 165 days). Mean survival was 107 days (range 0-411 days). Median hospital stay post-stent placement was 5.5 days, (range 1-55 days) with a majority of patients (75%) discharged home. The mean cost of each treatment episode was 4146 pounds ($7132 $US, 6,028 EUROS). The present series confirms that combined endoscopic and radiological gastroduodenal stenting is a highly favourable treatment for patients with inoperable malignant gastric outlet obstruction. The results suggest that this minimally invasive procedure has a very high technical success rate, whilst at the same time providing excellent palliation of symptoms with improved quality of life in the majority of patients.

Endoscopic stenting versus surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis

We attempted to elucidate the current status of endoscopic self-expanding metal stents for palliation of malignant gastroduodenal obstruction in comparison with surgical gastroenterostomy. Original articles and abstracts published from January 1990 to September 2006 were searched in Medline, EMBASE, and Cochrane Controlled Trials Register databases. Clinical appraisal and data extraction were independently conducted by two reviewers. Statistical analysis was performed by meta-analysis using a random effects model. Weighted mean differences with 95% confidence intervals (CI) were used to analyze continuous variables. Odds ratios with 95% CI were calculated for dichotomous variables. The outcomes of 307 procedures from nine studies were analyzed. Endoscopic stenting was found to be associated with higher clinical success (P = 0.007), a shorter time from the procedure to starting oral intake (P < 0.001), less morbidity (P = 0.02), lower incidence of delayed gastric emptying (P = 0.002), and a shorter hospital stay (P < 0.001) than surgical gastroenterostomy. There was no significant difference between the two groups in the analysis of 30-day mortality. Endoscopic stenting may be a feasible alternative to surgery for the palliation of inoperable malignant gastroduodenal obstruction, with a high clinical success and low morbidity rate. Additional well-designed randomized controlled trials with larger sample sizes are expected to further reinforce this conclusion.

Gastroduodenal Stent Placement: Current Status

Gastroduodenal obstruction is a preterminal event in patients with advanced malignancies of the stomach, pancreas, and duodenum. It severely limits the quality of life in affected patients due to constant emesis and associated malnutrition. Surgical gastrojejunostomy has been the traditional palliative treatment but is associated with a high complication rate, and delayed gastric emptying is a frequent problem. Gastroduodenal stent placement is a very safe and effective palliation method in patients with unresectable malignant tumors causing gastric outlet obstruction, with adequate palliation obtained in most cases. The procedure can be performed under fluoroscopic guidance or with a combination of fluoroscopic and endoscopic techniques. Advantages of gastroduodenal stent placement over surgical palliation include suitability as an outpatient procedure, more rapid gastric emptying, greater cost effectiveness, fewer complications, and improved quality of life. Covered duodenal stents are currently being evaluated and may play an increasingly important role in preventing recurrent obstruction secondary to tumor ingrowth. Moreover, simultaneous palliation of biliary and duodenal malignant strictures is possible with the use of metallic stents. Gastroduodenal stent placement is a promising new alternative for the palliation of malignant gastroduodenal obstruction.

Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass.

The primary therapeutic goals in patients with gastroduodenal obstruction secondary to advanced malignancy are the re-introduction of an enteral diet and early discharge. The endoscopic placement of expandable metal stents has been proposed as an alternative technique for palliation in patients not suitable for surgery. To review our experience with gastroduodenal metal stent insertion for the palliation of malignant gastric and duodenal obstruction. A retrospective review was conducted of the notes of all patients who underwent gastroduodenal stent insertion in our unit. Forty patients (mean age, 64.5 years; range, 34-93 years) underwent insertion of an enteral stent for malignant gastroduodenal obstruction. The primary tumour was gastric in 20 patients, pancreatico-biliary in 15 and metastatic in five. A stent was successfully placed in all cases. Thirty-two patients have subsequently died, the median (range) survival being 7 weeks (1 week to 10 months). Thirty-three patients (82.5%) were discharged from hospital. During follow-up, 12 patients (30%) returned to a solid diet, 20 (50%) required a soft diet, six (15%) tolerated liquids and two (5%) were unable to tolerate any enteral nutrition. The use of enteral stents achieves good palliation, allowing discharge from hospital and re-introduction of an enteral diet.