左半结肠恶性梗阻的金属支架置入治疗

目的 观察与评价金属支架置入术作为左半结肠恶性梗阻病人手术前开通狭窄的过渡性治疗与长期姑息治疗的安全性与临床疗效。方法 12例左半结肠梗阻并有手术指征的病人接受临时支架置入术，作为开通狭窄、辅助肠道准备的过渡性治疗；5例无手术指征的左半结肠梗阻病人接受支架置入术，作为永久性姑息治疗。观察支架操作成功率、操作相关并发症、支架长期疗效和并发症等指标。结果 ①17例病人支架操作一次成功率为88％，总成功率为100％。②过渡治疗组支架的平均放置时间为6．1d(4～9d)，在肠道准备完成后所有病人均行一期肿瘤切除术，未见肠瘘和腹腔感染等并发症；1例病人于支架置入后第4天因并发肠穿孔而行急症手术。③姑息治疗组支架的平均有效时间为81．7d(61～119d)，2例病人分别于术后62和119d发生肿瘤长入支架导致再次肠梗阻；1例病人于术后61d出现支架移位。结论 过渡金属支架置入术是有手术指征的左半结肠梗阻病人择期手术前一个非常有效而安全的缓解症状、开通狭窄的治疗手段，同时也是一种改善症状、提高终末左半结肠恶性肿瘤病人生存质量的姑息性治疗措施。     

Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction

AIM:To compare the clinical outcomes of uncovered and covered self-expandable metal stent placements in patients with malignant duodenal obstruction.METHODS:A total of 67 patients were retrospectivelyenrolled from January 2003 to June 2013.All patients had symptomatic obstruction characterized by nausea,vomiting,reduced oral intake,and weight loss.The exclusion criteria included asymptomatic duodenal obstruction,perforation or peritonitis,concomitant small bowel obstruction,or duodenal obstruction caused by benign strictures.The technical and clinical success rate,complication rate,and stent patency were compared according to the placement of uncovered(n = 38) or covered(n = 29) stents.RESULTS:The technical and clinical success rates did not differ between the uncovered and covered stent groups(100% vs 96.6% and 89.5% vs 82.8%).There were no differences in the overall complication rates between the uncovered and covered stent groups(31.6% vs 41.4%).However,stent migration occurred more frequently with covered than uncovered stents [20.7%(6/29) vs 0%(0/38),P < 0.05].Moreover,the overall cumulative median duration of stent patency was longer in uncovered than in covered stents [251 d(95%CI:149.8 d-352.2 d) vs 139 d(95%CI:45.5 d-232.5 d),P < 0.05 by log-rank test] The overall cumulative median survival period was not different between the uncovered stent(70 d) and covered stent groups(60 d).CONCLUSION:Uncovered stents may be preferable in malignant duodenal obstruction because of their greater resistance to stent migration and longer stent patency than covered stents.     

Factors associated with clinical failure of self-expandable metal stent for malignant gastroduodenal obstruction.

Objective. Endoscopic self-expandable metal stent (SEMS) placement has emerged as an effective palliative treatment for inoperable malignant gastric outlet obstruction (GOO). In spite of successful stent placement, some patients complain of ongoing dysphagia and vomiting. Most reported data on SEMS to date are about technical success of different types of stents and low complication rates. The aim of this study was to evaluate the associated factors of clinical failure after endoscopic SEMS placement for inoperable malignant GOO. Methods. A total 122 patients who underwent successful endoscopic SEMS placement for malignant GOO in an academic referral center were included in the analyses. We retrospectively evaluated variables associated with clinical outcomes after successful SEMS placement. Results. The clinical success rate was 81.1%. The common causes of GOO were pancreatic (39%) and gastric cancers (32%). The mean length of the stents (± standard deviation) was 10.06 ± 2.42 cm. Multivariate analysis revealed that gallbladder cancer (p = 0.016, OR 6.486, 95% CI, 1.509–59.655), poor performance status (ECOG ≥3) (p = 0.001, OR 10.200, 95% CI, 2.435–42.721), the presence of carcinomatosis peritonei (p < 0.001, OR 35.714, 95% CI, 5.556–250.000) and the failure of endoscope passage (p = 0.039, OR 6.945, 95% CI, 1.101–43.818) Conclusion. Our results suggest that gallbladder cancer, poor performance status (ECOG ≥3) and the presence of carcinomatosis peritonei related with clinical failure of palliative SEMS placement.     

Metal stent placement in acute malignant colorectal obstruction

BACKGROUND: Obstruction is a common complication of advanced colorectal cancer. Stent insertion can reduce the need for emergency surgery and allows chemotherapy to begin immediately. AIMS: To evaluate the technical and clinical success and long-term outcome of stent placement in the management of acute malignant colorectal obstruction. METHODS: From July 2002 to April 2005, 29 self-expanding metal stents were placed in 24 patients (13 men, mean age 67 years, range 36-83). Stents were inserted under endoscopic and fluoroscopic control. Patients were clinically and endoscopically followed up. RESULTS: Twenty-eight out of 29 stents were successfully placed (96.5%) in 23 out of 24 patients with 25 strictures. The clinical success rate was 95.8% (23/24). Two early stent migrations were observed in two patients (8.3%). Late complications developed in eight patients (33.3%) after a median of 3.8 months (range <1-8.6): two migrations and six occlusions. The median survival was 9.8 months (range <1-27). Eleven patients (45.8%) died from progressive disease without any clinical evidence of recurrent obstruction. CONCLUSION: Stent placement is safe and effective. Stent complications are frequent but not life-threatening, and are easy to manage. An improvement in stent design and well-scheduled follow-up are needed in order to prevent such complications.     

小肠减压管联合结肠金属支架置入治疗恶性结肠梗阻的临床研究

目的 探索小肠减压管联合结肠金属支架置入治疗恶性结肠梗阻的临床价值。方法 回顾性队列研究收集2010年6月至2018年9月在浙江大学医学院附属杭州市第一人民医院消化科因恶性结肠梗阻接受消化内镜治疗的患者，根据治疗方案，分为小肠减压管联合结肠金属支架置入组（联合组）和单纯结肠金属支架置入组（单纯组），比较两组在支架操作成功率、并发症发生率、后续外科手术吻合方式及并发症发生率、住院天数及治疗费用等方面的差异。结果 共纳入83例患者，其中联合组18例，单纯组65例，两组患者一般情况比较差异无统计学意义（P>0.05）。联合组与单纯组支架置入成功率比较差异无统计学意义[100%（18/18）比 98.5%（64/65），?2=0.280，P=0.597），支架置入术后并发症发生率比较差异也无统计学意义[5.6%（1/18）比 21.9%（14/64），?2=2.432，P=0.119）。联合在有8例、单纯组有24例在我院行外科手术治疗，联合组支架置入到外科手术时间（6.75±1.28）d，短于单纯组的（9.58±5.76）d（t=3.649，P=0.000），联合组外科术后感染并发症发生率12.5%（1/8），低于单纯组的54.2%（13/24）（P=0.045）。两组手术吻合方式、住院天数、住院费用比较差异无统计学意义（P>0.05）。结论 内镜下金属支架置入或联合小肠减压管治疗恶性肠梗阻安全有效，且金属支架置入前使用小肠减压管可缩短接受外科手术时间，降低外科手术后感染发生率。     

Clinical outcomes of secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction

Background

Although a substantial number of patients require secondary stents insertion due to primary stent malfunction in malignant gastric outlet obstruction, data on the outcomes of secondary self-expanding metal stents are sparse.

Aim

To investigate clinical outcomes and factors related with secondary stent malfunction in patients with malignant gastric outlet obstruction given secondary stent-in-stent self-expanding metal stent insertion.

Methods

For this retrospective study, a total 77 patients who underwent secondary stent-in-stent self-expanding metal stent placement for primary stent malfunction in malignant gastric outlet obstruction were enrolled. We compared the effectiveness and complications of secondary covered and uncovered stents and explored the predictive factors for stent malfunction.

Results

Stent-in-stent self-expanding metal stent placements were technically successful in all patients. Both groups also had comparable clinical success rates (covered stent, 87.2% and uncovered stent, 90.0%, P = 1.000). Stent malfunction rates (31.9% and 36.7% respectively, P = 0.805) and median patency time of stent (165 [95% confidence interval: 112–218] and 165 [95% confidence interval: 126–204] days, respectively, P = 0.358) were similar between secondary covered and uncovered stents. Longer patients’ survival time (≥100 days) was associated with increased risk of stent malfunction (odds ratio: 4.598; 95% confidence interval: 1.473–14.355; P = 0.009).

Conclusions

Secondary stent-in-stent self-expanding metal stent placement is feasible and effective treatment for primary stent malfunctions in malignant gastric outlet obstruction. Covered and uncovered stent are equally acceptable in terms of stent-related complications and stent patency, regardless of primary stent type.     

经皮肝穿刺胆道内支架植入治疗恶性胆道梗阻64例

目的：总结经皮肝穿刺胆道内支架植入治疗恶性梗阻性黄疸的经验，探讨其临床疗效及价值。方法：64例患者均采用X线透视下经皮肝穿刺胆道内支架植入术治疗恶性梗阻性黄疽。根据梗阻部位的不同解剖决定放置支架的方式。结果：64例患者中，50例植入单支支架于肝总管或(和)胆总管，14例植入2支以上支架于总管和分支胆管，其中2例肝内胆管支架的桥接通过肝实质。58例患者2周内血清胆红素降低75％以上。结论：经皮肝穿刺刺内支架植入是治疗恶性胆道梗阻性的有效方法。     

Clinical outcome of self-expandable metal stent placement in the management of malignant proximal colon obstruction

Background/Aims

There are limited data regarding the clinical outcomes of self-expandable metal stents in the treatment of proximal colon obstruction. We compared the clinical outcomes of stent placement in patients with malignant proximal to distal colon obstructions.

Methods

We reviewed medical records from 37 consecutive patients from three institutions (19 men; mean age, 72 years) who underwent endoscopic stent placement at a malignant obstruction of the proximal colon. We also examined the records from 99 patients (50 men; mean age, 65 years) who underwent endoscopic stent placement for a distal colon obstruction. Technical success, clinical improvements, complications and stent patency were compared between treatments.

Results

The technical success rate tended to be lower in stents inserted to treat proximal colon obstructions than in those used to treat distal colon obstructions (86% vs 97%, p=0.06). Clinical improvement was achieved in 78% of patients (29/37) with proximal colonic stenting and in 91% of patients (90/99) with distal colonic stenting (p=0.08). Complications (24% vs 27%), stent migration (8% vs 8%) and stent reocclusion rates (11% vs 17%) did not differ significantly between groups. Two cases of bowel perforation related to stenting (5%) occurred in patients with proximal colonic stenting.

Conclusions

The technical success and clinical improvement associated with self-expandable metal stents used to treat proximal colon obstruction tend to be lower than cases of distal colon obstruction. Technical failure is an important cause of poor clinical improvement in patients with proximal colon stenting. Complication rates and stent patency appear to be similar in both groups.     

Endoscopic ultrasound-guided biliary drainage with placement of a fully covered metal stent for malignant biliary obstruction

AIM: To determine the utility of endoscopic ultrasound-guided biliary drainage (EUS-BD) with a fully covered self-expandable metal stent for managing malignant biliary stricture.METHODS: We collected data from 13 patients who presented with malignant biliary obstruction and underwent EUS-BD with a nitinol fully covered self-expandable metal stent when endoscopic retrograde cholangiopancreatography (ERCP) fails. EUS-guided choledochoduodenostomy (EUS-CD) and EUS-guided hepaticogastrostomy (EUS-HG) was performed in 9 patients and 4 patients, respectively.RESULTS: The technical and functional success rate was 92.3% (12/13) and 91.7% (11/12), respectively. Using an intrahepatic approach (EUS-HG, n = 4), there was mild peritonitis (n = 1) and migration of the metal stent to the stomach (n = 1). With an extrahepatic approach (EUS-CD, n = 10), there was pneumoperitoneum (n = 2), migration (n = 2), and mild peritonitis (n = 1). All patients were managed conservatively with antibiotics. During follow-up (range, 1-12 mo), there was re-intervention (4/13 cases, 30.7%) necessitated by stent migration (n = 2) and stent occlusion (n = 2).CONCLUSION: EUS-BD with a nitinol fully covered self-expandable metal stent may be a feasible and effective treatment option in patients with malignant biliary obstruction when ERCP fails.     

An audit of metal stent palliation for malignant biliary obstruction

BACKGROUND AND AIMS: Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Metal stents have several advantages over the polyethylene alternatives, but are significantly more expensive. It has been reported that patients need to survive beyond 6 months to make metal stents more cost-effective. The aim of this study was to audit the performance of expanding metal biliary stents in our endoscopy unit, and to identify factors that might help with patient selection. METHODS: The records of all patients who were selected for endoscopic metal stent insertion at the Royal Perth Hospital for malignant biliary obstruction between September 1994 and November 1998 were reviewed. RESULTS: Thirty-two patients (16 males, mean age 71 years (range 34-88 years) were identified and followed up for a mean 201 days (range 3-810 days). Fifteen (47%) had cholangiocarcinoma, 13 (41%) had pancreatic cancer, and four had metastatic disease as the cause of obstruction. Mortality rates after metal stent insertion were 16, 41 and 55% at 30, 90 and 180 days, respectively. In total, 24 (75%) patients died during the follow-up period. Eleven (34%) stents became obstructed during follow up with a median time to occlusion of 125 days (range 44-729 days). Patients with cholangiocarcinoma had significantly longer survival than pancreatic cancer cases (median 286 vs 58 days, P = 0.04). No other factors were found to correlate with the survival or stent complications. CONCLUSIONS: Less than half of this mixed cohort survived beyond 6 months. Metal stent palliation of malignant biliary obstruction should probably be targeted at those with cholangiocarcinoma, as these patients tend to survive longer.     

金属支架治疗肠道恶性梗阻的临床研究

目的探讨金属自膨式支架治疗肠道恶性梗阻的临床疗效及意义。方法对1999年至今我院消化科门诊和住院的31例肠道恶性梗阻患者进行金属自膨式支架置入术。结果31例均放置成功，患者恶心、呕吐、排便困难等梗阻症状得到缓解，生活质量得到提高。结论金属自膨式支架无论是在肠道恶性梗阻无法手术、手术后复发还是在肿瘤切除术后吻合口狭窄等情况下，均可解决梗阻，达到提高患者生存质量的目的。     

Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction

AIM:To evaluate the safety and efficacy of partially covered self-expandable metallic stents(SEMSs)in benign pyloric obstruction.METHODS:We retrospectively analyzed data from 10consecutive patients with peptic ulcer-related pyloric obstructive symptoms(gastric outlet obstruction scoring system(GOOSS)score of 1)between March 2012and September 2013.The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center.We assessed the technical success,symptom improvement,and adverse events after stenting.RESULTS:Early symptoms were improved just 3 d after SEMS placement in all 10 patients.The GOOSS score of all patients improved from 1 to 3.There were no serious immediate adverse events.The overall rate of being symptom free was 90%at a median of 11mo of follow-up(range:4-43 mo).Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation.Among them,four patients had sustained symptom improvement after the SEMS procedure.During the follow-up period,migration of the SEMS was observed in two patients(20.0%),both of whom had previous endoscopic balloon dilatation before SEMS insertion.CONCLUSION:Despite the small number in this study,partially covered SEMSs showed a favorable and safe outcome in the treatment of na?ve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.     

结直肠金属支架置入术对左半结肠癌所致肠梗阻的治疗价值

目的 探讨结直肠金属支架置入术对左半结肠癌所致肠梗阻的治疗价值.方法 对2007年5月至2011年5月因左半结肠癌肠梗阻接受结直肠金属支架置入术的29例患者的病例资料进行回顾性分析.结果 27例成功进行支架置入术,腹胀、呕吐症状缓解,2例由于病变肠段较长,高度水肿,完全阻塞肠腔,导丝无法通过而未成功,支架置入成功率92.6％ (27/29).置入支架的27例中24例成功进行了Ⅰ期左半结肠切除无张力吻合术,术中发现支架穿透肠壁1例(1/27,3.7％),手术后好转,围手术期无死亡病例发生,平均住院天数11.7 d;3例未接受手术治疗者支架通畅时间平均为5个月.结论 对于左半结肠癌所致肠梗阻,金属支架置入术可有效解除梗阻,并作为过渡治疗,利于手术前进行充分的肠道准备,为择期行外科肿瘤根治术创造条件.     

Predictors of clinical outcomes of self-expandable metal stent treatment for malignant colorectal obstruction: A Honam Association for the Study of Intestinal Disease (HASID) multicenter study

There has been increased use of self-expandable metal stents (SEMS) in treating malignant colorectal obstruction (MCO). The aim of this study was to investigate factors that are associated with the outcomes of SEMS placement for MCO.Clinical data from patients who underwent SEMS placement for MCO at 6 hospitals in Honam province of South Korea between 2009 and 2018 were reviewed retrospectively. Eight hundred two patients were identified and their data were analyzed. Technical success, clinical success, complications, and predictors of outcome were included as main outcome measures.Technical and clinical success rates were 98.8% (792/802) and 90.1% (723/802), respectively. Complications including stent migration, stent occlusion due to tumor ingrowth and outgrowth, perforation, bacteremia/fever, and bleeding occurred in 123 (15.3%) patients. In multivariate regression analyses, procedure time was significantly associated with the technical success of SEMS placement (P = .001). Longer length of obstruction, the use of covered stent, and longer procedure time were significant independent predictive factors for the clinical success of SEMS placement (odds ratio [OR] 0.974 (95% confidence interval [CI] 0.950–0.990); P = .043, OR 0.255 (95% CI 0.138–0.471); P < .001, and OR 0.957 (95% CI 0.931–0.984); P = .002, respectively). Stage IV colorectal cancer and the use of covered stent were significant independent predictive factors for the development of complications after SEMS placement (OR 2.428 (95% CI 1.407–4.188); P = .001 and OR 3.329 (95% CI 2.060–5.378); P < .001, respectively).Longer length of obstruction, the use of covered stent, and longer procedure time were associated with lower clinical success rates. Having stage IV colorectal cancer and the use of covered stents were associated with an increased risk of complications.