Outcome of palliative self-expanding metal stent placement in malignant colorectal obstruction according to stent type and manufacturer

Background

Self-expandable metallic stents (SEMS) of varying designs and materials have been developed to reduce complications, but few comparative data are available with regard to the type of stent and the stent manufacturer. We analyzed the success rates and complication rates, according to stent type (uncovered vs. covered stent) and individual stent manufacturer, in malignant colorectal obstruction.

Methods

From November 2001 to August 2008, 103 patients were retrospectively included in this study: four types of uncovered stents in 73 patients and two types of covered stents in 30 patients. The SEMS was inserted into the obstructive site by using the through-the-scope method.

Results

Technical and clinical success rates were not different between stent type or among stent manufacturers: 100 and 100% (p?=?ns) and 100 and 96.6% (p?>?0.05), respectively, in uncovered and covered stents. Stent occlusion and migration rates were 12.3 and 3.3% (p?=?0.274) and 13.7 and 16.7% (p?=?0.761), respectively, in uncovered and covered stents, and 11.1, 5, and 9% (p?=?0.761) and 25.9, 15, and 0% (p?=?0.037) in Wallstent, Niti-S, and Bonastent uncovered stents, respectively.

Conclusions

The placement of SEMS is an effective and safe treatment for patients with malignant colorectal obstruction. Although minor differences in outcome were detected according to the type and the manufacturer of the stents, no statistically significant difference was observed, except in stent migration among the stent manufacturer.     

Comparison of uncovered and covered stents for the treatment of malignant duodenal obstruction caused by pancreaticobiliary cancer

Background

Few clinical studies to date have compared different types of self-expandable metallic stents (SEMS) and their outcomes in patients with pure duodenal obstruction caused by pancreaticobiliary cancer. The aim of this study was to compare the clinical effectiveness and side effects of uncovered and covered SEMS for the palliation of duodenal obstruction caused by pancreaticobiliary cancer.

Methods

We retrospectively analyzed all patients with pancreaticobiliary cancer who underwent upper endoscopy with SEMS placement for malignant duodenal obstruction at the National Cancer Center of Korea between April 2003 and December 2010. The technical and clinical success rates of the procedure, complications, and durations of stent patency and overall survival were evaluated.

Results

We identified 70 patients with a mean age of 51.2 years (range = 39–81 years); of these, 46 (65.7 %) had pancreatic cancer, 9 (12.9 %) had bile duct cancer, 11 (15.7 %) had gallbladder cancer, and 4 (5.7 %) had cancer of the ampulla of Vater. Twenty-four patients (34.3 %) received covered SEMSs and 46 (65.7 %) received uncovered SEMSs. Technical and clinical success rates were similar for the covered and uncovered stent groups. The complication rate was higher in the covered than in the uncovered group (62.5 vs. 34.8 %, P = 0.025), due primarily to a significantly higher stent migration rate (20.8 vs. 0 %, P = 0.004). Perforation as a late complication occurred in four patients, two in each group (8.3 vs. 4.3 %, P = 0.425). Stent patency tended to be shorter for covered than for uncovered duodenal stents (13.7 ± 8.6 weeks vs. not reached, P = 0.069).

Conclusions

The use of uncovered stents may be a preferred option for duodenal obstruction secondary to pancreaticobiliary malignancies, since they were effective in preventing stent migration and tended to have longer patency than covered stents. Careful attention should be paid to signs and symptoms of perforation during follow-up.     

Comparison of treatment outcomes of endoscopic stenting for colonic and extracolonic malignant obstruction

Background

Self-expandable metal stents (SEMS) have been used as a bridging or palliative treatment for malignant colorectal obstruction. Colonic obstruction also may arise from advanced extracolonic malignancy, but the clinical outcomes of stent placement for extracolonic malignancy are unclear. This study compared the clinical outcomes of SEMS between patients with colorectal cancer and those with extracolonic malignancy.

Methods

Patients who underwent endoscopic SEMS placement for a malignant colorectal obstruction were enrolled at Seoul National University Hospital from April 2005 and August 2011. Their medical records were retrospectively reviewed in terms of success rate, complications, and duration of stent patency.

Results

Endoscopic SEMS placements were performed for colorectal cancer in 149 patients and for extracolonic malignancy in 60 patients. The causes of obstruction in extracolonic malignancy were advanced gastric cancer in 39 patients (65 %), pancreatic cancer in nine patients (15 %), ovarian cancer in three patients (5 %) and other causes in nine patients (15 %). The clinical success rates were similar between the two groups (92.6 vs 86.7 %; p = 0.688), and multivariate analysis showed no significant risk factor for unsuccessful endoscopic SEMS placement. Reobstruction in palliative endoscopic SEMS placement occurred for 16 patients with colorectal cancer (21.9 %) and 18 patients with extracolonic malignancy (30 %) during a median follow-up period of 90 days (p = 0.288). The rates did not differ significantly between the two groups (4.1 vs 8.3 %; p = 0.467). The median duration of stent patency was 193 ± 42 days for the patients with colorectal cancer and 186 ± 31 days for the patients with extracolonic malignancy (p = 0.253). The duration of stent patency was not affected by underlying malignancy, previous surgery, or palliative chemotherapy.

Conclusions

Endoscopic SEMS placement is highly effective and comparable for palliation of obstruction in extracolonic malignancy and colorectal cancer in terms of clinical success, complications, and duration of patency.     

Partially covered self-expanding metal stent for unresectable malignant extrahepatic biliary obstruction: results of a large prospective series

Background

Endoscopic biliary stenting is a well-established palliative treatment in patients with unresectable malignant biliary strictures. Obstruction of uncovered self-expanding metal stent (SEMS) due to tumor ingrowth is the most frequent complication. Partially covered SEMS might increase stent patency but could favor complications related to stent covering, such as pancreatitis, cholecystitis, and migration. The aim of this study was to evaluate the efficacy and safety of partially covered SEMS in patients with an unresectable malignant biliary stricture.

Methods

Patients with malignant extrahepatic biliary obstruction treated endoscopically with partially covered SEMS were included in this multicenter, prospective, nonrandomized study.

Results

One hundred ninety-nine patients were endoscopically treated with partially covered SEMS in 32 Spanish hospitals. Clinical success after deep cannulation was 96%. Early complications occurred in 4% (3 pancreatitis, 2 cholangitis, 1 hemorrhage, 1 perforation, and 1 cholecystitis). Late complications occurred in 19.5% (18 obstructions, 10 migrations, 6 cholangitis without obstruction, 3 acute cholecystitis, and 2 pancreatitis), with no tumor ingrowth in any case. Median stent patency was 138.9 ± 112.6?days. One-year actuarial probability of stent patency was 70% and that of nonmigration was 86%. Multivariate analysis showed adjuvant radio- or chemotherapy as the only independent predictive factor of stent patency and previous insertion of a biliary stent was the only predictive factor of migration.

Conclusions

The partially covered SEMS was easily inserted, had a high clinical success rate, and prevented tumor ingrowth. The incidence of possible complications related to stent coverage, namely, migration, pancreatitis, and cholecystitis, was lower than in previously published series.     

Clinical outcomes of re-stenting in patients with stent malfunction in malignant gastric outlet obstruction

Background and aims

Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastric outlet obstruction (GOO). The aim of this study was to evaluate the clinical outcomes of salvage SEMS for stent malfunction and to identify the prognostic factors for a longer patency.

Methods

A total of 108 patients who underwent a secondary salvage SEMS placement for a primary stent malfunction were retrospectively reviewed at the Seoul National University Hospital between August 2004 and May 2013. The duration of patency for salvage SEMS was defined as the time between salvage SEMS placement and the recurrence of obstructive symptoms that were confirmed either endoscopically or radiologically.

Results

The technical and clinical success rates for salvage SEMS were 100 and 82.4 % (95 % confidence interval [CI] 74.0–89.0), respectively. A salvage SEMS malfunction occurred in 29 (26.9 %) of the 108 patients. The median duration of patency for salvage SEMS was 59.5 days (range 3–928, 95 % CI 73.7–118.3). Longer SEMS patencies of more than 60 days were significantly associated with palliative chemotherapy (odds ratio = 2.539, 95 % CI 1.031–6.252, p = .043). For salvage SEMS, covered–uncovered stents had a longer patency duration, as compared with other combinations of primary and salvage stent types.

Conclusions

Longer patency durations for salvage SEMS were associated with palliative chemotherapy after salvage SEMS insertion. Salvage SEMS could be a feasible and effective treatment for primary stent malfunction in malignant GOO.

     

Factors associated with 30-day readmission and long-term efficacy of enteral stent placement for malignancy

Background

Readmissions to the hospital within 30 days of discharge (30-day readmission rate) may impact stent use in palliative treatment of cancer.

Objective

Our objective was to investigate the incidence of readmission and factors predicting readmissions and long-term outcomes in patients with self-expanding metal stents (SEMS) placed for malignant obstruction.

Methods

Retrospective analysis of all patients who underwent placement of SEMS from 2007 to 2012 for malignant esophageal, gastroduodenal, and colonic obstruction. Incidence and variables associated with 30-day readmission and long-term outcomes were determined.

Results

A total of 191 patients underwent stent placement. The 30-day readmission rate was 17.3 % (N = 33). Readmissions were for stent-related complications in 7.3 % (N = 14) and non-stent-related complications in 9.9 % (N = 19). Stent placement was technically successful in 185 of 191 (96.9 %) and clinically successful in 170 of 191 (89.0 %) patients. On long-term follow-up, 32 (16.8 %) patients needed re-intervention. The mean stent patency was 142 days. Readmission within 30 days was independently associated with development of early complications (<7 days) following stent placement (odds ratio [OR] 5.90; 95 % confidence interval [CI] 2.04–17.1), while the stent location did not impact readmission risk. On Cox regression analysis, American Society of Anesthesiologists physical classification (OR 1.36; 95 % CI 1.02–1.87) and stent location in the esophagus (OR 1.82; 95 % CI 1.10–3.02) were independently associated with long-term mortality.

Conclusions

Early complications following stent placement increase the risk of 30-day readmission. SEMS is efficacious long-term for palliation of malignant gastrointestinal obstruction.     

Efficacy and safety of covered self-expandable metal stents for management of distal malignant biliary obstruction due to lymph node metastases

Background

Distal malignant biliary obstruction (MBO) due to lymph node metastases (LNM) is a common problem in advanced malignant disease. However, the role of covered self-expandable metal stents (SEMS) in treating MBO has not been studied. The aim of this study was to evaluate the efficacy and safety of covered SEMS for the treatment of distal MBO due to LNM.

Methods

Between November 1994 and December 2009, a total of 65 patients with distal MBO due to LNM underwent covered (n?=?44) and uncovered (n?=?21) SEMS placement.

Results

Successful drainage was achieved in all patients. There was no significant difference in patient survival. The cumulative stent patency of covered SEMS was significantly higher than that of uncovered SEMS (P?=?0.0020). Stent occlusion occurred in 5 patients (11%) with covered SEMS and in 8 (38%) with uncovered SEMS. There was no tumor ingrowth in covered SEMS, but seven in the uncovered SEMS group showed some ingrowth. Cholecystitis was not observed, but mild pancreatitis was observed in 6 (14%) of those with covered SEMS. No stent-insertion-related deaths occurred.

Conclusions

Covered SEMS are safe and effective for treatment of distal malignant biliary obstruction due to LNM.     

Endoscopic stenting for benign upper gastrointestinal strictures and leaks

Background

Self-expandable metal stents (SEMS) and self-expandable plastic stents (SEPS) maybe used for the treatment of benign upper gastrointestinal (GI) leaks and strictures. This study reviewed our experience with stent insertions in patients with benign upper GI conditions.

Methods

Patients who underwent stent placement for benign upper GI strictures and leaks between March 2007 and April 2011 at a tertiary referral academic center were studied using an endoscopic database and electronic patient records. The technical success, complications, and clinical improvement after stent removal were compared according to type of stent. The outcomes measured were clinical response, adverse events, and predictors of stent migration.

Results

Thirty-eight patients (50 % male, mean age = 54 years, range = 12–82) underwent 121 endoscopic procedures. Twenty patients had stents placed for strictures, and 18 had stents placed for leaks. Stent placement was technically successful in all patients. The average duration of stent placement was 54 days (range = 18–118). Clinical improvement immediately after stent placement was seen in 29 of the 38 patients (76.3 %). Immediate post-procedure adverse events occurred in 8 patients. Late adverse events were seen in 18 patients. Evidence of stent migration occurred in 16 patients and was seen in 42 of the 118 successfully placed stents (35.5 %). Migration was more frequent with fully covered SEMS (p = 0.002). After stent removal, 27 patients were evaluable for long-term success (median follow-up time of 283 days, IQR 38–762). Resolution of strictures or leaks was seen in 11 patients (40.7 %). Predictors for long-term success included increasing age and if the stent did not cross the GE junction.

Conclusions

Placement of SEPS and SEMS for benign refractory strictures and fistulas has modest long-term clinical efficacy and is limited by a significant migration rate. Stent migration is common and frequent with fully covered SEMS compared to other types of stents, regardless of indication or location.     

Clinical outcomes following secondary self-expandable metal stent (SEMS) insertion due to previous stent migration in malignant colorectal obstruction

Background

There has been no research on the clinical outcomes of secondary self-expandable metal stent (SEMS) placement after initial stent migration. Therefore, this study aimed to assess the clinical outcomes of secondary SEMS placement after initial stent migration compared to the outcomes of secondary SEMS placement done for reasons other than migration and identify factors predictive of long-term outcomes.

Methods

Between January 2005 and February 2011, a total of 422 patients underwent SEMS insertion for malignant colorectal obstruction at Severance Hospital. Of these, there were 98 cases of secondary SEMS placement, 38 of which were due to previous stent migration. We compared the clinical outcomes of secondary SEMS between stent migration and nonmigration groups. We also sought to identify risk factors for long-term outcomes of secondary SEMS after initial stent migration.

Results

The baseline clinical characteristics were similar between the two groups. The technical and clinical success rates of secondary SEMS insertion in the migration and nonmigration groups were 94.7 % and 83.3 % (p = 0.09) and 73.7 % and 53.3 % (p = 0.122), respectively. In the migration group, sustained clinical success after secondary SEMS was associated with the absence of complications after insertion of the first stent (p < 0.001) and a longer time interval (more than 100 days) between the first and second stent insertion (p = 0.011).

Conclusions

Our data showed that secondary colorectal SEMS after stent migration is safe and effective. Moreover, the sustained clinical success of the secondary stent following migration was dependent on the outcomes of the first stent.     

Self-expandable Metallic Stents in Patients with Stage IV Obstructing Colorectal Cancer

Background

The aim of the present study was to analyze the results of our experience with elective placement of self-expandable metallic stents (SEMS) in patients with stage IV obstructing colorectal cancer. A systematic review of the literature was also carried out to analyze the factors influencing the results of SEMS placement and to determine if there has been any improvement in the more recent period.

Materials and methods

The results of a personal series of 100 patients were analyzed. There was no case of mortality or major morbidity. The systematic review included 27 articles published from April 2007 to December 2011.

Results

In our experience the technical success rate was 96 % and the clinical success rate was 92 %. During the follow-up period a repeat colonoscopy was needed in 31 % of the patients for recurrent symptoms of obstruction due to fecal impaction (19 %), tumor growth (8 %), or stent dislodgment (4 %). Review of the literature showed similar results, with a significant improvement in the reports of the last 6 years; procedures performed on an emergency basis had poorer results.

Conclusions

Self-expandable metallic stent placement offers a valid alternative to surgery in patients with obstructing stage IV colorectal cancer, but careful follow-up is required.     

Outcome and safety of self-expandable metallic stents for malignant colon obstruction: a Korean multicenter randomized prospective study

Background

Newly developed uncovered stents are designed to have varied radial force and high conformability to improve clinical outcome and safety. This study aimed to determine and compare the clinical outcome and safety of the Taewoong D-type uncovered stent and the Boston Scientific Wallfex stent.

Methods

Patients with acute malignant colonic obstruction were treated with a colonic stent. For the purpose of palliation, patients were randomly allocated. For the purpose of bridging, the type of stent was determined by the discretion of the individual doctors. Technical and clinical success and complication occurrence were measured as primary outcomes.

Results

From 12 university hospitals, 123 patients with malignant colonic obstruction were enrolled. Of these 123 patients, 58 were treated with colonic stents for palliative purposes. The technical and clinical success rate was 100?% for both stents in the palliative group. Perforation occurred for one patient (3.6?%) in the Wallflex stent group (n?=?28) on day 5 and for no patients in the D-type stent group (n?=?30). Two cases of migration occurred: one with the Wallflex stent and one with the D-type stent. Stent restenosis occurred for one patient with the Wallflex stent. Preoperative bridging stents were placed in 65 patients. The median time to surgery was 10?days. The technical success rate was 93.4?%, and clinical success was achieved for 86.2?% of the patients. Perforation occurred for five patients: four with the Wallflex stent and one with the D-type stent. The efficacy and safety of the two stents did not differ statistically.

Conclusions

The D-type colonic uncovered stent and the Wallflex colonic uncovered stent are effective and safe for both palliative and preoperative bridging therapy used to treat acute malignant colonic obstruction.     

Management of distal malignant biliary obstruction with the ComVi stent, a new covered metallic stent

Background

The covered metallic stent is effective for managing malignant distal biliary obstructions. The most popular covered metallic stent is the covered Wallstent (CWS). This study estimated the efficacy and safety of a new expanded polytetrafluoroethylene (e-PTFE)-covered nitinol metallic stent, the ComVi stent. This covered metallic stent consists of an e-PTFE membrane sandwiched between two uncovered metallic stents with weak axial (straightening) force. Wire is exposed on both the inner and outer surfaces.

Methods

Between May 2005 and April 2007, ComVi stents were placed consecutively in 47 patients with unresectable malignant distal biliary obstruction. The cases involved 35 pancreatic cancers, 8 metastatic nodes, 2 gallbladder cancers, and 2 bile duct cancers. The patients were compared with 47 patients who received CWS placement between August 2001 and May 2005 matched for age, sex, and causative disease from 133 cases.

Results

No significant differences in stent patency or patient survival were found. Stent occlusion was observed in 13 patients (27.7%) in the ComVi group and 10 patients (21.3%) in the CWS group. The cause of occlusion in both groups was tumor overgrowth (4.25% vs 4.2%), sludge (8.5% vs 6.3%), impaction of food scraps (14.9% vs 2.1%), and bile duct kinking (0% vs 8.4%). Other complications were migration (2.1% vs 17.0%; p = 0.0304) and cholecystitis (2.1% vs 6.3%), and there were significant differences in the incidence of complications except for occlusion (4.2% vs 24.6%; p = 0.0142).

Conclusion

The ComVi stent has a patency similar to that of the CWS and a lower incidence of migration. However, early occlusion by food impaction was increased and should be resolved.     

Partially covered esophageal stents cause bowel injury when used to treat complications of bariatric surgery

Background

We hypothesized that an esophageal nitinol stent that is mainly silicone-covered but partially uncovered may allow tissue ingrowth and decrease the migration rate seen with fully covered stents and still allow safe stent removal. The aim of this study was to evaluate the first human results of using partially covered stents for anastomotic complications of bariatric surgery.

Methods

This was a retrospective evaluation of all patients with staple-line complications after bariatric surgery who received a partly covered stent at a single tertiary-care bariatric center. The stents varied in length from 10 to 15 cm and in diameter from 18 to 23 mm.

Results

From April 2009 to April 2010, eight patients received partially covered stents on 14 separate occasions. The indications were gastrojejunal stricture in four, acute leak in two, acute leak followed by a later stricture in one, and a perforated anastomotic ulcer in one patient. Single stents were placed in 12 sessions and two overlapping stents in two sessions. At the time of stent deployment, one patient had the uncovered proximal end of the stent in the stomach, with all others in the distal esophagus. Immediate symptom improvement occurred in 12/14 stent placements. Oral nutrition was initiated for 10/14 stent treatments within 48 h. Stents were removed after 25 ± 10 days. Minor stent displacement occurred with 9/13 stents, with the proximal end of the stent moving into the stomach, though the site of pathology remained covered. The stents were difficult to remove when tissue ingrowth was present. One patient required laparoscopic removal and one required two endoscopy sessions for removal. At the time of removal of ten stents, where the proximal end was found in the stomach, four had gastric ulceration, three had gastric mucosa replaced by granulation tissue, and three had normal gastric mucosa. In four cases where the proximal portion of the stent stayed in the esophagus, the esophageal deployment zone had abnormalities: three with granulation tissue and one with denuding of the esophageal mucosa. The distal uncovered portion of the stent in the Roux limb never became embedded in the mucosa and caused minimal injury.

Conclusions

A partially covered stent was successful in keeping the site of the pathology covered and provided rapid symptom improvement and oral nutrition in most patients. The proximal end of the stent generally moved from the esophagus to the stomach, probably due to esophageal peristalsis. The proximal uncovered portion of the stent causes significant bowel mucosal injury and sometimes becomes embedded in the esophagus or the stomach, making removal difficult. We no longer use partially covered stents.     

A new technique for placement of a self-expanding metallic stent (SEMS) in patients with colon rectal obstruction: a prospective study of 43 patients

Background

Self-expanding metallic stent (SEMS) placement is a valid form of therapy for patients with obstructing colon rectal cancer. The procedure is not feasible for a minority of patients with a very low risk of bowel perforation. This report analyzes the results of a technical detail used for SEMS placement.

Methods

In 43 patients with colon rectal obstruction, the SEMS apparatus was introduced through a guidewire passed above the obstruction in the channel of a pediatric nasogastroscope (diameter, 4.9 mm). The pediatric nasogastroscope was passed into the obstruction and above, allowing the anatomy of the colorectal lesion and the passage of the guidewire to be visualized directly.

Results

The SEMS was inserted successfully in all cases without complications. In a previous series of 82 patients who had passage of the guidewire through the obstruction blindly, four technical failures occurred (nonsignificant difference).

Conclusions

A pediatric nasogastroscope can be useful for passing the colon rectal obstruction and guiding the passage of the guidewire under direct vision.     

A prospective evaluation of short-term and long-term results from colonic stenting for palliation or as a bridge to elective operation versus immediate surgery for large-bowel obstruction

Background

The efficacy and safety of self-expandable metallic stent (SEMS) placement as a bridge to elective surgery or definitive palliation versus emergency operation to treat colorectal obstruction is debated. This study aimed to evaluate the outcomes of patients with colorectal obstruction treated using different strategies.

Methods

Subjects admitted to the authors’ department with colorectal obstruction (n = 134) were studied prospectively. They underwent endoscopic stenting as a bridge to elective surgery (SEMS group: n = 49) or for definitive palliation (n = 34). A total of 51 patients underwent immediate surgery without stenting (NO-SEMS). Treatment was decided by the senior on-call surgeon.

Results

Placement of SEMS was technically successful in 95.3 % and clinically successful in 98.7 % of cases. The short-term complications in the SEMS group were perforation (n = 1, 1.2 %), migration (n = 4, 4.9 %), occlusion (n = 4, 4.9 %), colon bleeding (n = 3, 3.7 %), and abdominal pain (n = 6, 7.4 %). The postoperative complication rate was 32.7 % in the SEMS group versus 60.8 % in the NO-SEMS group (P = 0.005), with a significant reduction in wound infections (26.5 vs 54.9 %; P = 0.004), abdominal abscess (14.3 vs 39.2 %; P = 0.006), respiratory morbidity (10.2 vs 37.3 %; P = 0.002), and intensive care treatment (10.2 vs 33.3 %; P = 0.007). The median postoperative hospital stay was 10 versus 15 days (P = 0.001). The in-hospital mortality rate in both groups was 2 %. Long-term follow-up evaluation showed less incisional hernia (6.3 vs 22.0 %; P = 0.04) and definitive stoma formation (6.3 vs 26.0 %; P = 0.01) in the SEMS group than in the NO-SEMS group, respectively. Kaplan–Meier survival curves showed a benefit for the SEMS group (log-rank test, 0.004). The long-term SEMS-related complication rate for the palliative patients was 43.8 %. The hospital readmission rate for SEMS complications was 34.4 %. Overall clinical success was 81.2 %.

Conclusions

In case of colorectal obstruction, endoscopic colon stenting as a bridge to elective operation should be considered as the treatment of choice for resectable patients given the significant advantages for short- and long-term outcomes. Palliative stenting is effective but associated with a high rate of long-term complications.     

Duodenal metal stent placement is a risk factor for biliary metal stent dysfunction: an analysis using a time-dependent covariate

Background

Although the combination of biliary and duodenal self-expandable metal stents (SEMS) is useful, the exacerbating effect of duodenal SEMS placement on biliary SEMS has not been documented. We conducted a multicenter retrospective study to evaluate the effect of duodenal SEMS placement on biliary SEMS.

Methods

Patients who underwent first-time biliary SEMS placement for a distal malignant biliary obstruction between September 1994 and November 2010 were included. Time to dysfunction of biliary SEMS was analyzed to identify risk factors for biliary SEMS dysfunction. Duodenal SEMS placement was analyzed as a time-dependent covariate.

Results

In total, 410 eligible patients were identified. Duodenal SEMS were placed in 33 patients (8 %). The median time to dysfunction of biliary SEMS was 170 days. Male gender (hazard ratio 1.37, 95 % confidence interval 1.03–1.83, P = 0.029) and duodenal SEMS placement (hazard ratio 2.00, 95 % confidence interval 1.16–3.45, P = 0.013) were risk factors in the multivariate Cox model. In patients undergoing duodenal SEMS, biliary SEMS dysfunction was observed in 17 (52 %) with a median time to dysfunction of 64 days after duodenal SEMS placement. As many as 60 % of the patients with biliary SEMS dysfunction after duodenal SEMS placement needed permanent percutaneous transhepatic biliary external drainage.

Conclusions

Duodenal SEMS placement is a risk factor for biliary SEMS dysfunction. Alternative methods for biliary drainage should be considered for better biliary drainage in patients with a gastric outlet obstruction.     

Oncologic safety of stent as bridge to surgery compared to emergency radical surgery for left-sided colorectal cancer obstruction

Background

There are still concerns about the oncologic safety of stent insertion for colorectal cancer obstruction. This study investigated whether the use of stents as a bridge to surgery negatively affect the long-term outcome compared to curative surgery for left-sided colorectal cancer obstruction.

Methods

Between January 2004 and December 2009, patients with left-sided colorectal cancer obstruction without distant metastasis were retrospectively reviewed. Forty-three patients underwent radical resection after preoperative stent insertion (stent group), whereas 48 underwent emergency surgery with curative intent (surgery group). The short- and long-term outcomes between the two groups were compared.

Results

The stent and surgery groups had similar demographics. There were no significant differences in primary anastomosis, laparoscopic-assisted surgery, operation time, time until first defecation and oral intake after surgery, postoperative hospital stay, and reoperation. The stent group had an average hospital stay 7 days longer than the surgery group. During the median follow-up period of 48.1 months, the 5-year disease-free survival rates were not significantly different between the stent and surgery groups (47.2 vs. 48.9 %, respectively; p = 0.499). Overall, the 5-year survival rate was also similar in the two groups (70.4 vs. 76.4 %, respectively; p = 0.941).

Conclusions

For left-sided colorectal cancer obstruction, stent insertion followed by surgery showed short-term advantages and similar oncologic outcomes compared to surgery without preoperative intervention. Stent insertion as a bridge to surgery is a safe and feasible treatment option for patients with colorectal cancer obstruction.     

Metallic Stent Placement in Patients with Recurrent Malignant Obstruction in the Surgically Altered Stomach

Purpose

The purpose of this study was to assess the technical feasibility and clinical effectiveness of expandable metallic stent placement in 196 patients with recurrent malignant obstruction in their surgically altered stomach.

Methods

The 196 patients were treated using five different types of gastric surgery performed for gastric cancer: total gastrectomy (type 1) in 73 patients; distal gastrectomy with gastroduodenostomy (type 2) in 39 patients; distal gastrectomy with a Roux-en-Y gastrojejunostomy (type 3) in 21 patients; distal gastrectomy with a gastrojejunostomy (type 4) in 49 patients; and palliative gastrojejunostomy for unresectable gastric cancer (type 5) in 14 patients. The technical and clinical success rates, complications, dysphagia score, and influence of chemotherapy were evaluated and the complications compared between the two stent types. The overall survival and stent patency were calculated using the Kaplan–Meier method.

Results

Stent placement was technically successful in 192 of 196 patients (97.9 %), with 184 of the 192 patients (95.8 %) showing symptomatic improvement. The mean dysphagia score improved from 3.24 ± 0.64 to 1.48 ± 0.82 (p < 0.001). The complication rate was 25 %. The incidence of stent migration was significantly higher in fully covered stents and in patients who underwent chemotherapy (p < 0.001 and p = 0.005, respectively). Chemotherapy was significantly associated with an increase of survival (p < 0.001). The median survival and stent patency were 131 and 90 days, respectively.

Conclusion

Placement of expandable metallic stents in patients with recurrent cancer after a surgically altered stomach is technically feasible and clinically effective. Chemotherapy was associated with increased stent migration and prolonged survival.     

Fully covered removable nitinol self-expandable metal stents (SEMS) in malignant strictures of the esophagus: a multicenter analysis

Background

Fully covered esophageal self-expandable metallic stents (SEMS) often are used for palliation of malignant dysphagia. However, experience and data on these stents are still limited. The purpose of this multicenter study was to evaluate the efficacy and safety of fully covered nitinol SEMS in patients with malignant dysphagia.

Methods

37 patients underwent placement of a SEMS during a 3?year period. Five patients underwent SEMS placement as a bridge to surgery: one for tracheoesophageal fistula in the setting of squamous cell carcinoma of the esophagus, one for perforation in setting of esophageal adenocarcinoma, 27 for unresectable esophageal cancer (16 adenocarcinoma, 11 squamous cell carcinoma), two for lung cancer, and one for breast-cancer-related esophageal strictures.

Results

SEMS placement was successful in all 37 patients. Immediate complications after stent deployment included chest pain (n?=?6), severe heartburn (n?=?1), and upper gastrointestinal bleeding requiring SEMS revision (n?=?1). Dysphagia scores improved significantly from 3.2?±?0.4 before stent placement to 1.4?±?1.0 at 1?month (P?P?P?=?0.0018) at 6?months. The stent was removed in 11 patients (30%) for the following indications: resolution of stricture (n?=?3), stent malfunction (n?=?5), and stent migration (n?=?3). After stent removal, three patients were restented, three underwent dilation, and two underwent PEG placement. Mean survival for the 37 patients after stent placement was 146.3?±?143.6 (range, 13–680) days.

Conclusions

Our study suggests that fully covered SEMS placement improve dysphagia scores in patients with malignant strictures, particularly in the unresectable population. Further technical improvements in design to minimize long-term malfunction and migration are required.     

Treating sleeve gastrectomy leak with endoscopic stenting: the kuwaiti experience and review of recent literature

Background

Obesity today is a leading cause of global morbidity and mortality, and bariatric surgeries such as laparoscopic sleeve gastrectomy (LSG) are increasingly playing a key role in its management. Such operations, however, carry many difficult and sometimes fatal complications, including leaks. This study aims at evaluating the effectiveness of endoscopic stenting in treating gastric leaks post-LSG.

Methods

A retrospective study was conducted to the patients who were admitted with post-LSG gastric leak at Al-Amiri Hospital Kuwait from October 2008 to December 2012 and were subsequently treated with stenting. The patients were stented endoscopically with self-expandable metal stent (SEMS), and a self-expandable plastic stent (SEPS) was used to facilitate stent removal.

Results

A total of 17 patients with post-LSG leaks underwent endoscopic stenting. The median age was 34 years (range 19–56), 53 % of the patients were male, and mean body mass index (BMI) was 43 kg/m ² . The median duration of SEMS placement per patient was 42 days (range 28–84). The SEPS-assisted retrieval process took a median duration of 11 days (range 14–35). Successful treatment of gastric leak was evident in 13 (76 %) patients, as evident by gastrografin swallow 1 week after stent removal. In addition, a shorter duration between the LSG and the time of stent placement was associated with a higher success rate of leak seal.

Conclusions

The use of SEMS appears to be a safe and effective method in the treatment of post-LSG leaks, with a success rate of 76 %. The time frame of intervention after surgery is critical, as earlier stent placement is associated with favorable outcomes. Finally, SEPS is often required to facilitate SEMS removal, and further modification of stents and its delivery system may improve results.