Clinical outcomes in patients undergoing multiple self-expandable metallic stent placement by stent in stent technique for malignant gastric outlet obstruction.
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88 Background: Self-expandable metallic stent (SEMS) placement is widely used for relieving the obstructive symptoms of malignant gastric outlet obstruction (MGOO). The aims were to evaluate the efficacy and safety of multiple gastroduodenal stent placement by stent in stent technique and identify predictive factors about stent patency. Methods: We retrospectively analyzed data from 170 patients with GOO receiving SEMS by stent in stent technique from July 2006 to July 2018. Among them, 90 patients had been treated with gastroduodenal SEMS placement for MGOO. Technical and clinical success rates were evaluated. And, clinical outcomes with predictors of stent patency were also analyzed. Results: Among the subjects, 34.4% were treated with secondary SEMS placement, and 9.7% were treated with third SEMS placement because of the previous stent dysfunction. The median stent patency time was 15.7 weeks (range 0-89) in the first SEMS, 10.4 weeks (range 0-44) in the second SEMS, and 11.3 weeks (range 1-29) in the third SEMS. The technical and clinical success rate were 100% and 97.8% in the first SEMS, 100% and 90.3% in the second SEMS, 100% and 100% in the third SEMS. In multivariable analysis, the first SEMS placement of covered type including Comvi stent was correlated with prolonged stent patency (OR 4.549, P = 0.001). And both chemotherapy after the first SEMS placement (OR 8.248, P = 0.006) and chemotherapy after the second SEMS placement (OR 7.467, P = 0.003) were correlated with prolonged stent patency. Serious complications such as gastrointestinal hemorrhage or perforation did not occur in any patient. Conclusions: Secondary and third gastroduodenal SEMS placement by stent in stent technique is a safe and effective treatment for the first stent dysfunction in MGOO. The stent placement of covered type and chemotherapy after stent placement is the predictor of stent patency. Keywords: Malignant gastric outlet obstruction, Self-expandable metallic stent, Stent in stent technique, Stent patency, Predictive factorKeywords:
Self-expandable metallic stent
Gastric Outlet Obstruction
Background and Aim To evaluate the efficacy and safety of secondary gastroduodenal stent placement after first stent dysfunction for malignant gastric outlet obstruction. Methods We conducted a retrospective analysis to investigate the efficacy and safety of secondary stent‐in‐stent gastroduodenal stent placement. Results Among 260 patients who had been treated with first gastroduodenal stent placement for malignant gastric outlet obstruction, 29 patients (11.2%) were treated with secondary gastroduodenal stent placement because of first stent dysfunction. Pancreatic cancer was the major primary cancer (55.2%). A W all F lex duodenal stent was the most frequently inserted stent both as a first stent (75.9%) and as a secondary stent (62.1%). There were 22 patients (75.9%) that received gastroduodenal stents at the bending site (supraduodenal angle or infraduodenal angle). Technical and clinical success rates were 100% and 86.2%, respectively. Median eating period was 3.0 months, and median survival time was 3.5 months. As for related complications, gastrointestinal perforation, insufficient stent expansion, tumor ingrowth, tumor overgrowth, and cholangitis were experienced in 13.8% (four cases), 6.9% (two cases), 6.9% (two cases), 3.4% (one case), and 3.4% (one case), respectively. Conclusion Secondary gastroduodenal stent placement might be effective for managing first stent dysfunction in malignant gastric outlet obstruction. However, gastrointestinal perforation was the major complication.
Gastric Outlet Obstruction
Perforation
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Gastric Outlet Obstruction
Endoscopic Stenting
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Malignant gastric outlet obstruction (GOO) is caused mainly by gastric or pancreaticobiliary neoplasms. GOO presents with uncomfortable symptoms, such as nausea, vomiting, and abdominal distension, leading to malnutrition and impaired quality of life [1] [2]. Endoscopic placement of a self‐expandable metal stent (SEMS) is widely accepted as nonsurgical palliative treatment of nonresectable malignant GOO [3]. However, the efficacy of the SEMS can be compromised, especially in patients affected by gastric antral neoplasia, in which GOO relief is not completely obtained. One of the reasons why gastric SEMS can be ineffective is possibly due to the impact of the proximal end of the stent at the great curvature of the gastric body ([Fig. 1 a]).
Gastric Outlet Obstruction
Gastric distension
Self-expandable metallic stent
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Abstract Self-expandable metallic stent (SEMS) placement is widely used for relieving symptoms in malignant gastric outlet obstruction (MGOO). This study aimed to evaluate the efficacy and safety of multiple gastroduodenal stent placement using the stent-in-stent technique and to identify factors predictive of stent patency. We retrospectively analyzed data from 170 patients with GOO receiving SEMS using the stent-in-stent technique between July 2006 and July 2018. Of these, 90 had been treated with SEMS placement for MGOO. Technical and clinical success rates were evaluated. Clinical outcomes and predictors of stent patency were also analyzed. Second SEMS placement was used in 34.4% of cases and 9.7% were treated with third SEMS placement because of prior stent dysfunction. Median stent patency time was 15.7 weeks for the first SEMS, 10.4 weeks for the second, and 11.3 weeks for the third. The technical and clinical success rates were 100% and 97.8% for the first SEMS, 100% and 90.3% for the second, respectively, and both 100% for the third. Multivariable analysis showed that use of covered SEMS and chemotherapy after first and second SEMS placement was significant predictors of stent patency. Serious complications such as bleeding or perforation did not occur in any patient. Second and third gastroduodenal SEMS placement using the stent-in-stent technique is safe and effective for management of first stent dysfunction in MGOO. Stent patency is significantly associated with the use of covered SEMS and chemotherapy after SEMS placement.
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Background/Aims: It has been reported the placement of a double-layered pyloric combination stent can overcome the disadvantage of the increased ingrowth observed for an uncovered stent and the increased migration for a covered stent. But this did not satisfactorily prevent stent migration and it caused stent migration more frequently than with using the uncovered stent. This study evaluated the usefulness of applying a clip in an effort to reduce stent migration. Methods: Fifteen patients with malignant gastric outlet obstruction were treated with endoscopic placement of a double-layered combination pyloric stent. Three endoscopic clips were then applied to fix the proximal end of the enteral stent to the gastric or duodenal mucosa. The clinical efficacy and especially the rate of migration were analyzed. Results: The technical and clinical success rate was 100% (15/15) and 93.3% (14/15), respectively. No stent migration was observed in any of the patients. Three patients (20%) experienced complications such as stent collapse. The median stent patency period was 83.4 days. Conclusions: Endoscopic clipping for enteral stent placement is effective for preventing stent migration in patients with malignant gastric outlet obstruction.
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CLIPS
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Tracheoesophageal Fistula
Esophageal stent
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Duodenal stenting has gradually been established as the first-line treatment for malignant gastric outlet obstruction (GOO). We encountered a case of duodenal stent fracture in a 76-year-old woman with gastric cancer and GOO. She underwent self-expandable metallic stent (SEMS) placement. The SEMS was found to be fractured 4 weeks after its placement. We removed the broken part of the stent and placed a second SEMS. SEMS fracture is a rare and - to the best of our knowledge - unreported complication; hence, clinicians and their patients should be aware of this possibility.
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Backgroud/Aims: Endoscopic stent placement is widely used to treat an unresectable malignant gastric outlet obstruction. The covered stent has the disadvantage of an increased risk of migration, and the uncovered stent has an increased risk of ingrowth. This study examined the technical and clinical efficiency of stent placement of a double-layered combination pyloric stent that was newly designed to reduce tumor ingrowth and stent migration. Methods: Fifteen patients with a gastric outlet obstruction caused by unresectable stomach cancer were treated with the endoscopic placement of a double-layered combination pyloric stent (an outer uncovered stent to reduce migration and an inner PTEF-covered stent to prevent tumor ingrowth). The technical success, clinical success, and complication especially tumor ingrowth and stent migration were analyzed. Results: Technical success was achieved in 15 out of 15 (100%) patients. Among the 15 patients in whom endoscopic stenting was placed successfully, the clinical success rate was 93.3%, the incidence of tumor ingrowth was 0%, the rate of migration was 6.7%, and tumor overgrowth was observed in 13.3%. The median stent patency period was 105 days. Conclusions: The placement of a double- layered pyloric combination stent appears to be effective in overcoming the disadvantage of the increased migration observed for a covered stent and the increased ingrowth observed for the uncovered stent. (Korean J Gastrointest Endosc 2007;35:221-227)
Gastric Outlet Obstruction
Covered stent
Endoscopic Stenting
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Uncovered self-expandable metal stents (UCSEMS) are commonly used for palliative treatment of malignant tumors resulting in gastric outlet obstruction (GOO). Tumor ingrowth is a frequent complication leading to stent restenosis and treatment failure requiring the need for additional intervention. Placement of a fully covered self expandable metal stent (FCSEMS) within an UCSEMS has been reported with successful alleviation of re-obstruction caused by stent ingrowth. While this technique can provide relief, it can be further complicated by stent migration of the fully covered stent. Placement of clips at the proximal ends of secondary stents has been shown to decrease stent migration rates. To our knowledge, no other stent-in-stent securing methods have been evaluated. We describe the successful treatment of recurrent GOO with a duodenal stent-within-stent secured in place with Apollo OverStitch (Apollo Endosurgery, Texas). A 56-year-old male with metastatic cholangiocarcinoma presented with worsening nausea and vomiting. Prior to presentation, the patient underwent placement of an UCSEMS through the pylorus and duodenum for GOO from tumor burden. The patient subsequently developed a repeat duodenal obstruction from tissue ingrowth and had a second UCSEMS deployed within the first stent 6 months after the original stent placement. At our evaluation, 4 months after the 2nd stent placement, it was noted that there was yet another stricture from further tissue ingrowth. Gastrojejunostomy tube placement was offered to the patient, but he declined. The decision was made to place a 3rd stent for symptom palliation. On endoscopy, a tight stricture was noted within the existing stents. Under endoscopic and fluoroscopic guidance, a wire was placed distally into the duodenum and a 100mm x 18mm FCSEMS was placed within the previous stents. Using Apollo OverStitch, the proximal edge of the stent was sutured into the antral gastric mucosa, and the lateral side of the stent was sutured into the proximal edge of the original stents. The patient tolerated the procedure well. The patient's symptoms of nausea and reflux resolved and follow-up at 6 months revealed continued resolution of obstructive symptoms. The Apollo OverStitch has shown a high technical success rate of securing stents in benign gastrointestinal conditions. Novel use of the OverStitch for stent fixation, particularly stent-within-stent fixation, is promising.
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Self-expandable metallic stent
Gastric Outlet Obstruction
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