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.     

Self-expanding metal stents for the palliation of malignant gastric outlet obstruction in patients with peritoneal carcinomatosis

AIM To evaluate the efficacy of self-expanding metal stents(SEMS) for the palliation of malignant gastric outlet obstruction in patients with and without peritoneal carcinomatosis(PC).METHODS We performed a retrospective analysis of 62 patients who underwent SEMS placement for treatment of malignant gastroduodenal obstruction at our hospital over a six-year period. Stents were deployed through the scope under combined fluoroscopic and endoscopic guidance. Technical success was defined as successful stent placement and expansion. Clinical success was defined as an improvement in the obstructive symptoms and discharge from hospital without additional parenteral nutrition. According to carcinomatosis status, patients were assigned into groups with or without evidence of peritoneal disease.RESULTS In most cases, obstruction was caused by pancreatic(47%) or gastric cancer(23%). Technical success was achieved in 96.8%(60/62), clinical success in 79%(49/62) of all patients. Signs of carcinomatosis were identified in 27 patients(43.5%). The diagnosis was confirmed by pathology or previous operation in 7 patients(11.2%) and suspected by CT, MRI or ultrasound in 20 patients(32.2%). Presence of carcinomatosis was associated with a significantly lower clinical success rate compared to patients with no evidence of peritoneal disease(66.7% vs 88.6%, P = 0.036). There was no significant difference in overall survival between patients with or without PC(median 48 d vs 70 d, P = 0.21), but patients showed significantly longer survival after clinical success of SEMS placement compared to those experiencing clinical failure(median 14.5 d vs 75 d, P = 0.0003).CONCLUSION Given the limited therapeutic options and a clinical success rate of at least 66.7%, we believe that SEMS are a reasonable treatment option in patients with malignant gastric outlet obstruction with peritoneal carcinomatosis.     

Covered nitinol stents for the treatment of esophageal strictures and leaks

AIM:To compare 2 different types of covered esophageal nitinol stents(Ultraflex and Choostent) in terms of efficacy,complications,and long-term outcome.METHODS:A retrospective review of a consecutive series of 65 patients who underwent endoscopic placement of an Ultraflex stent(n = 33) or a Choostent(n = 32) from June 2001 to October 2009 was conducted.RESULTS:Stent placement was successful in all patients without hospital mortality.No significant differences in patient discomfort and complications were obs...     

Successful stent-in-stent dilatation of the common bile duct through a duodenal prosthesis,a novel technique for malignant obstruction:A case report and review of literature

For patients suffering from both biliary and duodenal obstruction,endoscopic retrograde cholangiopancreatography(ERCP) with stent placement is the treatment of choice.ERCP through an already existing duodenal prosthesis is an uncommon procedure and furthermore no studies have reported installing a covered metal stent onto an already existing bare metal stent in the common bile duct(CBD).We describe a rare case of a stent-in-stent dilatation of the CBD through an already existing self-expanding metal stent in the second part of duodenum for the patient presenting with jaundice in setting of biliary and duodenal obstruction from pancreatic adenocarcinoma.The biliary obstruction was relieved with a decrease in bilirubin levels post-stenting.     

Vascular pedicled jejunal Roux-en-Y reconstruction with supercharge technique for necrosis of the gastric tube following subtotal esophagectomy

Necrosis of the esophageal conduit is a life-threatening complication in esophageal cancer surgery, and secondary reconstruction options for esophageal discontinuity are quite limited. We present a procedure in which we used a long-segment jejunal flap with a supercharged vascular pedicle to treat gastric tube necrosis following subtotal esophagectomy in a 64-year-old man with esophageal cancer. The proximal jejunal flap was pulled up in Roux-en-Y fashion through the subcutaneous route together with the vascular pedicle of the fourth branch of the jejunal vessels, and the cut edges of the second jejunal vessel were anastomosed microscopically to the internal thoracic vessels for supercharging. No problems occurred with either vessel or digestive tract anastomosis. The patient was able to commence oral intake on postoperative day (POD) 10, was discharged on POD 37, and obtained a good quality of life at home. This result suggests that supercharged vascular pedicled jejunum is a suitable alternative conduit for secondary reconstruction following necrosis of the esophageal conduit in esophageal cancer surgery.     

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiography for Roux-en-Y reconstruction patients with papilla of Vater or bilioenteric anastomosis

Objective. Roux-en-Y reconstructions can be divided into intact papilla of Vater and bilioenteric anastomosis (BEA) with respect to endoscopic retrograde cholangiography (ERC). Double-balloon enteroscopy-assisted ERC (DBE-ERC) may produce different results between the two populations but lacks studies. Material and methods. Forty-seven patients with Roux-en-Y anastomosis undergoing 73 procedures of DBE-ERC were enrolled between July 2007 and August 2013. There were 14 patients with intact papilla of Vater (group A) and 33 patients with BEA (group B). The effectiveness of DBE-ERC, including data of reaching the blind end, performance of ERC, results of endoscopic therapies, and follow-up were retrospectively analyzed and compared between the two groups. Results. For reaching the blind end, the success rate was not different between the groups (85.7% vs. 81.8%, p = 0.7), but the mean procedure time was significantly shorter for group A (28 min vs. 52 min, p = 0.01). For ERC, the success rate was not different between the groups (91.7% vs. 96.3%, p = 0.53), but the mean procedure time was significantly longer for group A (28.4 min vs. 4 min, p < 0.001). All endoscopic therapies could be successfully performed in both groups. No group A patients and five (23.8%) group B patients developed recurrent biliary stricture/stones requiring interventions during a mean follow-up period of 26.1 months. Conclusions. DBE-ERC was effective for both populations with biliary disorders. Reaching the blind end was more difficult but ERC was easier for patients with BEA in terms of procedure time rather than success rates.     

Actionable self-monitoring of blood glucose: redefining the role for patients using multiple daily injection therapy

Self-monitoring of blood glucose (SMBG) values is an accepted requirement for patients with diabetes using multiple daily injections of insulin. Nevertheless, for many patients, the full value of SMBG has yet to be realized due to a number of factors that contribute to patients not taking appropriate action based on the achieved result. The reasons for this are complex but are related to the burden imposed by performing the tests, the need for complex numerical calculations, and the demand for undertaking this activity multiple times each day. In the near future, SMBG devices are likely to include technological innovations that are aimed at overcoming these barriers, offering "actionable" SMBG for patients using insulin. These innovations should include technologies that will allow customization and individualization based upon specific therapy regimens.     

Temsirolimus, an mTOR inhibitor, in combination with lower-dose clofarabine as salvage therapy for older patients with acute myeloid leukaemia: results of a phase II GIMEMA study (AML-1107)

The mammalian target of rapamycin (mTOR) signalling pathway has emerged as an important therapeutic target for acute myeloid leukaemia (AML). This study assessed the combination of temsirolimus, an mTOR inhibitor, and lower-dose clofarabine as salvage therapy in older patients with AML. Induction consisted of clofarabine 20mg/m(2) on days 1-5 and temsirolimus 25mg (flat dose) on days 1, 8 and 15. Patients achieving complete remission with (CR) or without (CRi) full haematological recovery could receive monthly temsirolimus maintenance. In 53 evaluable patients, the overall remission rate (ORR) was 21% (8% CR, 13% CRi). Median disease-free survival was 3·5months, and median overall survival was 4months (9·1months for responders). The most common non-haematological severe adverse events included infection (48%), febrile neutropenia (34%) and transaminitis (11%). The 30-d all-cause induction mortality was 13%. Laboratory data from 25 patients demonstrated that a >50%in vivo inhibition of S6 ribosomal protein phosphorylation was highly correlated with response rate (75% with inhibition versus 0% without inhibition; P=0·0001), suggesting that targeting the mTOR pathway is clinically relevant. The acceptable safety profile and the predictive value of target inhibition encourage further investigation of this novel regimen.     

EPC/HPSG evidence-based guidelines for the management of pediatric pancreatitis

Background

Pediatric pancreatitis is an underdiagnosed disease with variable etiology. In the past 10–15 years the incidence of pediatric pancreatitis has increased, it is now 3.6–13.3 cases per 100,000 children. Up-to-date evidence based management guidelines are lacking for the pediatric pancreatitis. The European Pancreatic Club, in collaboration with the Hungarian Pancreatic Study Group organized a consensus guideline meeting on the diagnosis and management of pancreatitis in the pediatric population.