Gastroduodenal Stenting with a Flexible Stent Demonstrates Favorable Clinical Effectiveness despite Gradual Expansion: A Multicenter Prospective Study.

AIMS: This study aimed to evaluate the effectiveness and safety of stenting with a flexible braided self-expandable metal stent (SEMS) for unresectable malignant gastric outlet obstruction (GOO). METHODS: Palliative stenting was prospectively carried out at seven university hospitals between October 2017 and August 2020. All procedures were performed using a flexible branded SEMS of the same brand. The primary endpoint was clinical success rate at 7 days after stenting. Secondary endpoints were procedural success rate, adverse events, recurrent gastric outlet obstruction (RGOO), and patient survival time. RESULTS: Sixty patients were enrolled. The procedural and clinical success rates were 100% and 90%, respectively. RGOO occurred in 15 cases (25%). Adverse events other than RGOO were found in seven cases (12%). The 50% survival time was 75.5 days (range: 52-97 days). Median expansion rates at 1, 3, and 7 days after stenting were 55%, 65%, and 75%, respectively. CONCLUSIONS: A flexible braided stent woven with relatively thin wires was used for malignant GOO. Despite a gradual expansion with slightly lower expansile force, the stent functioned sufficiently well and showed favorable results. Clinical Trials Registry ID: UMIN000029496.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.

Gastrointestinal Luminal Stenting: The Early US Experience with the Duodenal HANAROSTENT.

Self-expandable metal stents (SEMSs) are frequently utilized for palliation of malignant gastric and/or duodenal outlet obstruction (GDOO). Re-establishing luminal patency with accurate SEMS positioning while limiting migration and adjacent tissue injury is an important technical consideration and aim. The duodenal HANAROSTENT® was introduced in the USA in 2019 and developed with these challenges in mind. As the first center in the USA to deploy the duo-denal HANAROSTENT® in clinical practice, we herein examine our early experience with its use. Specifically, we describe 7 consecutive cases of malignant GDOO in which a duodenal HANAROSTENT® was placed for on-label use, defined as palliative treatment of malignant gastric and/or duodenal obstruction. All stents were 22 mm in diameter, with 5 being 90 mm and 2 being 120 mm in length. Technical and clinical success with duodenal HANAROSTENT® placement were achieved in all 7 cases (100%). In no case was stent adjustment required post-deployment. There were no stent-related adverse events, and no subsequent endoscopic procedures were necessary in any of the patients during a mean follow-up of 5 months (range 1-12 months). In summary, the duodenal HANAROSTENT® appears to perform well and be a promising alternative to other available duodenal SEMSs. As experience in the USA with this newly introduced duodenal SEMS grows, multicenter prospective data should be collected to better establish its relative safety and efficacy.

Clinical observation of endoscopic X-ray combined with metal stent implantation in treatment of gastroduodenal malignant obstruction / 中国内镜杂志

Objective To investigate the clinical value of endoscopic stent implantation combined with X-ray monitoring in the treatment of malignant gastroduodenal obstruction. Methods 70 cases of malignant obstruction of stomach and duodenum from January 2013 to December 2015 were enrolled. According to the patients' hospitalization sequence, the odd number of patients were enrolled in the study group, the even number of patients were enrolled in the control group, 35 cases in each. The difference is that the study group were performed in metallic stent placement under fluoroscopic monitoring and endoscopic direct vision, while the control group only under endoscopic direct vision. Record the operation time, the success rate and accuracy of disposable implantation, diseases, thedisplacement and falling of the stent, and complications. we statistically analyzed the data. Results The operation time of the intervention group on average was (9.71 ± 3.60) min, while the control group was (21.01 ± 5.20) min. The success rate and accuracy of disposable implantation of the intervention group was 97.14%, while the control group was 77.14%; After 4 weeks after stent patency rate were 97.14%, 74.28% in the control group; Two groups are with the same diseases. All of the patients had small amount of bleeding, which were stoped after treatment. There was no gastrointestinal ulcers, 1 case with stent displacement, 1 case with gastrointestinal complications, 1 case with metabolic complications in the intervention group. There was 4 cases with stent displacement, 6 cases with gastrointestinal complications, 7 case with metabolic complications the control group. Conclusion Gastroscope-X-ray combined with metallic stent implantation in the treatment of malignant gastroduodenal obstruction, short operation time, high success rate, stent implantation of accurate positioning, less complications, long survival, is a kind of method is simple and feasible, safe and effective.

Retrospective Study of Surgical Gastrojejunostomy versus Gastroduodenal Stenting for Malignant Gastroduodenal Obstruction

Background: We retrospectively compared endscopic gastroduodenal stenting with gastrojejunostomy as a means of palliating malignant gastric and duodenal obstruction. Methods: This retrospective study investigated patients treated for malignant gastric and duodenal obstruction from April 2011 to April 2015 at Shikoku Cancer Center. Results: Of the 40 patients in this study, 25 underwent gastroduodenal stenting and 15 had operative gastrojejunostomy. Comparing the stenting and operative patients, technical success rate was 100% in both group, clinical success rate was 84% in stenting patients and 93% in operative patients. The median time to fluid intake was significantly shorter in stenting patients than operative patients(0 day vs 2 days, p=0.0003), and the median time to intake of solids was also significantly shorter in stenting patients(1day vs 3 days, p<0.0001).The median hospital stay was significantly shorter in stenting patients(9 days vs 23 days, p=0.0116). Median cost of hospitalization is more expensive in operative patients than stenting patients(¥1,106,170 vs ¥752,290, p=0.0052). Conclusion: Our study suggested that gastoroduodenal stent was less length of time to fluid/solid intake, and less costly than gastrojejunostomy.

[Palliative endoscopic treatment of malignant gastroduodenal obstructions with uncovered enteral stents]. / Malignus gastroduodenalis obstrukció endoszkópos palliációja fedetlen enteralis stenttel.

INTRODUCTION: Palliative treatment of malignant gastroduodenal obstructions with enteral stents is an effective and safe method, and a viable alternative to gastroenterostomy. AIM: The authors present the most common malignancies behind gastroduodenal obstructions, the aspects of stent selections, insertion techniques, technical and clinical success rates, and possible procedure-related complications. METHOD: Between 1 March, 2013 and 9 April, 2015 nineteen patients were treated with uncovered, self-expandable enteral stents. Out of the 19 patients, 6 were females and 13 males, with an average age of 67 years. Indications of stenting were peripyloric ventricular tumour in five cases, malignancies of the duodenum, gastroenteralis anastomosis, Vater papilla and gallbladder in one case respectively, pancreatic tumor in seven cases and bile duct malignancies in three cases. RESULTS: The technical success rate of stent placement was 100%. The evaluation of clinical success was analised on the basis of the Gastric Outlet Obstruction Scoring System. CONCLUSIONS: The use of enteral stents in malignant gastroduodenal obstructions is a reliable and safe method, which promptly decreases symptoms of the patients and improves their quality of life.

Predictors of the patency of self-expandable metallic stents in malignant gastroduodenal obstruction.

AIM: To investigate the predictive factors of self-expandable metallic stent patency after stent placement in patients with inoperable malignant gastroduodenal obstruction. METHODS: A total of 116 patients underwent stent placements for inoperable malignant gastroduodenal obstruction at a tertiary academic center. Clinical success was defined as acceptable decompression of the obstructive lesion within the malignant gastroduodenal neoplasm. We evaluated patient comorbidities and clinical statuses using the World Health Organization's scoring system and categorized patient responses to chemotherapy using the Response Evaluation Criteria in Solid Tumors criteria. We analyzed the relationships between possible predictive factors and stent patency. RESULTS: Self-expandable metallic stent placement was technically successful in all patients (100%), and the clinical success rate was 84.2%. In a multivariate Cox proportional hazards model, carcinoembryonic antigen (CEA) levels were correlated with a reduction in stent patency [P = 0.006; adjusted hazard ratio (aHR) = 2.92, 95%CI: 1.36-6.25]. Palliative chemotherapy was statistically associated with an increase in stent patency (P = 0.009; aHR = 0.27, 95%CI: 0.10-0.72). CONCLUSION: CEA levels can easily be measured at the time of stent placement and may help clinicians to predict stent patency and determine the appropriate stent procedure.

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

BACKGROUND: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Additional gastroduodenal stent placement: retrospective evaluation of 68 consecutive patients with malignant gastroduodenal obstruction.

BACKGROUND: Self-expandable metallic stent placement is widely used to manage malignant gastroduodenal obstructions. However, the techniques and effectiveness of additional gastroduodenal stent placement have not been evaluated until now. PURPOSE: To evaluate the technical feasibility, clinical effectiveness, and complications of additional gastroduodenal stent placement in patients with recurrent obstructive symptoms after primary gastroduodenal stenting. MATERIAL AND METHODS: We retrospectively analyzed data from 68 consecutive patients who had additional gastroduodenal stents placed for recurrent obstruction. Clinical effectiveness was assessed using technical and clinical success rates, gastric outlet obstruction score improvement after primary and additional stent placement, and complications. RESULTS: Additional stent placement was technically successful in 66 of the 68 patients (97%) and symptomatic improvement was achieved in 58 (85%). The gastric outlet obstruction score improved after primary stent placement (0.3 to 1.4) and additional stent placement (0.2 to 1.4). Complications occurred in 12 of 68 patients (18%) and were caused by tumor overgrowth (n = 7), stent collapse (n = 2), food impaction (n = 1), jaundice (n = 1), and duodenal perforation (n = 1). CONCLUSION: Additional gastroduodenal stent placement is technically feasible and clinically effective for patients with recurrent gastric outlet obstruction after stent placement.

The Technique of Metallic Self-expanding Stents in Treating Malignant Gastroduodenal Obstruction / 实用放射学杂志

Objective To explore the methods and curative effect of metallic self-expanding stent in inoperable malignant gas-troduodenal obstruction. Methods The data of 15 cases with gastroduodenal obstruction including 9 cases of carcinoma of head of pancreas and 6 cases of carcinoma of stomach were analyzed retrospectively. The operative procedures of the stent implanted and the tors accepted more radiation dose because the manipulation was under the fluoroscopy in a short distance and with a full field of view. sions, the postoperative eating habit and the development turnover of disease. The main death reasons were tumor transfer and sys-tem exhaustion. Conclusion To pay close attention to the details and main points of operative procedure is the key point to implant stent successfully for malignant gastroduodenal obstruction. The determinative factor to influence the curative effect is the develop-ment turnover of tumor.

The palliative treatment of malignant gastroduodenal obstruction / 国际外科学杂志

Malignant obstruction of the stomach or duodenum is a preterminal event in patients with ad-vanced malignancies of the upper gastrointestinal.It severely limits the quality of life in affected patients.Most patients are in bad conditions and have an short expecting live time,so they not only can not bear but also do not need such an invasive operation.Because of this,a minimally invasive but effective palliative treatment is quite necessary.This paper makes a summary and contrastive analysis of several ways of pallia-five treatment which are widely used for malignant gastroduodenal obstruction in recent years.

Stent placement under fluoroscopic monitoring and endoscopic direct vision for the treatment of malignant gastroduodenal obstruction:a report of 47 cases / 介入放射学杂志

Objective To discuss the operational technique and clinical effect of metallic stent placement in treating malignant gastroduodenal obstruction.Methods Metallic stent placement under fluoroscopic monitoring and endoscopic direct vision was performed in 47 patients with malignant gastroduodenal obstruction.A total of 54 metallic stents was used.Results The procedure was successfully completed in all 47 patients.During the follow-up period,all the patients could take liquid or ordinary diet and were markedly relived of vomiting.The living quality was much improved and no serious complications occurred.Conclusion Under fluoroscopic monitoring and endoscopic direct vision,stent placement is a safe,effective,technically-simple and time-saving procedure for the treatment of malignant gastroduodenal obstruction with less sufferings to the patient.Therefore,it is definitely worth popularizing this technique in clinical practice.

Gastroduodenal stenting.

Palliative procedures for patients with malignant gastroduodenal obstruction must be readily available, have a rapid onset of action, and be well tolerated by a patient with terminal cancer. Laparoscopic gastroenterostomy and insertion of self-expanding stents are emerging as the current methods of choice.An increasing number of dedicated enteral stents with different properties are now available. These can be placed under fluoroscopic guidance alone or with the help of an endoscope. Endoscopic placement has several advantages but requires good collaboration between the endoscopists and the radiology department. Appropriate imaging and work-up of each case at multidisciplinary meetings is required. Coexisting biliary obstruction may be dealt with endoscopically, but frequently requires percutaneous biliary stent placement prior to duodenal stenting. Reintervention is required in up to 25% of patients, usually due to stent occlusion by further tumor growth. This article suggests strategies for patient assessment, procedure planning, and stent insertion.

Application of separate stent placement in the treatment of malignant gastroduodenal obstruction / 介入放射学杂志

Objective To evaluate the feasibility and efficacy of Separate stent placement in the palliative treatment of inoperable malignant gastroduodenal obstruction.Methods Thirty four consecutive patients with inoperable malignant gastroduoenal obstruction were treated with peroral placement of Separate stent. Gastroduodenal obstruction was caused by gastric ( n =11), pancreatic ( n =12), matastatic ( n =3), biliary duct ( n =6) or duodenal ( n =2) cancers. Separate outer partial covered stent overlapping with inner bare stent were placed coaxially under fluoroscopic guidance.Results The technical successful rate reached 97% (33 of 34) with no major complication. Symptoms of gastroduodenal obstruction relieved in 33 patients. The average score of food intake capacity improved from 3.8 to 1.2 after Separate stent placment. Stent migration and tumor ingrowth were not detected during the follow up period. Tumor overgrowth was confirmed in one patient and a second stent was placed to solve the problem.Conclusions Peroral placement of Separate stent is a feasible and effective treatment for patients with inoperable malignant gastroduodenal obstruction.