Stent Placement For Malignant Obstruction Research Articles

Self-expandable metal stent placement for malignant obstruction of the proximal colon using single-balloon enteroscopy.

Self-expandable metal stent placement for malignant obstruction of the proximal colon using single-balloon enteroscopy.

Metal Stent Placement in the Afferent Loop Obstructed by Peritoneal Metastases-Experience of Five Cases.

Afferent loop syndrome is often difficult to resolve. Among patients with afferent loop syndrome whose data were extracted from databases, 5 patients in whom metal stent placement was attempted were included and evaluated in this study. The procedure was technically successful without any adverse events in all patients. Metal stent(s) was placed with an endoscope in the through-the-scope manner in 4 patients and via a percutaneous route in 1 patient. Obvious clinical efficacy was observed in all patients. Adverse events related to the procedure and stent occlusion during the follow-up period were not observed. Metal stent placement for malignant obstruction of the afferent loop was found to be safe and feasible.

Technical and Anatomic Factors Influencing the Success of Inferior Vena Caval Stent Placement for Malignant Obstruction

PurposeTo evaluate the outcomes of inferior vena cava (IVC) stent placement for malignant obstruction and to identify anatomic and procedural factors influencing technical and clinical success. Materials and MethodsA total of 57 patients (37 male, 20 female; age range, 22–86 y) underwent 62 IVC stent placement procedures using 97 stents (47 Wallstents, 15 S.M.A.R.T. stents, 18 Wallflex stents, 17 others) from 2005 to 2016 for malignant IVC obstruction caused by hepatic metastases (n = 22; 39%), primary hepatic malignancy (n = 16; 28%), retroperitoneal metastases (n = 16; 28%), or other primary malignancy (n = 5; 9%). Presenting symptoms included lower-extremity edema (n = 54; 95%), ascites (n = 28; 50%), and perineal edema (n = 14; 25%). Sixteen percent (n = 10) and 10% (n = 6) of the procedures involved tumor and bland thrombus, respectively. ResultsStent placements resulted in 100% venographic patency and significantly decreased pressure gradients (P < .0001). Lower-extremity swelling, perineal swelling, and abdominal distension improved within 7 days in 83% (35 of 42), 100% (9 of 9), and 40% (6 of 15) of patients, respectively, and at 30 days after the procedure in 86% (25 of 29), 89% (8 of 9), and 80% (4 of 5) of patients, respectively. Increased pre- and post–stent placement pressure gradients were associated with worse outcomes. A 4% stent misplacement rate (4 of 97) was related to the use of Wallstents with caudal stent tapering, asymmetric deployment superior to the obstruction, suprahepatic IVC involvement, and decreased stent adherence to the IVC wall as a result of local mechanical factors. ConclusionsStent placement is reliable, rapid, and durable in improving malignant IVC syndrome. Understanding of technical and anatomic factors can improve accuracy and avoid complications of stent misplacement.

Predictors of outcome in palliative colonic stent placement for malignant obstruction

Emergency surgery for large bowel obstruction carries significant morbidity and mortality. After initially promising results, concerns have been raised over complication rates for self-expandable metal stents (SEMS) in both the palliative and bridge-to-surgery settings. This article documents the technique used at the authors' institution, and reports on success and complication rates, as well as identifying predictors of endoscopic reintervention or surgical treatment. Data were collected for a prospective cohort of consecutive patients undergoing attempted colonoscopic SEMS insertion at a single institution between 1998 and 2013. Multivariable logistic models were fitted to assess possible predictors of endoscopic reintervention and surgical treatment. Palliative SEMS insertion was attempted in 146 patients. Primary colorectal cancer was the most common cause of obstruction (95.2 per cent). The majority of patients (77.4 per cent) were treated in an acute setting, with a high technical success rate of 97.3 per cent. The perforation rate was 4.8 per cent and the 30-day procedural mortality rate 2.7 per cent. No predictors of early complications were identified, although patients with metastases and those who received chemotherapy were more likely to have late complications. Some 30.8 per cent of patients required at least one further intervention, with 11.0 per cent of the cohort requiring a stoma. Endoscopic reintervention was largely successful. SEMS offer a valid alternative to operative intervention in the palliative management of malignant large bowel obstruction. Patients receiving chemotherapy are more likely to receive endoscopic reintervention, which is largely successful.

Self-expandable metallic stent placement for malignant obstruction in patients with locally recurrent gastric cancer

Self-expandable metallic stents (SEMSs) provide effective palliation for inoperable malignant gastric outlet obstruction (GOO). The objective of this study was to evaluate the effectiveness of SEMSs in patients with recurrent gastric cancer after radical gastrectomy. We retrospectively analyzed data from patients with gastric cancer who underwent endoscopic SEMS placement. The patients had obstructive symptoms due to recurrent gastric cancer after curative-intent subtotal or total gastrectomies. Technical and clinical success rates of stent placement were evaluated and clinical outcomes were compared according to operation types. A total of 15 patients underwent total gastrectomies with esophagojejunostomies and Roux-en-Y reconstructions, 8 underwent subtotal gastrectomies with Billroth I reconstructions, and 12 underwent subtotal gastrectomies with Billroth II reconstructions. Four patients in the Billroth II group received stents in afferent and efferent loops, so a total of 39 stents were placed. Technical success was achieved with 92% (36/39) of stents, and clinical success occurred with 90% (35/39) of stents, with no significant differences among surgery groups or between stent types (covered vs. uncovered). The GOO score (preprocedure: 0.45±0.62) increased by 1 week (2.06±0.51, p<0.001) and was maintained up to 1 month (1.71±1.15, p<0.001 compared with initial score). Complications occurred with 17 of 39 stents (44%) and included 2 perforations, 3 migrations, and 12 restenoses. Median stent patency duration was 10.7 weeks and median survival was 21.3 weeks; these did not significantly differ by surgery group (p=0.25 and 0.93, respectively) or stent type (covered vs. uncovered, p=0.51 and 0.96, respectively). Endoscopic SEMS placement for obstruction due to recurrent cancer after total or subtotal gastrectomy is feasible and provides effective short-term palliation, independent of the type of surgical procedure or stent (covered vs. uncovered) used.

Percutaneous Transcholecystic Metallic Stent Placement for Malignant Obstruction of the Common Bile Duct: Preliminary Clinical Evaluation

To evaluate the technical success and clinical effectiveness of percutaneous transcholecystic placement of self-expanding metallic stents for the treatment of malignant obstructions of the common bile duct. Fifteen patients with malignant obstruction at the lower level of the common bile duct not amenable to surgery were retrospectively reviewed in this study. In all patients, conventional biliary drainage via transhepatic peripheral duct access or endoscopic retrograde biliary drainage (ERBD) were technically difficult or deemed so at imaging evaluation. The causes of obstruction were cholangiocarcinoma (n = 7), pancreatic carcinoma (n = 6), and metastatic lymphadenopathy from gastric carcinoma in the hepatoduodenal ligament (n = 2). Following percutaneous cholecystostomy, a 5-F catheter was inserted into the common bile duct, duodenum, or the anastomosed jejunum through the cystic duct and the malignant obstruction and metallic stents were placed. The technical success was defined as the removal of the drainage tube after the stent placement for the obstruction. The mean follow-up period was 25.4 months. Sixteen stents were placed in 15 patients. Technical success was achieved in all patients (100%) without major complications. Minor complications included controllable pain or self-limited hemobilia in six of the 15 patients (40%). Lower bilirubin levels compared with those before the procedure were achieved in 14 of the 15 patients (93%). Percutaneous transcholecystic placement of metallic stents is a feasible and effective method to manage malignant obstruction at the lower level of the common bile duct not amenable to surgery when conventional biliary drainage via transhepatic peripheral duct access or ERBD were technically difficult or deemed so at imaging evaluation.

Placement of Stents in Proximal Colonic Obstructions Using a Percutaneous Retroperitoneal Colostomy

In cases of proximal colonic obstruction, the long distances and the tortuosity of the distal bowel make it difficult to advance and position the stent in the target lesion. We report 2 cases of stent placement for malignant obstruction of the proximal colon in which access was obtained through percutaneous retroperitoneal colostomy. In these cases, we initially tried to place a stent through the rectum under endoscopic guidance, but it was not possible to reach the lesion. We then decided to cross the lesion through percutaneous puncture of the retroperitoneum. The procedures were completed without complications and the patients' symptoms improved. A percutaneous retroperitoneal approach for the deployment of colonic stents has not been described earlier in the literature. We suggest that our technique provides an alternative means of colonic decompression in cases in which conventional retrograde methods fail to provide acceptable palliation in nonsurgical candidates.

What Happens to Serum Carbohydrate Antigen 19-9 after Biliary Stent Placement in Pancreaticobiliary Malignancy?

Purpose: CA19-9 is frequently followed to monitor disease progression. Bile duct obstruction has been associated with increased CA19-9. The purpose was to evaluate the correlation of CA 19–9 with the regression of bilirubin after stent placement for malignant biliary obstruction. The hypothesis was that biliary decompression would result in a downward trend of CA19-9. Methods: The records at MD Anderson Cancer Center were reviewed for patients who underwent first time ERCP with biliary stent placement for malignant obstructive jaundice from Oct. 2002 to Sept. 2005. Patients who achieved serum bilirubin ≤ 2 mg/dL and those with adequate CA19-9 data were identified and analyzed to determine association. CA19-9 levels needed to have been recorded within 15 days prior to stent placement and then post stent when bilirubin ≤ 2. Other examined variables included type of cancer, presence of metastasis, and level of pre-stent bilirubin. Statistics: Spearman rank correlation methods were used to assess the correlation between variables. Fisher's exact test was performed. Results: A total of 52 patients with adequate serum CA 19–9 data who achieved bilirubin ≤ 2 after biliary stent placement were identified (pre-stent bilirubin range 2.8–21.9 mg/dL; mean 10.23; median 9.4). Forty (77%) had pancreatic cancer, 12 (23%) other biliary malignancies, and 23 (44%) with liver metastasis. 27/52 (52%) demonstrated a downward trend of CA19-9 post stent, 16/52 (31%) an upward trend, and 9/52 (17%) an equivocal change (defined arbitrarily as a change less than 20 U/mL). Although a change of CA19-9 was significantly correlated with bilirubin regression (Spearman correlation coefficient 0.36 and p= 0.009), the direction of change in CA 19–9 was variable. Patients whose CA19-9 decreased had significantly higher baseline bilirubin as compared with patients whose CA19-9 level increased (p= 0.02). The change of CA19-9 was not significantly associated with cancer diagnosis (pancreatic vs other) (p= 0.16) or the presence of liver metastasis (p= 0.22). Conclusions: Unlike the regression of CA 19–9 post stent placement in benign biliary obstruction, the change in CA 19–9 is unpredictable in cases of malignant biliary obstruction despite adequate biliary decompression and bilirubin regression. Further studies are necessary to find other confounding variables affecting CA 19–9 i.e. tumor burden.

Percutaneous Cystic Duct Stent Placement for the Treatment of Acute Cholecystitis Resulting from Common Bile Duct Stent Placement for Malignant Obstruction

Common bile duct (CBD) stent placement to relieve malignant biliary obstruction can occasionally cause cystic duct obstruction and acute cholecystitis. Cholecystostomy tube placement is often performed in patients with limited life expectancy but can have a significant impact on quality of life. To allow cholecystostomy tube removal, percutaneous metallic stent placement was performed across the cystic duct via the tube tract in such a patient. The procedure included traversal across the previously placed CBD stent. At 5-month follow-up, the patient remained symptom-free. In select patients who develop acute cholecystitis after CBD stent placement for malignant obstruction, percutaneous stent placement across the cystic duct may be considered a treatment option.

Delayed Complications after Esophageal Stent Placement for Treatment of Malignant Esophageal Obstructions and Esophagorespiratory Fistulas

To evaluate delayed complications after esophageal expandable metallic stent placement. From April 1993 to December 1997, 90 expandable metallic stents were placed in 82 consecutive patients with inoperable malignant esophageal obstruction (n = 49) or malignant esophagorespiratory fistula (n = 33). Stents used included covered Gianturco-Rosch Z stents (n = 20), Wallstents (covered, n = 31; uncovered, n = 13), and Ultraflex stents (covered, n = 8; uncovered, n = 10). Patients were followed prospectively and monitored for delayed complications, defined as major (hemorrhage, tracheal compression, stent migration, perforation or fistula formation, granulomatous obstruction, tumor ingrowth and overgrowth, funnel phenomenon, and stent covering disruption) or minor (reflux, chest pain, and food impaction). Mean survival was 4.5 months after stent placement (range, 3 weeks to 26 months). The overall incidence of delayed complications was 64.6%, with 17 patients (20.7%) experiencing more than one complication. The rates of delayed complications in patients with Z stents, Wallstents, and Ultraflex stents were 75.0%, 68.1%, and 44.4%, respectively (P <.05). Most complications were life-threatening and occurred more frequently when stents were placed in the proximal third of the esophagus, compared with more distally (P <.05). Thirteen patients (15.9%) died from complications directly related to stent placement. Esophageal stent placement for malignant obstruction or fistula is associated with a substantial incidence of delayed complications.