Self-expandable Metallic Stent Placement Research Articles

Successful endoscopic removal of a partially covered self-expandable metallic stent that had migrated to the oral side of the tumor

An 83-year-old man with vomiting visited our hospital. Computed tomography revealed wall thickening of the descending colon and dilated proximal colon. Colonoscopy revealed obstructive descending colon cancer (CROSS 0, cT3N0M0 cStage IIa). We inserted a partially covered self-expandable metallic stent (SEMS). Two months after SEMS placement, he was admitted to our hospital because of difficulty in passing stool. While we were attempting to resolve the obstruction, the SEMS migrated to the oral side of the tumor. We successfully removed the SEMS using the sliding tube of a single balloon endoscope.

Metallic stent placement versus catheter drainage for malignant bilioenteric anastomotic stricture.

The purpose of the study was to compare self-expandable metallic stent placement with catheter drainage for malignant bilioenteric anastomotic stricture in terms of efficacy and safety. This study included 54 patients with malignant bilioenteric anastomotic stricture treated from March 2016 to February 2021. Twenty-seven patients underwent insertion of self-expandable metallic stent (Stent group); the remaining twenty-seven patients underwent internal-external catheter drainage (Catheter group). Technical success was defined as successful placement of stent or drainage catheter in the appropriate position; clinical success was defined as a 20% reduction in serum bilirubin within 1week after the procedure, compared with baseline. Complications, duration to stent/catheter malfunction, and overall survival were evaluated. Technical success was achieved in all patients in both groups. In the Stent group, 21 patients received one stent and the other 6 patients required two stents. Clinical success rates were similar between the groups [Stent group, 92.6% (25/27); Catheter group, 88.9% (24/27)]. There were no major complications. The median duration to stent/catheter malfunction was significantly longer in the Stent group (130days) than in the Catheter group (82days; P = 0.010). The median overall survival was also significantly longer in the Stent group (187days) than in the Catheter group (118days; P = 0.038). Self-expandable metallic stent placement might be better than internal-external catheter drainage for malignant bilioenteric anastomotic stricture in terms of the duration before stent/catheter malfunction and patient survival.

Use of endoscopic ultrasound-guided biliary drainage as a rescue of re-intervention after the placement of multiple metallic stents for malignant hilar biliary obstruction.

Endoscopic transpapillary re-intervention (ETP-RI) after multiple self-expandable metallic stent (SEMS) placement for unresectable malignant hilar biliary obstruction (MHBO) is challenging, but endoscopic ultrasound-guided biliary drainage (EUS-BD) could be an alternative following failed ETP-RI. We investigated appropriate re-intervention (RI) methods in MHBO after multiple SEMS placement and evaluated RI with EUS-BD (EUS-RI) benefits following ETP-RI failure. Patients requiring RI after multiple SEMS placement for MHBO between October 2017 and April 2021 were enrolled. Patients' characteristics, metallic-stent type, stent-placement configuration, overall survival, stent patency, re-intervention results, and re-intervention technical and clinical success rates were reviewed. Forty-nine patients underwent ETP-RI for MHBO. ETP-RI's technical success rate was 69.4%. Of 15 failed ETP-RI cases, all underwent EUS-RI, achieving technical and clinical success rates of 86.7% and 100%, respectively. Time to recurrent biliary obstruction (TRBO) after RI was significantly different between EUS-RI and ETP-RI (212 vs 84days; P=.01). On multivariate analysis, EUS-RI was the only factor associated with TRBO (odds ratio: 4.48; 95% confidence interval: 1.01-19.91; P=.04). Acute pancreatitis and bile peritonitis were present in 6.1% of ETP-RI and 13.3% of EUS-RI cases, respectively; both improved conservatively. EUS-RI was effective and safe in difficult ETP-RI cases after multiple SEMS placement for MHBO.

Hepatic arterial infusion chemotherapy following simultaneous metallic stent placement and iodine-125 seed strands for advanced cholangiocarcinoma causing malignant obstructive jaundice: a propensity score matching study.

This study aims to evaluate the effectiveness and safety of hepatic arterial infusion chemotherapy (HAIC) following the simultaneous placement of self-expandable metallic stent (SEMS) and iodine-125 (125I) seed strands for the management of advanced cholangiocarcinoma (CCA) patients presenting with malignant obstructive jaundice (MOJ). Data from 74 patients with MOJ caused by advanced CCA treated with stent placement with 125I seed strands with or without HAIC between November 2015 and October 2020 were analysed retrospectively. Eighteen patients received 5 sessions of HAIC after SEMS placement with 125I seed strands (HAIC group), and 56 patients only underwent SEMS placement with 125I seed strands and served as controls (control group). HAIC consisted of infusions of gemcitabine (600-1000mg/m2 given over 30min) followed by oxaliplatin (60-100mg/m2 given over 2h), with an interval of 4weeks. Propensity score matching (PSM) analysis was used to adjust for differences in the baseline characteristics of the groups (including age, total bilirubin, and serum alanine aminotransferase level). Overall survival (OS), stent patency, and adverse events were compared between the two groups. OS and stent patency were significantly better in patients in the HAIC group than in those in the control group (median survival time: before PSM, 362 vs. 185days, p = 0.005; after PSM, 357 vs. 183days, p = 0.012; median duration of stent patency: before PSM, 294 vs. 156days, p = 0.001; after PSM, 287 vs. 183days, p = 0.039). All adverse reactions were controllable by temporary symptomatic treatment. Serious complications and treatment-related deaths were not observed. Our preliminary study showed that HAIC following SEMS placement with 125I seed strands is effective and safe for the management of advanced CCA patients presenting with MOJ and could improve stent patency and patient survival.

70-Year-Old Man With Chronic Nausea and Vomiting

70-Year-Old Man With Chronic Nausea and Vomiting

Short-Term Outcomes of Colorectal Stenting Using a Low Axial Force Self-Expandable Metal Stent for Malignant Colorectal Obstruction: A Japanese Multicenter Prospective Study.

(1) Background: Endoscopic colorectal stenting with high technical success and safety is essential in discussing the oncological outcomes for the management of malignant colorectal obstruction. Mechanical properties of self-expandable metal stents are usually considered to affect clinical outcomes. (2) Methods: A multicenter, prospective study was conducted in Japan. A self-expandable metal stent with low axial force was inserted endoscopically. The primary endpoint was clinical success, defined as the resolution of symptoms and radiological findings within 24 h. Secondary endpoints were technical success and adverse events. Short-term outcomes of 7 days were evaluated in this study. (3) Results: Two hundred and five consecutive patients were enrolled. Three patients were excluded, and the remaining 202 patients were evaluated. The technical and clinical success rates were 97.5% and 96.0%, respectively. Major stent-related adverse events included stent migration (1.0%), insufficient stent expansion (0.5%), and stent occlusion (0.5%). No colonic perforation was observed. There were two fatal cases (1%) which were not related to stent placement. (4) Conclusions: The placement of self-expandable metal stents with low axial force is safe with no perforation and showed high technical and clinical success rates in short-term outcomes for the management of malignant colorectal obstruction.

Endoscopic ultrasound-guided pancreaticoduodenostomy with a forward-viewing echoendoscope.

Video 1EUS-guided pancreaticoduodenostomy with a forward-viewing echoendoscope.

Experience in the management of neoplastic gastric outlet obstruction in patients at the Hospital Universitario San Ignacio in Bogotá, Colombia

IntroductionMalignant gastric outlet obstruction is a condition that alters patient quality of life, conditioning progressive malnutrition. However, self-expanding metal stents (SEMSs) and surgical gastrojejunostomy (SGJ) are palliative options in patients with unresectable disease. AimTo characterize patients diagnosed with malignant gastric outlet obstruction requiring SEMS placement or SGJ. Materials and methodsSequential non-probability convenience sampling was conducted and included 68 patients, 40 of whom had SEMS placement and 28 of whom underwent SGJ. ResultsPatients sought medical consultations for the symptoms of vomiting, abdominal pain, weight loss, and upper gastrointestinal bleeding. Ninety-five percent of the patients in the SEMS group and 64.3% in the SGJ group presented with metastasis. Technical and clinical success, patency duration, and number of patients with no complications were greater in the SGJ group. Mean survival in days was 88 (SD ± 21) in the SEMS group versus 501 (SD ± 122) in the SGJ group. The log-rank test detected a statistically significant difference between subgroups (p = 0.00). ConclusionSGJ has greater technical and clinical success rates but SEMS placement continues to be utilized in distal gastric cancer, especially in cases in which surgery is not an option.

S1666 EUS Choledochoduodenostomy: A Novel Way to Treat Recurrent Malignant Biliary Obstruction in the Setting of an Existing Biliary and Duodenal Stent

Introduction: EUS-guided choledochoduodenostomy (EUS-CD) is an effective way to manage patients with malignant biliary obstruction and an inaccessible papilla. It involves creation of a fistula between the duodenal bulb and distal common biliary duct (CBD) using a lumen-apposing metal stent (LAMS). Data shows high technical and clinical success rates, with low adverse event rates and improved morbidity and mortality. Advantages of this approach include the ability to provide drainage to altered or inaccessible anatomy, and minimal invasiveness due to internalized drainage. We present a report of a patient with cholangitis due to recurrent biliary and gastric outlet obstruction (GOO) treated successfully with duodenal stenting and EUS-CD despite indwelling hardware. Case Description/Methods: A 71-year-old male with as history of locally invasive pancreatic adenocarcinoma presented with cholangitis and intolerance to oral intake. His prior course was complicated by GOO and biliary obstruction that required biliary fully covered self-expandable metal stent (FC-SEMS) and uncovered duodenal stent placement. Despite palliative chemotherapy, he presented 6 months later with cholangitis and imaging findings concerning for CBD stent occlusion, partial GOO and new ascites. Upper endoscopy showed significant stenosis within the duodenal stent that involved the major papilla, preventing conventional ERCP. The decision was made to evaluate for EUS biliary drainage. Presence of significant ascites precluded hepaticogastrostomy or gastrojejunostomy, however, there was an area superior to the indwelling biliary stent amenable to EUS-CDS. A 10mm x10mm LAMS was placed into the common hepatic duct with drainage of purulent fluid (Figure 1). Cholangiogram confirmed correct placement and excluded a leak. An uncovered duodenal stent was deployed through the indwelling duodenal stent and placement confirmed radiographically (Figure 1). The patient was discharged 2 days later with downtrending liver chemistries and tolerating oral intake. Discussion: Patients with combined malignant biliary and duodenal obstruction can be challenging to manage. Existing hardware complicates management even further. This case highlights the versatility of EUS biliary drainage allowing patient directed therapy with EUS-CDS in the setting of an existing biliary stent as an effective means of biliary drainage when ERCP was not possible.Figure 1.: A: occluded biliary stent B: LAMS with pigtail stents C: duodenal stent D: KUB showing stents in place.

Long-term outcomes of standardized colonic stenting using WallFlex as a bridge to surgery: Multicenter prospective cohort study.

ObjectivesThe oncological outcomes, especially high recurrence rate, of bridge‐to‐surgery (BTS) self‐expandable metallic stent (SEMS) placement remain concerning, emphasizing the necessity of standardized SEMS placement. However, its impact on long‐term BTS outcomes is unknown. We investigated the long‐term outcomes of BTS colonic stenting using standardized SEMS placement.MethodsThis prospective, multicenter cohort study conducted at 46 hospitals in Japan (March 2012 to October 2013) included consecutive patients with stage II and III obstructive colorectal cancer managed with BTS SEMS placement. The SEMS placement technique was standardized by information dissemination among the participating hospitals. The primary outcome was overall survival (OS) after SEMS placement, and the secondary outcomes were relapse‐free survival (RFS), recurrence, and short‐term outcomes of SEMS placement and surgery.ResultsThe 1‐, 3‐, and 5‐year OS rates were 94.1%, 77.4%, and 67.4% (Kaplan–Meier), respectively, with high technical success (99.0%, 206/208) and low perforation (1.9%, 4/208) rates. The 1‐, 3‐, and 5‐year RFS rates were 81.6%, 65.6%, and 57.9% (Kaplan–Meier), respectively, and the overall recurrence rate was 31.0% (62/200). The RFS rate was significantly poorer in patients with perforation (n = 4) than in those without perforation (n = 196) (log‐rank P = 0.017); moreover, perforation was identified as an independent factor affecting RFS (hazard ratio 3.31; 95% confidence interval 1.03–10.71, multivariate Cox regression).ConclusionThis large, prospective, multicenter study revealed satisfactory long‐term outcomes of BTS colonic stenting using a standardized SEMS insertion method, which might be specifically due to the reduced perforation rate. (UMIN000007953).

S3551 Unique Communication: A Case Report of Acquired Esophageal Pulmonary Fistula

Introduction: Esophageal respiratory fistula is an abnormal communication between the esophagus and the respiratory system. We present a case of esophageal pulmonary fistula in a patient with a history of broncho-esophageal fistula treated with esophageal stent placement. Case Description/Methods: A 53-year-old homeless male with a history of alcoholism, perforated peptic ulcer status post antrectomy with type II billroth reconstruction, pseudodiverticulum of the distal third of esophagus, broncho-esophageal fistula and HIV presented with dyspnea and productive cough for 2 weeks. He reported dysphagia to liquids and unintentional weight loss. Review of medical records revealed admission for pneumonia 3 years ago with workup suggestive of broncho-esophageal fistula followed by endoscopic fully covered self-expandable metallic stent placement with removal after 2 months to reassess fistula. Repeat Computed tomography (CT) chest showed resolution of fistula. However, he lost the follow up afterwards. On this admission, the patient appeared disheveled with crackles on the right side. CT chest without contrast showed debris filling the middle and lower esophagus, right pleural effusion with multiple areas of gas. CT chest with contrast showed irregular and debris distended esophagus with locules of air extending from the region of the esophagus into the mediastinum and right lower lung parenchyma. Fluoroscopy esophagram documented contrast extravasation from the right side of the distal esophagus into the right lower lobe parenchyma compatible with esophageal pulmonary fistula. An esophageal stent placement was planned but was declined by the patient. Discussion: Non-malignant etiologies of acquired esophageal respiratory fistula include post-operative, intubation associated, history of tracheal and esophageal stents, blunt trauma and pseudodiverticulum of the esophagus. In our case, etiologies of broncho-esophageal fistula and then esophageal-pulmonary fistula were multifactorial which include esophagitis due to history of chronic gastroesophageal reflux disease (GERD), history of antral gastrectomy, history of stent placement for a broncho esophageal fistula and pseudodiverticulum of distal third of the esophagus. Given the significant morbidity and mortality associated with a missed diagnosis of esophageal pulmonary fistula, early diagnosis with prompt treatment with an endoscopically placed covered stent and close follow up is crucial.Figure 1.: The distal one third of esophagus is markedly dilated and irregular in contour. Contrast is seen extravasating from the right side of the esophagus into the right lower lobe parenchyma consistent with esophageal pulmonary fistula.

Safety of biliary stent placement followed by definitive chemoradiotherapy in patients with pancreatic cancer with bile duct obstruction.

Although patients with malignant bile duct obstruction due to pancreatic cancer are often initially treated with biliary stent placement, concurrent chemoradiotherapy with stents poses a potential risk of increased toxicity. This retrospective study aimed to evaluate the safety of biliary stent placement followed by definitive concurrent chemoradiotherapy in patients with pancreatic cancer. Patients with pancreatic cancer who underwent either a plastic stent or a self-expanding metallic stent placement for malignant bile duct obstruction before definitive concurrent chemoradiotherapy were retrospectively reviewed. Radiotherapy was delivered in 1.8 Gy per fraction to a total dose of 50.4 Gy. Gemcitabine, TS-1 plus Gemcitabine, or TS-1 was the concurrent chemotherapy/regimen. The primary endpoint was the rate of biliary stent-related toxicities, defined as biliary bleeding, duodenal perforation, or bile duct perforation. Thirty patients were included. Plastic stents were placed in 23 patients and self-expanding metallic stent in seven patients at the start of irradiation. The median follow-up time was 20 (range, 2-63) months, and 27 patients (90%) completed concurrent chemoradiotherapy. Biliary stent-related toxicity (grade 3 biliary bleeding) was confirmed in one patient (3%) with a plastic stent 9 months after concurrent chemoradiotherapy. The median duration of locoregional control, progression-free survival, and overall survival were 31.1, 7.3, and 10.5 months, respectively. Stent placement followed by concurrent chemoradiotherapy was not associated with an apparent increase in toxicity and may be an appropriate treatment for patients with locally advanced pancreatic head cancer with bile duct obstruction.

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction.

Duodenal obstruction is often accompanied with unresectable malignant distal biliary obstruction in patients who have undergone biliary self-expandable metal stent (SEMS) placement. Duodenobiliary reflux (DBR) is a major cause of recurrent biliary obstruction (RBO) after covered biliary SEMS placement. We analyzed the risk factors for DBR-related SEMS dysfunction following treatment for malignant duodenal obstruction. Sixty-one patients with covered SEMS who underwent treatment for duodenal obstruction were included. We excluded patients with tumor-related stent dysfunction (n = 6) or metal stent migration (n = 1). Fifty-four patients who underwent covered biliary SEMS placement followed by duodenal metal stenting or surgical gastrojejunostomy were included. Eleven patients had DBR-related biliary SEMS dysfunction after treatment of duodenal obstruction. There was no difference between the duodenal metal stenting group and the surgical gastrojejunostomy group. Duodenal obstruction below the papilla of Vater and a score of ≤2 on the Gastric Outlet Obstruction Scoring System after treatment for duodenal obstruction were associated with DBR-related covered biliary SEMS dysfunction. Thus, creating a reliable route for ensuring good oral intake and avoiding DBR in patients with duodenal obstruction below the papilla of Vater are both important factors in preventing DBR-related covered biliary SEMS dysfunction.

Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasound-guided gastroentero-anastomosis.

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by postprandial vomiting, abdominal pain, bloating and, in advanced cases, by weight loss secondary to inadequate oral intake. This clinical entity may be caused by mechanical obstruction, either benign or malignant, or by motility disorders. In this review we will focus on malignant GOO and on its endoscopic ultrasound (EUS)-guided palliative treatment. The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas; other causes include duodenal or ampullary neoplasms, gastric lymphomas, retroperitoneal lymphadenopathies and, more infrequently, gallbladder and bile duct cancers. Surgery represents the treatment of choice when radical and curative resection is potentially feasible; if the malignant cause is not likely to be completely resected, palliative treatments should be proposed. Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent. Both treatments are effective; however, endoscopic stent placement is less invasive and it is associated with good short-term results, while surgery provides longer-lasting effects with a lower frequency of reintervention. In the last few years, EUS-guided gastroenterostomy (GE) has been proposed as palliative treatment for malignant GOO. This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction, through the deployment of a lumen-apposing metal stent under EUS-view. EUS-GE has the advantage of being as minimally invasive as enteral stent placement, and of guaranteeing long-term results similar to those of surgery.

Self-expandable metallic stent placement for malignant biliary stricture using a novel device delivery system.

Video 1Self-expandable metallic stent placement for malignant biliary strictures using a novel device delivery system.

Unilateral versus bilateral Y-type stent-in-stent metal stent insertions in inoperable malignant hilar biliary strictures: A multicenter retrospective study

BackgroundTo date, there is controversy regarding unilateral versus bilateral stent placement in patients with malignant hilar biliary strictures (MHBSs). The aim of this study was to compare the clinical outcomes and complications of unilateral and bilateral (stent-in-stent method) stent placements for these patients. MethodsWe conducted a multicenter retrospective analysis of patients with inoperable MHBS who underwent endoscopic self-expandable metal stent (SEMS) placement from January 2009 to December 2019. Two groups classified according to the stent procedure method were compared for demographic, procedural, and postprocedure factors. Survival analysis for patency loss and overall survival was also conducted. ResultsA total of 236 subjects were included. A superior technical success rate was found in the unilateral stent group (98.8% vs. 82.5%, P < 0.001), whereas the clinical success rate was higher in the bilateral group (85.7% vs. 70.5%, P = 0.028). There was no significant difference with respect to complications or patency loss, and the bilateral group had better overall survival (P < 0.01). In the Cox proportional hazard model, MHBSs from lymph node compression were associated with a higher risk of death (HR = 9.803, P = 0.003). In contrast, bilateral SEMS insertion showed reduced postprocedural mortality (HR = 0.316, P = 0.001). ConclusionsY-type stent-in-stent bilateral SEMSs are technically difficult but demonstrated more favorable overall survival for palliative bile drainage of inoperable MHBS patients compared to unilateral insertions.

Hemorrhage after laser-cut covered self-expandable metal stent removal.

Endoscopic covered self-expandable metal stent (CSEMS) placement is widely used for distal malignant biliary obstruction (MBO) as the stent prevents ingrowth and is easily removed [1] [2]. The usefulness of the laser-cut CSEMS (LC-CSEMS) and its endoscopic removal have been reported [3] [4] [5]; there have been no previous reports of complications related to LC-CSEMS removal. We here report a case of hemorrhage following LC-CSEMS removal.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction.

Gastric outlet obstruction (GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum. GOO can be caused by either benign or malignant etiologies, often resulting in early satiety, nausea, vomiting and poor oral intake. GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies. Traditional treatment options for GOO can be broadly divided into surgical [surgical gastrojejunostomy (GJ)] and endoscopic interventions (dilation and/or placement of luminal self-expanding metal stents). While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting, it has also been associated with a higher rate of adverse events. Furthermore, many patients with advanced metastatic disease are not good surgical candidates. More recently, endoscopic ultrasound (EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches. This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Clinical management for malignant afferent loop obstruction.

Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

P-249 Long-term oncologic safety of self-expandable metal stent as a bridge to surgery for obstructing colon cancer

About 10-25% patients of with colorectal cancer suffer from acute colonic obstruction. Recently, placement of a self-expanding metal stent (SEMS) was widely used and it seems to be a safe and effective “bridge to surgery”, offering good palliation. But there is concern about long-term survival after the use of SEMS. Theoretically, tumor cell seeding can occur due to mechanical force during the stent insertion. To identify this theoretical validity, we surveyed long-term survival of malignant colonic obstruction using SEMS placement.