Outcomes of patients with malignant duodenal obstruction after receiving self-expandable metallic stents: A single center experience.

OBJECTIVES: Self-expandable metallic stent (SEMS) placement is a safe and effective palliative treatment for malignant gastric outlet obstruction; however, the clinical outcomes of gastric and duodenal stenoses may differ. This study aimed to investigate the clinical efficacy of SEMS placement and the predictors of clinical outcomes, specifically in malignant duodenal obstruction (MDO). METHODS: Between September 2009 and March 2021, 79 patients with MDO who received SEMS placement in our hospital were retrospectively enrolled. Patients were divided into three groups according to the obstruction levels: above-papilla group (type 1), papilla involved group (type 2), and below-papilla group (type 3). The clinical outcomes and predictors of survival and restenosis were analyzed. RESULTS: The technical and clinical success rates were 97.5% and 80.5%, respectively. Among patients who had successful stent placement, stent restenosis occurred in 17 patients (22.1%). The overall median stent patency time was 103 days. The overall median survival time after stent placement was 116 days. There was no difference in the stent patency, or stent dysfunction and procedure-related adverse events among the three groups. A longer length of duodenal stenosis ≥ 4 cm was associated with poor prognosis (hazard ratio [HR] = 1.92, 95% confidence interval [CI] = 1.06-3.49, p = 0.032) and post-stent chemotherapy was associated with lower mortality (HR = 0.33; 95% CI = 0.17-0.63, p = 0.001). CONCLUSION: SEMS is a safe and effective treatment for MDO. Chemotherapy after SEMS implantation improve the survival for these patients and a longer length of stenosis predicts higher mortality.

Clinical characteristics and management of gastric outlet obstruction in acute pancreatitis.

OBJECTIVE: The aim of this study was to describe the clinical characteristics and management of gastric outlet obstruction following acute pancreatitis(AP). BACKGROUND: Gastric outlet obstruction (GOO) is not uncommon in acute pancreatitis (AP) and can occur throughout the course. However, the clinical features and related treatment of GOO is rarely reported. METHODS: A retrospective review of AP patients with a diagnosis of GOO from March 2017 to June 2020 was performed. The diagnosis and management of GOO, as well as the demographic characteristics and clinical outcomes of the study patients, were collected and analyzed. RESULTS: Over the three years, there were 60 AP patients developed GOO, constituting an incidence of 5.7%. Thirty-three patients (55.0%, 33/60) developed GOO in the first 4 weeks and 27 patients (45.0%, 27/60) after 4 weeks from onset. Pancreatic necrosis compression (60.6%; 20/33), gastric outlet gastrointestinal edema (27.3%, 9/33) are the main causes of early-onset GOO (≤4 weeks), while wall-off necrosis (92.6%, 25/27) is the leading cause in the late phase (>4 weeks). The management of GOO incorporates both supportive and specific treatment like gastric decompression, gastric juice reinfusion, percutaneous catheter drainage, etc. The mortality of AP patients with GOO (≤4 weeks) was 21.2% and none patients who developed GOO (>4 weeks) died. CONCLUSIONS: GOO, as a gastrointestinal complication developed in AP patients, has two peak incidences in the duration of AP and needs to be paid more attention to.

Stomach in a parastomal hernia: a rare complication of stomas.

Parastomal hernia (PSH) is one of the most known complications to end colostomies. However, PSH containing the stomach is rare: not many case reports were found in literature search. This case is a 92-year-old woman who was brought in by ambulance to the accident and emergency department with vomiting, abdominal distension, palpable mass on the left side of her abdomen and with reduced stoma effluent. Her abdominal CT scan showed a PSH containing a partially incarcerated gastric hernia. Although there are only few similar cases of PSH containing the stomach reported in the literature, an almost similar pattern in presentation of this unique case can be deduced following a thorough comparison of cases in the literature, which can be quite helpful both academically and clinically: they are often advanced in age and are usually women with end colostomies.

Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer.

BACKGROUND: The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO. METHODS: The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS). RESULTS: The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS. CONCLUSION: In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.

Palliative Management of Advanced Pancreatic Cancer: The Role of Gastroentero-hepatologist.

Pancreatic cancer commonly diagnosed at late stage due to subtle clinical manifestation and associated with low 5-year survival rate. Only 10-20% of patients were found in resectable or localized stage. Several complications may arise due to advanced pancreatic cancer such as obstructive jaundice, gastric outlet obstruction, pancreatic cancer cachexia, pruritus of cholestasis, and cancer pain. Palliative management should be optimized in order to improve patient's quality of life. A gastroentero-hepatologist should collaborate with other specialties to give comprehensive palliative care for advanced pancreatic cancer patients.

Outcomes of duodenal stenting: Experience in a French tertiary center with 220 cases.

INTRODUCTION: Endoscopic stenting for malignant gastroduodenal outlet obstruction (MGOO) is described as ineffective and not long-lasting despite a few favorable studies. This study aimed to evaluate the clinical outcomes of a large series of patients in a tertiary center. METHODS: A single-center retrospective study was performed using data collected from all patients who received palliative duodenal self-expandable metal stents between January 2011 and December 2016. The primary endpoints were patient diet after the first duodenal procedure (Gastric Outlet Obstruction Scoring System, GOOSS) and clinical success. The secondary endpoints were the median patency duration (calculated according to the Kaplan-Meier method) and the cumulative incidence of reintervention. RESULTS: Two-hundred twenty patients were included. The increase in the GOOSS score was significant (p < 0.001), and the clinical success rate was 86.3%. The median estimated patency duration was 9.0 months [6.5-29.1]. Patients with pancreatic adenocarcinoma had significantly longer patency durations (p = 0.02). The estimated cumulative probability of a second duodenal procedure after 4 months was 13%. CONCLUSIONS: In this large series of patients who underwent duodenal stenting for MGOO, we observed significant changes in GOOSS scores, a relatively long patency duration compared to findings in previous series, and a low probability of subsequent duodenal procedures, primarily due to a low median overall survival time (4 months).

A Multidisciplinary Approach to Management of Bouveret Syndrome.

Bouveret Syndrome is a rare complication of gallstone disease that occurs when a gallstone enters the stomach or bowel through a biliary enteric fistula and becomes impacted, resulting in gastric outlet obstruction. It is frequently seen in elderly chronically ill patients with neglected biliary disease. We describe a multidisciplinary approach to management of Bouveret Syndrome that could be adopted by healthcare systems with resources commonly found in facilities with a general urologist and gastroenterologist or general surgeon. Successful application of laser lithotripsy under endoscopic guidance sufficiently fractured the stone to allow for disimpaction and relief of the gastric outlet obstruction.

Endoscopic treatment for patients with gastric outlet stricture and biliary obstruction in the absence of endoscopic ultrasound: a retrospective study.

BACKGROUND AND AIM: Endoscopic biliary drainage is difficult in patients with biliary obstruction combined with gastric outlet stricture (GOS). Endoscopic ultrasound is useful for such patients, but needs advanced technique and sophisticated equipment. This study aimed to evaluate the efficacy and safety of conventional endoscopic retrograde cholangiopancreatography (ERCP) in patients with GOS and biliary obstruction without the assistance of endoscopic ultrasound. PATIENTS AND METHODS: Seventy-four patients with GOS proximal to the ampulla and biliary obstruction, including 27 with benign GOS and 47 with malignant GOS, were retrospectively enrolled. Three conventional methods were used to pass through the stricture and allow the duodenoscope to reach the papilla: adjusting the endoscope, balloon dilation, and metal stent insertion. The uncovered metal stent insertion was applied only in patients with malignant GOS. The primary outcome evaluated was successful biliary drainage. RESULTS: No serious complications occurred during or after ERCP. The overall success rate of biliary drainage in the patients was 81.1%. The success rate of duodenoscopy insertion by endoscope adjustment, balloon dilation, and stent insertion was 44.6, 68.9, and 71.4%, respectively. Endoscope adjustment was more successful in the patients in the benign group compared with the patients in the malignant group (60.9 vs. 35.7%). Similar findings were obtained for balloon dilation (92.3 vs. 59.4%). CONCLUSION: Most GOS, encountered during ERCP, can be safely dealt with using conventional endoscopic approaches in patients with biliary obstruction. However, the efficacy of endoscope adjustment or balloon dilation is better for benign GOS than for malignant GOS.

Updates in Therapeutic Endoscopic Ultrasonography.

The last decade has seen a dramatic rise in the possibilities of therapeutic endoscopic ultrasound (EUS). From EUS fine needle aspiration of cancerous lesion to pseudocyst drainage, it has now not only replaced some of the percutaneous techniques but has permitted to bypass all together laparoscopic approach for patient with altered anatomy or malignant gastric outlet obstruction. This review will emphasize the novel therapeutic EUS procedures added to our arsenal.

Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction.

BACKGROUND AND AIMS: Peptic ulcer disease (PUD)-related gastric outlet obstruction (GOO) is known to respond favorably to endoscopic balloon dilation (EBD). However, data on efficacy of EBD for other etiologies of benign GOO are sparse. We aimed to compare the response of EBD among different etiologies of GOO. METHODS: Records of all patients with benign GOO who underwent EBD at our tertiary-care center between January 1998 and December 2017 were analyzed. Dilation was done by using through-the-scope balloons. Procedural and clinical success of EBD was compared among different etiologies. RESULTS: A total of 306 patients were evaluated, of whom 264 (mean [± standard deviation] [SD] age 37.89 ± 17.49 years; men 183, women 81) underwent dilation. Etiologically, caustic ingestion was the commonest cause of GOO (53.8%) followed by PUD (26.1%) and medication-induced (8.3%). Overall procedural and clinical success was achieved in 200 (75.7%) and 243 (92.04%) patients, respectively, requiring a mean (± SD) of 2.55 (2.8) and 5.37 (3.9) sessions, respectively. Caustic-induced GOO responded less favorably, requiring a higher number of dilation sessions and having more refractory strictures than other etiologies. Medication-induced GOO performed worse than PUD-related GOO. Of the 264 patients, 9 (3.4%) had perforations during EBD, 3 had contained leaks and were managed conservatively, and 6 underwent successful surgery. CONCLUSION: EBD is successful in a majority of patients with benign GOO, with caustic-induced GOO and medication-induced GOO being more difficult than PUD-related GOO.

Endoscopic stenting for palliation of intra-abdominal gastrointestinal malignant obstruction: predictive factors for clinical success.

BACKGROUND: Endoscopic stenting proved to be a safe alternative to surgery for malignant intra-abdominal gastrointestinal obstruction. Although high technical success rates have been reported, some patients do not experience relief in symptoms. AIM: This study aimed to analyse the factors predicting the effectiveness of stent placement in patients with gastrointestinal obstruction. PATIENTS AND METHODS: A retrospective study was carried out including 160 patients who underwent palliative stenting for intra-abdominal obstruction in a tertiary centre from December 2012 to July 2017. Technical and clinical success, stent dysfunction and adverse events were analysed. RESULTS: The rate of technical success was 98%. The rate of early clinical success was 69 and 81% in upper and lower gastrointestinal obstructions, respectively (P=0.107). In the upper tract, obstruction caused by carcinomatosis was the only independent factor predicting early and late clinical failure [odds ratio (OR): 9.7, 95% confidence interval (CI): 2.5-38.4, P=0.001 and OR: 7.6, 95% CI: 1.8-31.9, P=0.006, respectively]. In the colon, Eastern Cooperative Oncology Group score of at least 3 was an independent factor for early clinical failure (OR: 29.8, 95% CI: 1.9-464.9, P=0.002) and obstruction caused by carcinomatosis was an independent factor for late clinical failure (OR: 14.4, 95% CI: 1.7-119.6, P=0.013). Perforation occurred in 4 patients (2.5%) and stent dysfunction occurred in 15% of patients (4% stent migration; 9% restenosis). Carcinomatosis was a risk factor for perforation (P=0.039) and migration was higher with shorter 6 cm stents (P=0.044). CONCLUSION: Stents are effective and safe for palliation of intra-abdominal obstruction. Carcinomatosis predicts an unfavourable clinical outcome. Palliative stenting as an option should be weighed carefully in these patients.