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Ng AP, Hadaya JE, Sanaiha Y, Chervu NL, Girgis MD, Benharash P. A national perspective on palliative interventions for malignant gastric outlet obstruction. J Gastrointest Surg 2025; 29:101884. [PMID: 39547591 DOI: 10.1016/j.gassur.2024.101884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2024] [Revised: 10/22/2024] [Accepted: 11/08/2024] [Indexed: 11/17/2024]
Abstract
BACKGROUND Of note, 15% to 20% of patients with duodenal or periampullary malignancies develop gastric outlet obstruction (GOO). Although small randomized trials have reported more rapid recovery and shorter hospital stay with endoscopic stenting (ES), limited studies have evaluated outcomes at a national level. The current study characterized short-term clinical and financial outcomes associated with gastrojejunostomy (GJ) vs ES in malignant GOO. METHODS Adults with malignant GOO treated with ES or GJ were identified in the 2016-2020 Nationwide Readmissions Database. Entropy balancing was used to balance covariates between groups, and multivariate regression was used to evaluate the association between GJ or ES and in-hospital mortality, total parenteral nutrition (TPN) use, complications, length of stay (LOS), costs, and 90-day readmission. RESULTS Of 8186 patients with GOO, 5603 (68.4%) underwent ES, and 2583 (31.6%) underwent GJ. The cohorts were similar in age, female/male sex, and comorbidities. However, patients who underwent GJ were more commonly frail. After risk adjustment, mortality, composite complications, and 90-day readmission were comparable between patients who underwent GJ and those who underwent ES. GJ was associated with greater odds of blood transfusion (adjusted odds ratio [AOR], 1.74; 95% CI, 1.37-2.21) and postoperative TPN use (AOR, 3.76; 95% CI, 2.64-5.35). Furthermore, patients who underwent GJ experienced a significant increment of >$15,800 in costs and >6.9 days in LOS. In subgroup analysis of patients with metastatic disease, mortality, complications, and readmission remained comparable among palliation strategies. CONCLUSION ES seems to yield comparable short-term morbidity and mortality relative to GJ with significant cost reduction. Increasing access to endoscopic technology and regionalizing care to high-volume centers may help improve outcomes for patients with malignant GOO.
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Affiliation(s)
- Ayesha P Ng
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Joseph E Hadaya
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Yas Sanaiha
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Nikhil L Chervu
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Mark D Girgis
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States
| | - Peyman Benharash
- Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States.
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Yu Z, Liu H, Li R, Hu L, Xiao C, Gao Y, Li P, Liang W, Zhou S, Zhao X. Clinicopathological Factors and Nomogram Construction for Lymph Node Metastasis in Locally Advanced Gastric Cancer. Cancer Manag Res 2024; 16:1475-1489. [PMID: 39439918 PMCID: PMC11495200 DOI: 10.2147/cmar.s487247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2024] [Accepted: 10/15/2024] [Indexed: 10/25/2024] Open
Abstract
Background The research on lymph node metastasis (LNM) in locally advanced gastric cancer (LAGC) infiltrating the subserous tissue and serous membrane (T3-4a) is significantly inadequate. This study aims to explore the clinicopathological factors related to LNM in stages T3 and T4a LAGC, while also developing predictive nomograms. Methods After systematic searching and rigorous screening, 1995 T3 and 1244 T4a LAGC cases who underwent surgery without neoadjuvant or perioperative chemotherapy were selected. The risk factors associated with LNM were identified using both univariate and multivariate logistic regression analyses. Subsequently, the independent variables identified through the multivariate analyses were utilized to construct a nomogram. Results The incidence of LNM in T3 and T4a LAGC was 77.1% (1539/1995) and 83.8% (1043/1244), respectively. The following factors were found to be independently associated with LNM in T3 LAGC: preoperative serum albumin <41g/L (P=0.007), gastrointestinal obstruction (P<0.001), tumor location (P=0.040), tumor size >4cm (P=0.002), mixed (P=0.001) and undifferentiated histological types (P=0.002), presence of lymphovascular invasion (LVI) (P<0.001) and nerve invasion (P<0.001). Additionally, in T4a LAGC cases, serum albumin < 39g/L (P=0.004), tumor size >6cm (P=0.020), mixed (P<0.001) and undifferentiated histological types (P<0.001), presence of gastrointestinal hemorrhage (P=0.016), neuroendocrine differentiation (P=0.024), and LVI (P<0.001) independently influenced the occurrence of LNM. Conclusion This study identified the risk factors associated with LNM in T3-4a LAGC cases and constructed nomograms, thereby providing valuable guidance for formulating and implementing a multidisciplinary perioperative treatment program.
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Affiliation(s)
- Zhiyuan Yu
- Medical School of Chinese PLA, Beijing, People’s Republic of China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
- School of Medicine, Nankai University, Tianjin, People’s Republic of China
| | - Haopeng Liu
- Department of Hepatobiliary Surgery, Zhangqiu District People’s Hospital, Jinan, Shandong Province, People’s Republic of China
| | - Rui Li
- Medical School of Chinese PLA, Beijing, People’s Republic of China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
- School of Medicine, Nankai University, Tianjin, People’s Republic of China
| | - Liai Hu
- School of Medicine, Nankai University, Tianjin, People’s Republic of China
| | - Chun Xiao
- Department of General Surgery, PLA Rocket Force Characteristic Medical Center, Beijing, People’s Republic of China
| | - Yunhe Gao
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Peiyu Li
- Medical School of Chinese PLA, Beijing, People’s Republic of China
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
- School of Medicine, Nankai University, Tianjin, People’s Republic of China
| | - Wenquan Liang
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Sixin Zhou
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Xudong Zhao
- Department of General Surgery, The First Medical Center, Chinese PLA General Hospital, Beijing, People’s Republic of China
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Nishida T, Sugimoto A, Hosokawa K, Masuda H, Okabe S, Fujii Y, Nakamatsu D, Matsumoto K, Yamamoto M, Fukui K. Impact of time from diagnosis to chemotherapy on prognosis in advanced pancreatic cancer. Jpn J Clin Oncol 2024; 54:658-666. [PMID: 38422230 DOI: 10.1093/jjco/hyae027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/06/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Due to the aggressive nature and poor prognosis of advanced pancreatic cancer, prompt initiation of treatment is critical. We investigated the effect of the interval between cancer diagnosis and initiation of chemotherapy on survival in patients with advanced pancreatic cancer. METHODS In this retrospective, single-centre study, consecutive patients with advanced pancreatic cancer between April 2013 and March 2022 were analyzed. Data were extracted from the electronic medical records of patients who received chemotherapy for metastatic, locally advanced or resectable pancreatic cancer or who received chemotherapy due to either being intolerant of or declining surgery. We compared overall survival between two groups: the early waiting time group (waiting time ≤30 days from diagnosis to chemotherapy initiation) and the elective waiting time group (waiting time ≥31 days). Prognostic factors, including biliary drainage, were considered. The impact of waiting time on survival was assessed by univariate and multivariate analyses with Cox proportional hazard models. A 1:1 propensity score matching approach was used to balance bias, accounting for significant poor prognosis factors, age and sex. RESULTS The study involved 137 patients. Overall survival exhibited no statistically significant difference between the early and elective waiting time groups (207 and 261 days, P = 0.2518). Univariate and multivariate analyses identified poor performance status and metastasis presence as predictors of worse prognosis. This finding persisted post propensity score matching (275 and 222 days, P = 0.8223). CONCLUSIONS Our study revealed that initiating chemotherapy ˃30 days later does not significantly affect treatment efficacy compared to within 30 days of diagnosis.
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Affiliation(s)
- Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Aya Sugimoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Kana Hosokawa
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Haruka Masuda
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Satoru Okabe
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Yoshifumi Fujii
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
| | - Koji Fukui
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka 560-8565, Japan
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Yamashige D, Hijioka S, Nagashio Y, Maruki Y, Fukuda S, Yagi S, Okamoto K, Hara H, Hagiwara Y, Agarie D, Takasaki T, Chatto M, Ohba A, Kondo S, Morizane C, Ueno H, Sone M, Saito Y, Okusaka T. Incidence and factors associated with stent dysfunction and pancreatitis after gastroduodenal stenting for malignant gastric outlet obstruction. Endosc Int Open 2024; 12:E367-E376. [PMID: 38464977 PMCID: PMC10919994 DOI: 10.1055/a-2261-2833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/13/2023] [Indexed: 03/12/2024] Open
Abstract
Background and study aims Endoscopic gastroduodenal stent (GDS) deployment is currently a standard treatment for malignant gastric outlet obstruction (mGOO) in patients with limited life expectancy; however, stent dysfunction (SD) and complicated pancreatitis often occur after GDS deployment. We investigated incidence and contributing factors of SD and complicated pancreatitis. Patients and methods We retrospectively reviewed 203 patients who underwent initial GDS deployment for palliation of mGOO symptoms between October 2017 and July 2022, including 109 who underwent GDS deployment across the duodenal papilla (sub-cohort). Results SDs, including tumor ingrowth (n = 26), kinking (n = 14), and migration (n = 13), occurred in 68 patients (33.5%). Cumulative SD incidence was 41.1% (95% confidence interval, 32.6-49.4%). SD incidence increased to 0.4%, 0.16%, and 0.06% per day at < 8, 8-16, and>16 weeks, respectively. On multivariate analysis, Niti-S pyloric/duodenal stent deployment (sub-distribution hazard ratio [sHR] 0.26, P = 0.01) and survival length ≥ 90 days (sHR 2.5, P = 0.01) were respectively identified as favorable and risk factors significantly associated with SD. Pancreatitis developed in 14 patients (12.8%) in the sub-cohort, which had significantly higher parenchymal diameter ( P < 0.01) and lower main pancreatic duct (MPD) caliber ( P < 0.01) than the non-pancreatitis cohort. On multivariate analysis, MPD caliber < 3 mm independently predicted pancreatitis (odds ratio 6.8, P = 0.03). Conclusions Deployment of the Niti-S pyloric/duodenal stent, with conformability even for angulated strictures, significantly reduced the incidence of SD. Stent selection, life expectancy, and MPD caliber should be taken into consideration during decision-making for GDS deployment for mGOO.
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Affiliation(s)
- Daiki Yamashige
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Susumu Hijioka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Yoshikuni Nagashio
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Yuta Maruki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Soma Fukuda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Shin Yagi
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Kohei Okamoto
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Hidenobu Hara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Yuya Hagiwara
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Daiki Agarie
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Tetsuro Takasaki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Mark Chatto
- Department of Gastroenterology, Makati Medical Center, Makati City, Philippines
| | - Akihiro Ohba
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Shunsuke Kondo
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Hideki Ueno
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Japan, Chuo-ku, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takuji Okusaka
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan
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Kozarek RA. DDS Perspective: If Gastroenterology Were a Dog, Would Endoscopy Be Its Tail? Has Therapeutic GI Endoscopy Learned to Wag the Dog? Dig Dis Sci 2023; 68:4297-4300. [PMID: 37798571 DOI: 10.1007/s10620-023-08115-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Richard A Kozarek
- Emeritus Executive Director, Digestive Disease Institute, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98101, USA.
- Clinical Investigator, Center for Interventional Immunology, Benaroya Research Institute, 1201 Ninth Ave, Seattle, WA, 98101, USA.
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Lai H, Wu K, Liu Y, Li D, Peng T, Zhang B. Efficacy and safety of self-expandable metal stent placement for treatment of primary and metastatic gastric outlet obstruction. Ir J Med Sci 2023; 192:2077-2084. [PMID: 36441448 DOI: 10.1007/s11845-022-03195-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND GOALS: Gastric outlet obstruction (GOO) usually occurs at the pylorus or the duodenum through primary gastric, duodenal, or pancreatic tumors. However, metastatic GOO is relatively rare. Although self-expandable metal stent (SEMS) placement is often performed as an alternative and practical palliative approach for primary GOO, there are few reports of metastatic GOO treatment with SEMS. This study aimed to investigate the efficacy, safety, stent patency, and complications of SEMS for treating primary and metastatic GOO. METHODS The data of 42 patients with GOO who received SEMS from November 2016 to April 2022 were reviewed retrospectively. Patients were divided into primary group (n = 25) and metastatic group (n = 17) according to the cause of GOO. The rates of technical and clinical success, stent patency, and complications were compared between the two groups. RESULTS The overall technical and clinical success rates were 97.9% and 93.5%, respectively. The total SEMS implantation time was 48.2 ± 33.5 (10.0-140.0) minutes. The primary technical success rate was 100.0% in both primary and metastatic groups, and the primary clinical success rate was 96.0% (24/25) in the primary group vs 88.2% (15/17) in the metastatic group (P = 0.350). After reintervention, the secondary technical success rate was 100.0% (27/27) in the primary group vs 95.0% (19/20) in the metastatic group (P = 0.330); and the secondary clinical success rate was 96.3% (26/27) in the primary group vs 89.5% (17/19) in the metastatic group (P = 0.367). No serious complications, such as gastrointestinal perforation, stent migration, bleeding, or aspiration pneumonia, were observed in these patients. CONCLUSIONS SEMS under fluoroscopic guidance is an effective and safe treatment for primary and metastatic GOO. The etiology of obstruction did not influence stent patency or complications. Therefore, stent implantation is recommended for patients with metastatic GOO caused by multiple peritoneal metastases to improve their quality of life.
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Affiliation(s)
- Haiyang Lai
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Ketong Wu
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Yang Liu
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Dan Li
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Tao Peng
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Bo Zhang
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China.
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Zhang H, Liu X, Zheng Z, Xue Y, Yin J, Zhang J. Exploring the safety and efficacy of stomach-partitioning gastrojejunostomy with distal selective vagotomy versus conventional gastrojejunostomy with highly selective vagotomy for treating benign gastric outlet obstruction: study protocol for a randomised controlled trial. BMJ Open 2023; 13:e070735. [PMID: 37770279 PMCID: PMC10546111 DOI: 10.1136/bmjopen-2022-070735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 08/15/2023] [Indexed: 09/30/2023] Open
Abstract
INTRODUCTION Benign gastric outlet obstruction (BGOO) severely impacts the quality of life of patients. The main treatment methods for BGOO include surgery and endoscopy, but both have significant drawbacks. Therefore, this study aims to explore the safety and efficacy of a new technique, to develop a new option for treating BGOO. METHODS AND ANALYSIS This is an ongoing prospective, single-centre, single-blind randomised controlled trial. The study will be conducted from January 2022 to December 2025, and 50 patients will be enrolled. The participants will be randomly assigned in a 1:1 ratio to either the experimental (stomach-partitioning gastrojejunostomy with distal selective vagotomy) or control groups (conventional gastrojejunostomy with highly selective vagotomy). We will collect baseline characteristics, laboratory tests, auxiliary examinations, operation, postoperative conditions and follow-up data. Follow-up will last for 3 years. The main outcome is the incidence of delayed gastric emptying within 30 days after surgery. Secondary outcomes include the efficacy indicator (consisting of serum gastrin level, pepsinogen level, 13C breath test, gastrointestinal quality of life index, operation time, blood loss and postoperative recovery), a safety evaluation index (consisting of complications and mortality within 30 days after surgery) and follow-up data (consisting of the incidence of primary ulcer progression in 3 years after surgery, and the gastroscopy results in 1 and 3 years after surgery). ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of Beijing Friendship Hospital, Capital Medical University (no. 2021-P2-274-02). The study conformed to the provisions of the Declaration of Helsinki (as revised in 2013). Written informed consent will be obtained prior to study enrolment. The results of this study will be published in peer-reviewed publications. TRIAL REGISTRATION NUMBER ChiCTR2100052197.
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Affiliation(s)
- Haiqiao Zhang
- Department of General Surgery, Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaoye Liu
- Department of General Surgery, Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhi Zheng
- Department of General Surgery, Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yasheng Xue
- Department of General Surgery, Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jie Yin
- Department of General Surgery, Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jun Zhang
- Department of General Surgery, Affiliated Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Takahara N, Nakai Y, Ishida K, Endo G, Kurihara K, Tange S, Takaoka S, Tokito Y, Suzuki Y, Oyama H, Kanai S, Suzuki T, Sato T, Hakuta R, Ishigaki K, Saito T, Hamada T, Fujishiro M. Second Covered and Uncovered Self-Expandable Metal Stents for Recurrent Gastric Outlet Obstruction: A Retrospective Comparative Study. J Clin Med 2023; 12:5241. [PMID: 37629282 PMCID: PMC10455318 DOI: 10.3390/jcm12165241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Background: Endoscopic self-expandable metal stent (SEMS) placement is a current mainstay for malignant gastric outlet obstruction (GOO), but symptomatic recurrence due to initial SEMS dysfunction commonly occurs. We aimed to compare the safety and effectiveness of second SEMS for recurrent GOO (RGOO). Methods: Between April 2006 and December 2022, a total of 95 cases with malignant RGOO undergoing second endoscopic SEMS placement were enrolled. Technical and clinical success rates, RGOO, time to RGOO (TRGOO), stent patency rate, adverse events (AE), and overall survival (OS) were retrospectively compared between covered and uncovered SEMS (cSEMS/uSEMS) groups. Risk factors for TRGOO were also explored. Results: Baseline characteristics were well balanced between cSEMS (n = 48) and uSEMS (n = 47) groups, except for the causes of the initial SEMS dysfunction. High technical and clinical success rates with a similar incidence of AE (15% vs. 17%, p = 0.78) and OS (median of 101 vs. 102 days, p = 0.68) were achieved in both groups. There were no statistical differences in cumulative incidence of RGOO (19% vs. 13%, p = 0.58), TRGOO (median, not reached in both groups, p = 0.57), and stent patency rates at 1, 2, and 3 months between the groups (60%, 47% and 26%, respectively vs. 70%, 55% and 38%, respectively). However, TRGOO tended to be longer in cSEMS in cases with RGOO due to tumor ingrowth (median, not reached vs. 111 days, p = 0.19). A Cox regression analysis demonstrated that chemotherapy after second SEMS placement was significantly associated with an improved TRGOO (the hazard ratio of 0.27 [95% confidence interval, 0.08-0.93], p = 0.03). Conclusions: Regardless of the type of SEMS, second SEMS placement was similarly safe and effective for RGOO. The type of second SEMS might be considered based on the cause of initial SEMS dysfunction.
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Affiliation(s)
- Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Kota Ishida
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Go Endo
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Kohei Kurihara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Shuichi Tange
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Shinya Takaoka
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Yurie Tokito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Yukari Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Hiroki Oyama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Sachiko Kanai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
| | - Tatsunori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Tatsuya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Chemotherapy, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo 135-8550, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan; (N.T.); (K.I.); (G.E.); (K.K.); (S.T.); (S.T.); (Y.T.); (Y.S.); (H.O.); (S.K.); (T.S.); (T.S.); (R.H.); (K.I.); (T.S.); (T.H.); (M.F.)
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9
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Okamoto T, Sasaki T, Yoshio T, Mori C, Mie T, Furukawa T, Yamada Y, Takeda T, Kasuga A, Matsuyama M, Ozaka M, Fujisaki J, Sasahira N. Outcomes after partially covered self-expandable metal stent placement for recurrent duodenal obstruction. Surg Endosc 2023; 37:319-328. [PMID: 35941307 DOI: 10.1007/s00464-022-09519-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/25/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Outcomes of partially covered self-expandable metal stents (SEMS) as an additional stent after recurrent duodenal obstruction (RDO) have not been elucidated. In this study, we compared outcomes of partially covered and uncovered SEMS placement after RDO in patients with malignant duodenal obstruction and explored factors affecting re-recurrent obstruction and overall survival in this population. METHODS We conducted a retrospective study of patients undergoing SEMS placement for RDO at a cancer institute in Japan from July 2014 to June 2021. Clinical variables and outcomes of patients undergoing partially covered and uncovered SEMS placement were compared. RESULTS Sixty-one patients underwent SEMS placement after RDO, for which the COMVI stent was used in 38 cases and uncovered stents were used in 23 cases. Stent ingrowth was the most common cause of RDO (51.4%). Stent migration only occurred after partially covered stent placement (20% vs. 0%, p = 0.018). Choice of SEMS had no impact on time to re-RDO (median 2.8 vs. 4.1 months, p = 0.776) or overall survival (median 2.6 vs. 2.4 months, p = 0.703). Median overall survival was longer in patients receiving chemotherapy after second stenting (4.6 vs. 1.8 months, p < 0.001) and shorter in those with early RDO, regardless of the SEMS used. Use of the partially covered stent had no impact on survival or time to RDO. CONCLUSIONS While outcomes after partially covered SEMS placement for RDO were not significantly different from uncovered SEMS, migration remains a concern when they are used as a second stent. Chemotherapy after second stenting was associated with longer overall survival but not with longer time to re-RDO.
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Affiliation(s)
- Takeshi Okamoto
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.
| | - Toshiyuki Yoshio
- Upper Gastrointestinal Division, Department of Gastroenterological Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Chinatsu Mori
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takafumi Mie
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takaaki Furukawa
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Yuto Yamada
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Tsuyoshi Takeda
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akiyoshi Kasuga
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masato Matsuyama
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masato Ozaka
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Junko Fujisaki
- Upper Gastrointestinal Division, Department of Gastroenterological Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Naoki Sasahira
- Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
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10
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Inokuma A, Takahara N, Ishibashi R, Hakuta R, Ishigaki K, Saito K, Saito T, Hamada T, Mizuno S, Yagioka H, Takahashi S, Kogure H, Sasaki T, Hirano K, Ito Y, Isayama H, Nakai Y, Koike K, Fujishiro M. Comparison of novel large-bore and conventional-bore covered self-expandable metal stents for malignant gastric outlet obstruction: Multicenter, retrospective study. Dig Endosc 2023; 35:111-121. [PMID: 35916499 DOI: 10.1111/den.14418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 07/31/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Covered self-expandable metal stent (cSEMS) for gastric outlet obstruction (GOO) has been developed to overcome tumor ingrowth but is prone to be associated with an increased risk of migration. Clinical impact of the novel large-bore cSEMS for malignant GOO remains unclear. METHODS A total of 117 patients undergoing endoscopic cSEMS placement for malignant GOO were enrolled in this multicenter retrospective study. Technical and clinical success, adverse events, recurrent GOO, and survival after stent placement were compared between 24 mm-cSEMS (n = 49) and 20 mm-cSEMS (n = 68). RESULTS Patient characteristics were well-balanced and thus similar survival was observed between the two groups (136 days vs. 89 days, P = 0.60). Technical success rate of 100% and clinical success rate of 96% were achieved both in 24 mm-cSEMS and 20 mm-cSEMS, respectively. The median cumulative time to recurrent GOO was significantly longer in 24 mm-cSEMS than in 20 mm-cSEMS (380 days vs. 138 days, P = 0.01). The incidence of adverse events and recurrent GOO was comparable: 12% vs. 15% (P = 0.91), and 16% vs. 31% (P = 0.11); however, no stent migration was observed in 24 mm-cSEMS. In a subgroup analysis, the superiority of 24 mm-cSEMS to 20 mm-cSEMS was demonstrated in extrinsic cancers (380 days vs. 121 days, P = 0.01) but not in intrinsic cancers (151 days vs. not reached, P = 0.47). CONCLUSIONS The 24 mm-cSEMS may improve time to recurrent GOO with ensuring acceptable safety in patients with malignant GOO.
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Affiliation(s)
- Akiyuki Inokuma
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Rei Ishibashi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yagioka
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Sho Takahashi
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Sasaki
- Department of Hepato-Biliary Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Kenji Hirano
- Department of Gastroenterology, Tokyo Takanawa Hospital of Japan Community Health-care Organization, Tokyo, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Juntendo University, Tokyo, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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11
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Petzel MQB, Ebrus CS, Cheng JT, Parker N, Ngo-Huang A. Physical Activity and Nutrition Optimization in Pancreatic Cancer. PANCREATIC CANCER 2023:169-189. [DOI: 10.1007/978-3-031-38623-7_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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12
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Hodo Y, Takatori H, Komura T, Asahina Y, Chiba T, Takabatake H, Hasatani K, Nishino R, Yano M, Takata Y, Suda T, Shugo H, Nakanishi H, Yamada K, Miwa K, Kaji K, Nishitani M, Miyazawa M, Yamashita T. Prognostic impact of clinical outcome after endoscopic gastroduodenal stent placement for malignant gastric outlet obstruction: a multicenter retrospective cohort study using a time-dependent analysis. Therap Adv Gastroenterol 2023; 16:17562848231156279. [PMID: 36895284 PMCID: PMC9989375 DOI: 10.1177/17562848231156279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023] Open
Abstract
Background Endoscopic gastroduodenal stent (GDS) placement is widely used as a safe and effective method to rapidly improve gastrointestinal symptoms of malignant gastric outlet obstruction (MGOO). While previous studies reported the utility of chemotherapy after GDS placement for prognosis improvement, they did not fully address the issue of immortal time bias. Objectives To examine the association between prognosis and clinical course following endoscopic GDS placement, using a time-dependent analysis. Design Multicenter retrospective cohort study. Methods This study included 216 MGOO patients who underwent GDS placement between April 2010 and August 2020. Data of patient baseline characteristics, including age, gender, cancer type, performance status (PS), GDS type and length, GDS placement location, gastric outlet obstruction scoring system (GOOSS) score, and history of chemotherapy before GDS were collected. The clinical course following GDS placement was evaluated by GOOSS score, stent dysfunction, cholangitis, and chemotherapy. A Cox proportional hazards model was used to identify prognostic factors after GDS placement. Stent dysfunction, post-stent cholangitis, and post-stent chemotherapy were analyzed as time-dependent covariates. Results Mean GOOSS scores before and after GDS were 0.7 and 2.4, respectively, with significant improvement after GDS placement (p < 0.001). The median survival time after GDS placement was 79 [95% confidence interval (CI): 68-103] days. In multivariate Cox proportional hazards model with time-dependent covariates, PS 0-1 [hazard ratio (HR): 0.55, 95% CI: 0.40-0.75; p < 0.001], ascites (HR: 1.45, 95% CI: 1.04-2.01; p = 0.028), metastasis (HR: 1.84, 95% CI: 1.31-2.58; p < 0.001), post-stent cholangitis (HR: 2.38, 95% CI: 1.37-4.15; p = 0.002), and post-stent chemotherapy (HR: 0.01, 95% CI: 0.002-0.10; p < 0.001) significantly affected prognosis after GDS placement. Conclusion Post-stent cholangitis and tolerability to receive chemotherapy after GDS placement influenced prognosis in MGOO patients.
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Affiliation(s)
- Yuji Hodo
- Department of Gastroenterology, Saiseikai Kanazawa Hospital, Kanazawa, Ishikawa, Japan
| | - Hajime Takatori
- Department of Endoscopy, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa 921-8641, Japan
| | - Takuya Komura
- Department of Gastroenterology, National Hospital Organization Kanazawa Medical Center, Kanazawa, Ishikawa, Japan
| | - Yoshiro Asahina
- Department of Gastroenterology, National Hospital Organization Kanazawa Medical Center, Kanazawa, Ishikawa, Japan
| | - Tomoyoshi Chiba
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Ishikawa, Japan
| | - Hisashi Takabatake
- Department of Gastroenterology, Kanazawa Red Cross Hospital, Kanazawa, Ishikawa, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Fukui, Japan
| | - Ryuhei Nishino
- Department of Gastroenterology, Hakui General Hospital, Hakui, Ishikawa, Japan
| | - Masaaki Yano
- Department of Gastroenterology, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Yoshiko Takata
- Department of Gastroenterology, Tonami General Hospital, Tonami, Toyama, Japan
| | - Tsuyoshi Suda
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan
| | - Haruhiko Shugo
- Department of Gastroenterology, Keiju Medical Center, Nanao, Ishikawa, Japan
| | - Hiroyoshi Nakanishi
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Kazutoshi Yamada
- Department of Gastroenterology, Toyama City Hospital, Toyama, Toyama, Japan
| | - Kazuhiro Miwa
- Department of Gastroenterology, Komatsu Municipal Hospital, Komatsu, Ishikawa, Japan
| | - Kiichiro Kaji
- Department of Gastroenterology, Komatsu Sophia Hospital, Komatsu, Ishikawa, Japan
| | - Masaki Nishitani
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masaki Miyazawa
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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13
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Maetani I. How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction? Front Med (Lausanne) 2022; 9:967740. [PMID: 36017000 PMCID: PMC9395687 DOI: 10.3389/fmed.2022.967740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.
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Huang TL, Zhong WQ, Shen YH, Ni MH, Xu GF, Lyu Y, Li W, Zhou XL, Cai W, Wang L, Zou XP. Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in different sites: A single-center retrospective study. J Dig Dis 2022; 23:358-364. [PMID: 35880323 DOI: 10.1111/1751-2980.13118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/31/2022] [Accepted: 07/22/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently been employed as a novel treatment for gastric outlet obstruction (GOO). The aim of this study was to evaluate the safety and efficacy of EUS-GE for GOO at different sites. METHODS Consecutive hospitalized patients who underwent EUS-GE for GOO at the Department of Gastroenterology, Nanjing Drum Tower Hospital from March 2017 to April 2020 were recruited in this retrospective study. Patients were divided into three groups depending on the obstruction site. The primary outcomes included technical success and clinical success. The secondary outcomes were operation time, post-procedure length of stay (LOS), hospitalization cost, and complications such as peritonitis, bleeding, pneumoperitoneum, abdominal pain, and infection. RESULTS A total of 51 patients were included. Technical success achieved in 100% patients with proximal GOO and in 88.9% with distal GOO (P = 0.176). Clinical success declined from the oral side to the anal side (P = 0.510). Operation time, hospitalization costs, and post-procedural LOS were similar among groups (P = 0.532, 0.520, and 0.144, respectively). Complications were observed in 28 (54.9%) patients. In approaching the mature phase of the endosopist, clinical success improved, while the secondary outcomes showed no statistically significant difference compared with the initial phase. CONCLUSIONS EUS-GE may be challenging for distal GOO; however, it is safe and effective when carried out by experienced endoscopists. A complete preoperative evaluation to assess the difficulty of the procedure is necessary. Prospective studies with large sample size are needed to further validate our findings.
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Affiliation(s)
- Tian Lu Huang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Wen Qi Zhong
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yong Hua Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Mu Han Ni
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Gui Fang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Ying Lyu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Wen Li
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Xiao Liang Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Wei Cai
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Xiao Ping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
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15
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Takamatsu Y, Fujimori N, Miyagahara T, Suehiro Y, Kaku T, Kawabe K, Ohno A, Matsumoto K, Murakami M, Teramatsu K, Takeno A, Oono T, Ogawa Y. The Glasgow Prognostic Score and stricture site can predict prognosis after endoscopic duodenal stent placement for malignant gastric outlet obstruction. Sci Rep 2022; 12:9746. [PMID: 35697819 PMCID: PMC9192609 DOI: 10.1038/s41598-022-13209-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 05/23/2022] [Indexed: 11/24/2022] Open
Abstract
Endoscopic duodenal stent (DS) placement for malignant gastric outlet obstruction (GOO) is rapidly increasing in clinical practice; however, the most suitable patient candidates for DS placement have not been determined. One hundred and thirty-five patients with GOO who underwent DS placement in three Japanese referral centers between January 2010 and October 2019 were retrospectively evaluated. Overall survival (OS) after DS placement, technical/clinical success rates, adverse events, and predictive factors affecting OS after DS placement were also analyzed. The median OS after DS placement of all patients was 81 (7–901) days. Technical and clinical success rates were 99.3% and 83.7%, respectively. The GOO Scoring System score significantly increased before and after DS placement (0.9 vs. 2.7, P < 0.001). The procedure-related complication rate was 6.0%. All 19 patients (14.1%) with stent occlusion underwent endoscopic re-intervention successfully. Multivariate analyses revealed chemotherapy after DS placement (P = 0.01), stricture site in D3 (distal part of the papilla) (P = 0.01), and a Glasgow Prognostic Score (GPS) of 0–1 before duodenal stent placement (P < 0.001) were factors significantly associated with prolonged OS. In conclusion, patients with a GPS of 0–1 and D3 stricture who are tolerant of chemotherapy are suitable candidates for DS placement.
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Affiliation(s)
- Yu Takamatsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Nao Fujimori
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Tsukasa Miyagahara
- Department of Gastroenterology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Yuta Suehiro
- Department of Gastroenterology, Nakatsu Municipal Hospital, Nakatsu, Japan
| | - Toyoma Kaku
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ken Kawabe
- Department of Gastroenterology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Akihisa Ohno
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kazuhide Matsumoto
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masatoshi Murakami
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Katsuhito Teramatsu
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ayumu Takeno
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takamasa Oono
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Krishnamoorthi R, Bomman S, Benias P, Kozarek RA, Peetermans JA, McMullen E, Gjata O, Irani SS. Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis. Endosc Int Open 2022; 10:E874-E897. [PMID: 35692924 PMCID: PMC9187371 DOI: 10.1055/a-1794-0635] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background and study aims Malignant disease accounts for up to 80 % of gastric outlet obstruction (GOO) cases, which may be treated with duodenal self-expanding metal stents (SEMS), surgical gastrojejunostomy (GJ), and more recently endoscopic-ultrasound-guided gastroenterostomy (EUS-GE). These three treatments have not been compared head-to-head in a randomized trial. Methods We searched the Embase and MEDLINE databases for studies published January 2015-February 2021 assessing treatment of malignant GOO using duodenal SEMS, endoscopic (EUS-GE) or surgical (laparoscopic or open) GJ. Efficacy outcomes assessed included technical and clinical success rates, GOO recurrence and reintervention. Safety outcomes included procedure-related bleeding or perforation, and stent-related events for the duodenal SEMS and EUS-GE arms. Results EUS-GE had a lower rate of technical success (95.3%) than duodenal SEMS (99.4 %) or surgical GJ (99.9%) ( P = 0.0048). For duodenal SEMS vs. EUS-GE vs. surgical GJ, rates of clinical success (88.9 % vs. 89.0 % vs. 92.3 % respectively, P = 0.49) were similar. EUS-GE had a lower rate of GOO recurrence based on limited data ( P = 0.0036), while duodenal SEMS had a higher rate of reintervention ( P = 0.041). Overall procedural complications were similar (duodenal SEMS 18.7 % vs. EUS-GE 21.9 % vs. surgical GJ 23.8 %, P = 0.32), but estimated bleeding rate was lowest ( P = 0.0048) and stent occlusion rate was highest ( P = 0.0002) for duodenal SEMS. Conclusions Duodenal SEMS, EUS-GE, and surgical GJ showed similar clinical efficacy for the treatment of malignant GOO. Duodenal SEMS had a lower procedure-related bleeding rate but higher rate of reintervention.
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Affiliation(s)
- Rajesh Krishnamoorthi
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shivanand Bomman
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Petros Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, United States
| | - Richard A. Kozarek
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Joyce A. Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Shayan S. Irani
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
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17
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Outcomes of patients with malignant duodenal obstruction after receiving self-expandable metallic stents: A single center experience. PLoS One 2022; 17:e0268920. [PMID: 35613143 PMCID: PMC9132295 DOI: 10.1371/journal.pone.0268920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/10/2022] [Indexed: 12/27/2022] Open
Abstract
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.
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18
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Petzel MQB, Ebrus CS. Nutrition in Pancreatic Cancer. PANCREATIC CANCER: A MULTIDISCIPLINARY APPROACH 2022:317-341. [DOI: 10.1007/978-3-031-05724-3_26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Rodríguez JI, Kutscher M, Lemus M, Crovari F, Pimentel F, Briceño E. Palliative gastrojejunostomy in unresectable cancer and gastric outlet obstruction: a retrospective cohort study. Ann R Coll Surg Engl 2021; 103:197-202. [PMID: 33645283 DOI: 10.1308/rcsann.2020.7016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Palliative gastrojejunostomy is a surgical technique that allows restoration of oral intake among patients with gastric outlet obstruction (GOO) caused by unresectable neoplasms. Research suggests standard treatment for malignant GOO should be laparoscopic gastrojejunostomy (LGJ). This study presents the clinical outcomes of palliative gastrojejunostomy and compares results from LGJ and open gastrojejunostomy (OGJ) at our centre. METHODS We performed a retrospective analysis on patients who underwent palliative gastrojejunostomy for GOO caused by unresectable neoplasms between 2008 and 2018. We included demographic variables, time to recover intestinal transit, time to recover oral intake, hospital stay, complications and global survival. RESULTS A total of 39 patients underwent palliative gastrojejunostomy (20 OGJ, 19 LGJ). Patients in the LGJ group recovered oral intake and intestinal transit faster than those in the OGJ group (3 vs 5 days, p<0.05). There were no statistically significant differences in median operating time, hospital stay or postoperative complications between the two groups. No intraoperative complications occurred. The estimated global survival was 178 days, with no significant difference between the groups. CONCLUSIONS Palliative LGJ allows earlier restoration of oral intake and does not increase morbidity or mortality. Palliative LGJ should be considered the standard treatment for these patients.
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Affiliation(s)
- J I Rodríguez
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Medical Education, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - M Kutscher
- Medical School, Faculty of Medicine, Pontifical Catholic University of Chile,, Santiago, Chile
| | - M Lemus
- Medical School, Faculty of Medicine, Pontifical Catholic University of Chile,, Santiago, Chile
| | - F Crovari
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - F Pimentel
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - E Briceño
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
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20
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Orr J, Lockwood R, Gamboa A, Slaughter JC, Obstein KL, Yachimski P. Enteral Stents for Malignant Gastric Outlet Obstruction: Low Reintervention Rates for Obstruction due to Pancreatic Adenocarcinoma Versus Other Etiologies. J Gastrointest Surg 2021; 25:720-727. [PMID: 32077045 DOI: 10.1007/s11605-019-04512-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Enteral stents (ES) have emerged as first-line therapy for the treatment of malignant gastric outlet obstruction (GOO). Stent occlusion arising from tissue ingrowth may require endoscopic or surgical reintervention. The objective of this study was to compare rates of reintervention following palliative ES for patients with GOO due to pancreatic adenocarcinoma (PDAC) versus other malignant etiologies. METHODS Patients who had undergone ES for palliation of malignant GOO between 2009 and 2018 were retrospectively identified and demographic, clinical, and procedural data were collected. Primary outcome was procedural reintervention for recurrent symptomatic GOO following ES placement. RESULTS Forty-three patients were included in the study cohort. 62.8% (27/43) of patients had PDAC while 37.2% (16/43) of patients had other malignant etiologies. 11.6% (5/43) of patients were alive at follow-up. Thirty-day and 90-day mortality rates were 22.8% and 70.7% for PDAC and 25% and 56.3% for other malignant etiologies, respectively. Seven patients required reintervention for symptomatic GOO: 14.3% (1/7) had PDAC and 85.7% (6/7) had GOO due to other malignancy (P < .01). Ninety-six percent (26/27) of patients with PDAC required no further intervention for GOO prior to death or end of follow-up. On multivariate analysis, patients with PDAC were significantly less likely to require reintervention than patients with other malignant etiologies (OR 0.064, 95% CI 0.01-0.60). CONCLUSION ES offer durable symptom palliation without requirement for reintervention for the overwhelming majority of patients with malignant GOO due to PDAC. Reintervention rates are higher following ES placement for GOO due to other malignant etiologies and future study may be needed to define the optimal palliative intervention for this group of patients.
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Affiliation(s)
- Jordan Orr
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA.
| | - Robert Lockwood
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
| | - Anthony Gamboa
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, 37232-5280, USA
| | - Keith L Obstein
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
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21
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Chen XJ, Chen GM, Wei YC, Yu H, Wang XC, Zhao ZK, Luo TQ, Nie RC, Zhou ZW. Palliative Gastrectomy versus Gastrojejunostomy for advanced Gastric cancer with outlet obstruction: a propensity score matching analysis. BMC Cancer 2021; 21:188. [PMID: 33622258 PMCID: PMC7903659 DOI: 10.1186/s12885-021-07904-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 02/08/2021] [Indexed: 12/27/2022] Open
Abstract
Background Gastric outlet obstruction (GOO) is a late complication of advanced gastric cancer, and it is controversial how to select the therapeutic strategies: gastrojejunostomy and palliative gastrectomy? Therefore, this study was to compare the surgical and survival outcomes of gastrojejunostomy and palliative gastrectomy. Methods In total, 199 gastric cancer patients with outlet obstruction treated by surgery between January 2000 and December 2015 at Sun Yat-sen University Cancer Center were retrospectively reviewed. Patients were divided into gastrojejunostomy group and palliative gastrectomy group. Propensity score matching (PSM) was performed to balance the selection bias. Results After 1:1 PSM, a total of 104 patients were included for final analysis. The median overall survival (OS) times in the gastrojejunostomy group and palliative gastrectomy group were 8.50 and 11.87 months, respectively (P = 0.243). The postoperative complication rates in the gastrojejunostomy group and palliative gastrectomy group were 19.23% (10/52) and 17.31% (9/52), respectively (P = 0.800), and no treatment-related death was observed. Multivariate analysis showed that periton0eal seeding (P = 0.014) and chemotherapy (P < 0.001) were independent prognostic factors. Among them, peritoneal seeding was a risk factor and postoperative chemotherapy was a protective factor. Conclusions Our results indicated that although the surgical complications of palliative gastrectomy were manageable, it showed no survival benefit. Therefore, relieving obstruction symptom, improving patients’ quality of life and creating better conditions for chemotherapy appear to be the main therapeutic strategies for advanced gastric cancer with GOO.
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Affiliation(s)
- Xiao-Jiang Chen
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Guo-Ming Chen
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Yi-Cheng Wei
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Hong Yu
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Xi-Cheng Wang
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Zhou-Kai Zhao
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Tian-Qi Luo
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China
| | - Run-Cong Nie
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China.
| | - Zhi-Wei Zhou
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, No.651 Dongfeng Road East, Guangzhou, 510060, Guangdong, China.
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22
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Takahara N, Nakai Y. Endoscopic Management of Gastrointestinal Obstruction from Pancreatic Cancer and Cholangiocarcinoma. MANAGEMENT OF PANCREATIC CANCER AND CHOLANGIOCARCINOMA 2021:299-312. [DOI: 10.1007/978-981-16-2870-2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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23
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Xu G, Shen Y, Lv Y, Zhou X, Li W, Wang Y, Hassan S, Wang L, Zou X. Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy using double balloon occlusion methods: a clinical retrospective study in 36 patients with malignant gastric outlet obstruction. Endosc Int Open 2020; 8:E1690-E1697. [PMID: 33140026 PMCID: PMC7581485 DOI: 10.1055/a-1221-9656] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Gastric outlet obstruction (GOO) is common in the late stage of many malignant tumors of the digestive system. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is commonly used for palliative treatment of malignant GOO. The objective of this study was to investigate the safety, efficacy, and prognosis of EUS-GE in treatment of malignant GOO in Chinese patients. Patients and methods This was a retrospective, single-center study with 36 consecutive patients with malignant GOO who were treated with EUS-GE. The main outcome measures were technical success rate, clinical success rate, incidence of adverse events (AEs), and median survival time. Results A total of 36 patients with malignant GOO underwent double-balloon-assisted EUS-GE between March 2017 and June 2019 in our hospital. GOO occurred mainly in elderly men (mean age 69.0 years, M:F 0.89). The most common etiology of GOO was pancreatic cancer (41.7 %). The most common obstruction site was the second part of the duodenum (63.9 %). The technical success rate was 100 % (36/36). The clinical success rate was 94.4 % (34/36). Median time for the total procedure was 52 minutes (range 34 - 156 min). Median time for determination of puncture site was 20 minutes (range 15 - 28 min). Median time between puncture and successful delivery of the stent was 38 minutes (range 19 - 128 min). The GOOSS score was 0.2 before EUS-GE. The GOO Scoring System (GOOSS) score was 2.2 at 15 days after the EUS-GE ( P = 0.001). The GOOSS score was still higher than 2 during a median follow-up period of 89 days. AEs were observed in nine patients (25.0 %) and 13 total AEs occurred. One patient died as a result of delayed stent migration and bleeding. Mean length of hospital stay was 5.8 ± 4.7 days. The median survival period was 103 days. The rate of GOO recurrence was 2.7 % (1/36). Conclusion EUS-GE was associated with increased safety and efficacy for treatment of malignant GOO in Chinese Mainland.
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Affiliation(s)
- Guifang Xu
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Yonghua Shen
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Ying Lv
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Xiaoliang Zhou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Wen Li
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Yi Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Shahzeb Hassan
- Northwestern University Feinberg School of Medicine, Chicago 60611, IL, United States
| | - Lei Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Xiaoping Zou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
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Qayed E, Anand GS, Aihara H, Cassani L, Chahal P, Dacha S, Duloy A, Ghassemi S, Huang C, Kowalski TE, Kushnir V, Sheth SG, Simons-Linares CR, Taylor JR, Umar SB, Vela SAF, Walsh CM, Williams RL, Wagh MS. Core curriculum for endoluminal stent placement. Gastrointest Endosc 2020; 92:463-468. [PMID: 32711868 DOI: 10.1016/j.gie.2020.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Emad Qayed
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Gobind S Anand
- Division of Gastroenterology, University of California San Diego, San Diego, CA, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Cassani
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, and Atlanta VA Medical Center, Atlanta, GA, USA
| | - Prabhleen Chahal
- Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA; Digestive Disease and Surgery Institute, Cleveland Clinic, OH
| | - Sunil Dacha
- Division of Gastroenterology, Department of Internal Medicine, Houston Methodist Hospital and Texas A&M University, Houston, Texas, USA
| | - Anna Duloy
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO, USA; Division of Gastroenterology, University of Colorado-Denver, Aurora, CO, USA
| | - Sahar Ghassemi
- Division of Gastroenterology and Hepatology, Duke University, Durham, NC
| | - Christopher Huang
- Section of Gastroenterology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Thomas E Kowalski
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | | | - Jason R Taylor
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Saint Louis University, St Louis, Missouri, USA
| | - Sarah B Umar
- Division of Gastroenterology Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Stacie A F Vela
- Gastroenterology Section, Phoenix VA Health Care System, University of Arizona-Phoenix
| | - Catharine M Walsh
- Division of Gastroenterology, Hepatology and Nutrition and the Research and Learning Institutes, Hospital for Sick Children, Department of Paediatrics and the Wilson Centre, University of Toronto, Toronto, Canada
| | - Renee L Williams
- Department of Medicine, Division of Gastroenterology, NYU Grossman School of Medicine, New York, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado-Denver, Aurora, CO, USA
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Fan W, Tan S, Wang J, Wang C, Xu H, Zhang L, Liu L, Fan Z, Tang X. Clinical outcomes of endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a systematic review and meta-analysis. MINIM INVASIV THER 2020; 31:159-167. [PMID: 32672479 DOI: 10.1080/13645706.2020.1792500] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Wentao Fan
- Digestive Endoscopy Department and General Surgery Department, The First Affiliated Hospital with Nanjing Medical University and Jiangsu Province Hospital, Nanjing, China
| | - Shali Tan
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jiankun Wang
- Digestive Endoscopy Department and General Surgery Department, The First Affiliated Hospital with Nanjing Medical University and Jiangsu Province Hospital, Nanjing, China
| | - Chengfan Wang
- Digestive Endoscopy Department and General Surgery Department, The First Affiliated Hospital with Nanjing Medical University and Jiangsu Province Hospital, Nanjing, China
| | - Huan Xu
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Lu Zhang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Li Liu
- Digestive Endoscopy Department and General Surgery Department, The First Affiliated Hospital with Nanjing Medical University and Jiangsu Province Hospital, Nanjing, China
| | - Zhining Fan
- Digestive Endoscopy Department and General Surgery Department, The First Affiliated Hospital with Nanjing Medical University and Jiangsu Province Hospital, Nanjing, China
| | - Xiaowei Tang
- Department of Gastroenterology, Affiliated Hospital of Southwest Medical University, Luzhou, China
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Ratone JP, Caillol F, Zemmour C, Bories E, Pesenti C, Lestelle V, Godat S, Hoibian S, Proux A, Capodano G, Giovannini M. Outcomes of duodenal stenting: Experience in a French tertiary center with 220 cases. Dig Liver Dis 2020; 52:51-56. [PMID: 31401023 DOI: 10.1016/j.dld.2019.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/19/2019] [Accepted: 06/30/2019] [Indexed: 02/07/2023]
Abstract
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).
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Affiliation(s)
| | - Fabrice Caillol
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | - Christophe Zemmour
- Inst Paoli Calmettes, Dept Clin Res & Invest, Biostat & Methodolo Unit, Marseille, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, Marseille, France.
| | - Erwan Bories
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | | | | | - Sébastien Godat
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | - Solène Hoibian
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | - Aurélien Proux
- Paoli-Calmettes Institute, Palliative Unit, Marseille, France.
| | | | - Marc Giovannini
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
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Chang KB, Ye BW, Chou CK, Lee IC, Li CP, Chao Y, Huang YH, Hou MC, Lee KC. Outcomes of enteral metallic stent in patients with pancreatic carcinoma and gastric outlet obstruction: A single center experience. J Formos Med Assoc 2020; 119:238-246. [PMID: 31171401 DOI: 10.1016/j.jfma.2019.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 04/29/2019] [Accepted: 05/07/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Duodenal obstruction is uncommon in patients with pancreatic cancer. However, the obstruction rate is increasing as a result of advancements in chemotherapy and target therapy. This study aimed to investigate the effect of self-expandable metal stent placement on outcomes of patients with duodenal obstruction secondary to pancreatic carcinoma. METHODS Twenty-nine consecutive inoperable patients with pancreatic cancer and gastric outlet obstruction who received metallic stent placement in our hospital between September 2009 and October 2017 were enrolled for analysis. RESULTS Fifteen male patients and 14 female patients receiving stent placement with a median age of 68 years (range, 50-85 years) were included. The technical and clinical success rates of the procedure were 100% and 89.7%, respectively. The Gastric Outlet Obstruction Scoring System scores were significantly improved at day 1 (1.14 ± 0.51) and days 7 (2.21 ± 0.9) after the implantation compared to those prior to the procedure (0.38 ± 0.49) (p < 0.001). Aspiration pneumonia and bleeding developed in 1 patient (3.4%) after the procedure. Stent dysfunction developed in 6 of 29 patients (20.6%). The median stent patency time was 109 days (range, 10-314 days). The median survival time was 114 days (range, 15-323 days). Post-stent chemotherapy predicted better survival (hazard ratio: 0.2, 95% confidence interval: 0.08-0.51, p = 0.001). CONCLUSION Metallic stent placement is an effective treatment for patients with inoperable pancreatic cancer leading to gastric outlet obstruction. Chemotherapy may be considered following stent placement.
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Affiliation(s)
- Ke-Bin Chang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Bing-Wei Ye
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, Taiwan Adventist Hospital, Taipei, Taiwan
| | - Chung-Kai Chou
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Division of Gastroenterology, Department of Medicine, National Yang-Ming University Hospital, Ilan, Taiwan
| | - I-Cheng Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chung-Pin Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yee Chao
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Department of Oncology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
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Shia BC, Qin L, Lin KC, Fang CY, Tsai LL, Kao YW, Wu SY. Age comorbidity scores as risk factors for 90-day mortality in patients with a pancreatic head adenocarcinoma receiving a pancreaticoduodenectomy: A National Population-Based Study. Cancer Med 2019; 9:562-574. [PMID: 31789464 PMCID: PMC6970054 DOI: 10.1002/cam4.2730] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/05/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022] Open
Abstract
Background To estimate easily assessed preoperative factors for predicting 90‐day mortality in patients with a pancreatic head adenocarcinoma (PHA) receiving a pancreaticoduodenectomy. Methods We analyzed data from the Taiwan Cancer Registry Database of patients with a PHA who received a pancreaticoduodenectomy. Basic demographic characteristics, including gender and age, were categorized. The selection of preoperative comorbidities was based on the preoperative American Society of Anesthesiologists score and Charlson comorbidity index. Results We enrolled 8490 patients with a PHA who received a pancreaticoduodenectomy without distant metastasis. Currently, a pancreaticoduodenectomy for a PHA achieves an overall 90‐day mortality rate of 8.39%. Univariate and multivariate Cox regression analyses indicated that an older age (65‐74 and ≥75 years) and specific comorbidities (chronic obstructive pulmonary disease, chronic kidney disease, dementia, and sepsis) were significant independent prognostic factors for predicting 90‐day mortality after a pancreaticoduodenectomy. After adjustment, the adjusted hazard ratios (aHRs) (95% confidence intervals [CIs]) of subjects with middle and high comorbidity scores for 90‐day mortality in 65 to 74‐year‐old patients were 1.36 (1.05‐1.75) and 2.25 (1.03‐4.90), respectively, compared to subjects with low comorbidity scores. The aHRs (95% CIs) of subjects with middle and high comorbidity scores for 90‐day mortality in ≥75‐year‐old patients were 1.35 (1.07‐1.78) and 2.07 (1.19‐3.62), respectively, compared to those with low comorbidity scores. Conclusions Elderly patients with a PHA and moderate or high comorbidity scores have an increased risk of 90‐day mortality after a pancreaticoduodenectomy.
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Affiliation(s)
- Ben-Chang Shia
- Research Center of Big Data, College of management, Taipei Medical University, Taipei, Taiwan.,College of Management, Taipei Medical University, Taipei, Taiwan.,Executive Master Program of Business Administration in Biotechnology, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Lei Qin
- School of Statistics, University of International Business and Economics, Beijing, China
| | - Kuan-Chou Lin
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Yuan Fang
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Lo-Lin Tsai
- Division of Oral and Maxillofacial Surgery, Department of Dentistry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Wei Kao
- Graduate Institute of Business Administration, Fu Jen Catholic University, Taipei, Taiwan
| | - Szu-Yuan Wu
- Department of Food Nutrition and Health Biotechnology, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Division of Radiation Oncology, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.,Big Data Center, Lo-Hsu Medical Foundation, Lotung Poh-Ai Hospital, Yilan, Taiwan.,Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.,Department of Radiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute at Virginia Mason Medical Center, Seattle, Washington, USA
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Kerdsirichairat T, Irani S, Yang J, Brewer Gutierrez OI, Moran R, Sanaei O, Dbouk M, Kumbhari V, Singh VK, Kalloo AN, Khashab MA. Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction. Endosc Int Open 2019; 7:E144-E150. [PMID: 30705945 PMCID: PMC6353651 DOI: 10.1055/a-0799-9939] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background and study aims EUS-guided gastroenterostomy (GE) is a novel, minimally invasive endoscopic procedure for the treatment of gastric outlet obstruction (GOO). The direct-EUS-GE (D-GE) approach has recently gained traction. We aimed to report on a large cohort of patients who underwent DGE with focus on long-term outcomes. Patients and methods This two-center, retrospective study involved consecutive patients who underwent D-GE between October 2014 and May 2018. The primary outcomes were technical and clinical success. Secondary outcomes were adverse events (AEs), rate of reintervention, procedure time, time to resume oral diet, and post-procedure length of stay (LOS). Results A total of 57 patients (50.9 % female; median age 65 years) underwent D-GE for GOO. The etiology was malignant in 84.2 % and benign in 15.8 %. Technical success and clinical success were achieved in 93 % and 89.5 % of patients, respectively, with a median follow-up of 196 days in malignant GOO and 319.5 days in benign GOO. There were 2 (3.5 %) AEs, one severe and one moderate. Median procedure time was 39 minutes (IQR, 26 - 51.5 minutes). Median time to resume oral diet after D-GE was 1 day (IQR 1 - 2 days). Median post D-GE LOS was 3 days (IQR 2 - 7 days). Rate of reintervention was 15.1 %. Conclusions D-GE is safe and effective in management of both malignant and benign causes of GOO. Clinical success with D-GE is durable with a low rate of reintervention based on a long-term cohort.
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Affiliation(s)
- Tossapol Kerdsirichairat
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States,Corresponding author Mouen A. Khashab, M.D. Associate Professor of MedicineDirector of Therapeutic EndoscopyJohns Hopkins HospitalShiekh Zayed BuildingDivision of Gastroenterology and Hepatology1800 Orleans Street, Suite 7125GBaltimore, MD 21287+1- 410-502-7010
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Matsumoto K, Kato H, Horiguchi S, Tsutsumi K, Saragai Y, Takada S, Mizukawa S, Muro S, Uchida D, Tomoda T, Okada H. Efficacy and safety of chemotherapy after endoscopic double stenting for malignant duodenal and biliary obstructions in patients with advanced pancreatic cancer: a single-institution retrospective analysis. BMC Gastroenterol 2018; 18:157. [PMID: 30367599 PMCID: PMC6203985 DOI: 10.1186/s12876-018-0886-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 10/16/2018] [Indexed: 01/05/2023] Open
Abstract
Background Advanced pancreatic cancer is accompanied not only by bile duct obstruction, but also occasionally by duodenal obstruction. With new advances in chemotherapy and improvement in the management of stent dysfunction, the life expectancy of patients with pancreatic cancer has increased. This study aimed to evaluate the efficacy and safety of chemotherapy for advanced pancreatic cancer, as well as to analyze the prognostic factors, following endoscopic double stenting. Methods This retrospective study was conducted from January 1, 2007 to October 31, 2015 at an academic center. Fifty consecutive patients with pancreatic cancer who had undergone endoscopic double stenting, comprising duodenal and biliary stenting, were analyzed. We reviewed the patients records and analyzed the data of stent dysfunction rates after double stenting, reintervention for stent dysfunction, chemotherapy after double stenting, adverse events associated with chemotherapy after double stenting, survival times following double stenting, and overall survival times. The hospital’s institutional review board for human research approved this study. Results The overall survival time and the survival time following double stenting were 10.9 months (IQR 6.0–18.4 months) and 2.4 months (IQR 1.4–5.2 months), respectively. After double stenting, duodenal stent dysfunction occurred in 6 patients (12%), and biliary stent dysfunction occurred in 12 patients (24%), respectively. All patients who experienced stent dysfunction underwent endoscopic reintervention, and all of the procedures were successful. Twenty-one (42%) patients were treated with chemotherapy post double stenting; 9 patients received chemotherapy as a first-line treatment, 9 as a second-line treatment, and 3 as a third-line treatment. During chemotherapy, 8 (38%) patients had grade 3–4 adverse events, which were manageable. Chemotherapy post double stenting (OR, 0.19; 95% CI, 0.059–0.60; P = .0051), reintervention for biliary stent dysfunction (OR, 0.21; 95% CI, 0.081–0.50; P = .0002), and performance status (< 2) (OR, 0.28; 95% CI, 0.098–0.71; P = .0064) were significant prognostic factors after double stenting. Conclusions Systemic chemotherapy was manageable, even in patients with double stenting. Chemotherapy after double stenting and appropriate reintervention for stent obstructions potentially prolonged the survival of patients with advance pancreatic cancer.
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Affiliation(s)
- Kazuyuki Matsumoto
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan.
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Shigeru Horiguchi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Koichiro Tsutsumi
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Yosuke Saragai
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Saimon Takada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Sho Mizukawa
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Shinichiro Muro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Daisuke Uchida
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Takeshi Tomoda
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Science, 2-5-1 Shikata-cho, Okayama, 700-8558, Japan
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Endoscopic stenting for palliation of intra-abdominal gastrointestinal malignant obstruction: predictive factors for clinical success. Eur J Gastroenterol Hepatol 2018; 30:1033-1040. [PMID: 29851864 DOI: 10.1097/meg.0000000000001178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Uemura S, Iwashita T, Iwata K, Mukai T, Osada S, Sekino T, Adachi T, Kawai M, Yasuda I, Shimizu M. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology 2018; 18:601-607. [PMID: 29753623 DOI: 10.1016/j.pan.2018.04.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment. AIMS To compare the efficacy and safety of GJJ and DS for GOO with APC. METHODS Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis. RESULTS GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS. CONCLUSIONS There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.
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Affiliation(s)
- Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinji Osada
- Multidisciplinary Therapy for Hepato-Biliary-Pancreatic Cancer, Gifu University School of Medicine, Gifu, Japan
| | - Takafumi Sekino
- Department of General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Masahiko Kawai
- Department of Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Down CJ, Kumar L, Singh S, Veeramootoo D. A unique complication of self-expandable metal stent placement in malignant duodenal obstruction. J Surg Case Rep 2017; 2017:rjx169. [PMID: 28928926 PMCID: PMC5597866 DOI: 10.1093/jscr/rjx169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/29/2017] [Indexed: 11/12/2022] Open
Abstract
Intestinal obstruction is a common complication in patients with advanced gastrointestinal malignancies. In the last two decades, endoscopic placement of duodenal stents has become a mainstay of palliative treatment in patients with unresectable obstructive duodenal pathology. Self-expandable metal stents have been reported to have excellent success rates, besides dramatically improve the patient's quality of life by reinstating the oral feeding ability. Re-intervention rates remain high, commonly as a consequence of tumour ingrowth resulting stent occlusion. We describe a unique case of duodenal stent obstruction secondary to impacted gallstones. To the best of our knowledge, this is the first case described in the literature and should alert clinicians to this unusual complication.
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Affiliation(s)
- Christopher J Down
- Department of General Surgery, Frimley Health NHS Foundation Trust, Frimley, GU16 7UJ, UK
| | - Lalit Kumar
- Department of General Surgery, Frimley Health NHS Foundation Trust, Frimley, GU16 7UJ, UK
| | - Sukhpal Singh
- Department of General Surgery, Frimley Health NHS Foundation Trust, Frimley, GU16 7UJ, UK
| | - Darmarajah Veeramootoo
- Department of General Surgery, Frimley Health NHS Foundation Trust, Frimley, GU16 7UJ, UK
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Abstract
PURPOSE OF REVIEW Gastric outlet obstruction (GOO) can result from benign and malignant causes. Until recently, surgical gastrojejunostomy was the treatment of choice for patient with benign and malignant GOO with a good functional status. Endoscopic placement of luminal self-expandable metal stents is currently widely accepted as the first line of treatment for malignant GOO because of its effectiveness and minimally invasive nature. The main shortcoming of luminal stents is the high incidence of recurrent GOO most commonly because of tumor ingrowth/overgrowth. More recently, endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) has emerged as an alternative to both luminal stent placement and surgical gastrojejunostomy. Advantages of EUS-GE include its minimally invasive nature, efficacy and low incidence of recurrent GOO in cancer patient. We will describe five different techniques to perform this novel and rapidly evolving procedure using a biflanged, lumen-apposing metal stent and compare benefits and risks of each approach. These approaches include antegrade EUS-GE or 'traditional/downstream' and 'rendezvous' methods, retrograde EUS-GE or 'enterogastrostomy,'17 (EPASS), and antegrade EUS-GE 'direct' method. RECENT FINDINGS A preprocedural computed tomography scan allows the proximity of the duodenum or jejunum to the stomach to be determined and to assess for the presence of significant ascites, which is a contraindication to EUS-GE. Technical success rates even in the early studies approximate 90%, regardless of the technique used. Clinical success rates have been exceptionally high as well, with only a minority of patients experiencing persistent symptoms despite technical success. One procedure-related death has been reported so far with an overall low morbidity. Pain, bleeding, pneumoperitoneum and peritonitis have been reported in one patient each. However, duration of follow-up in these studies has been short. SUMMARY We describe five different techniques to performing EUS-GE. Early studies show excellent efficacy. Stent misdeployment/displacement is the most frequent relevant adverse event. Prospective and preferably randomized trials with comparison to endoluminal enteral stents and surgical gastroenterostomy are needed.
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Abstract
Most patients with pancreatic cancer will present with metastatic or locally advanced disease. Unfortunately, most patients with localized disease will experience recurrence even after multimodality therapy. As such, pancreatic cancer patients arrive at a common endpoint where decisions pertaining to palliative care come to the forefront. This article summarizes surgical, endoscopic, and other palliative techniques for relief of obstructive jaundice, relief of duodenal or gastric outlet obstruction, and relief of pain due to invasion of the celiac plexus. It also introduces the utility of the palliative care triangle in clarifying a patient's and family's goals to guide decision making.
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Affiliation(s)
- Jennifer A Perone
- Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
| | - Taylor S Riall
- Department of Surgery, Banner-University Medical Center, University of Arizona, 1501 North Campbell Avenue, Tucson, AZ 85724, USA.
| | - Kelly Olino
- Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
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Chen YI, Itoi T, Baron TH, Nieto J, Haito-Chavez Y, Grimm IS, Ismail A, Ngamruengphong S, Bukhari M, Hajiyeva G, Alawad AS, Kumbhari V, Khashab MA. EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surg Endosc 2016; 31:2946-2952. [PMID: 27834024 DOI: 10.1007/s00464-016-5311-1] [Citation(s) in RCA: 142] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 10/25/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Endoscopic enteral stenting (ES) in malignant gastric outlet obstruction (GOO) is limited by high rates of stent obstruction. EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers sustained patency without tumor ingrowth/overgrowth. The aim of this study is to compare EUS-GE with ES in terms of (1) symptom recurrence and need for re-intervention, (2) technical success (proper stent positioning as determined via endoscopy and fluoroscopy), (3) clinical success (ability to tolerate oral intake without vomiting), and (4) procedure-related adverse events (AEs). METHODS Multicenter retrospective study of all consecutive patients who underwent either EUS-GE at four centers between 2013 and 2015 or ES at one center between 2008 and 2010. RESULTS A total of 82 patients (mean age 66-years ± 13.5 and 40.2% female) were identified: 30 in EUS-GE and 52 in ES. Technical and clinical success was not significantly different: 86.7% EUS-GE versus 94.2% ES (p = 0.2) and 83.3% EUS-GE versus 67.3% ES (p = 0.12), respectively. Symptom recurrence and need for re-intervention, however, was significantly lower in the EUS-GE group (4.0 vs. 28.6%, (p = 0.015). Post-procedure mean length of hospitalization was comparable at 11.3 days ± 6.6 for EUS-GE versus 9.5 days ± 8.3 for ES (p = 0.3). Rates and severity of AEs (as per the ASGE lexicon) were also similar (16.7 vs. 11.5%, p = 0.5). On multivariable analysis, ES was independently associated with need for re-intervention (OR 12.8, p = 0.027). CONCLUSION EUS-GE may be ideal for malignant GOO with comparable effectiveness and safety to ES while being associated with fewer symptom recurrence and requirements for re-intervention.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Takao Itoi
- Division of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan.
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Jose Nieto
- Borland-Groover Clinic, Jacksonville, FL, USA
| | - Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, NC, USA
| | - Amr Ismail
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Gulara Hajiyeva
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Ahmad S Alawad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
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Grunwald D, Cohen J, Bartley A, Sheridan J, Chuttani R, Sawhney MS, Pleskow DK, Berzin TM, Mizrahi M. The location of obstruction predicts stent occlusion in malignant gastric outlet obstruction. Therap Adv Gastroenterol 2016; 9:815-822. [PMID: 27803736 PMCID: PMC5076776 DOI: 10.1177/1756283x16667893] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastric outlet obstruction (GOO) can occur with locally invasive or metastatic cancer involving the upper gastrointestinal tract at the pylorus or the duodenum. Endoscopic management with self-expanding metal stents (SEMSs) is often the preferred palliative approach. Stent occlusion is a common reason for failure and reintervention. We set out to determine whether the location of the malignant obstruction is associated with the angulation of the stent and can predict stent occlusion. METHODS We performed a retrospective review of consecutive patients who underwent successful duodenal stenting with SEMS for malignant GOO between 2006 and 2015 at a large advanced endoscopy referral center. We determined the location of obstruction, the stent angle, and the rate of technical and clinical success of stent placement. We then identified cases of subsequent stent occlusion confirmed by endoscopic evaluation. RESULTS A total of 100 consecutive patients were included in the study; 91 of these patients had enough data to evaluate SEMS occlusion. A total of 21 patients (23%) developed stent occlusion with a median time of 39 days. The risk of occlusion sequentially increased as the obstruction occurred more distally from the antrum to the third or fourth portion of the duodenum (p = 0.006). This relationship was maintained after controlling for stent angle (p = 0.05). CONCLUSIONS A distal location of malignant GOO was strongly predictive of stent occlusion, independent of stent angle. This may be due to longer and more complex distal obstructions, along with foreshortening of the stent during placement and tumor infiltration. If replicated, these results will have implications for endoscopic practice and future device development.
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Affiliation(s)
| | - Jonah Cohen
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Anthony Bartley
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jennifer Sheridan
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ram Chuttani
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Mandeep S. Sawhney
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Douglas K. Pleskow
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Tyler M. Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Meir Mizrahi
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Abstract
PURPOSE OF REVIEW Malignant gastric outlet obstruction (GOO) is a debilitating complication of cancer associated with a poor prognosis. The primary aim in the management of malignant GOO is usually palliation starting with the reinstitution of luminal patency with either surgical bypass or enteral stenting. These traditional modalities, however, have important limitations. Endoscopic bypass is a novel approach to GOO and may be an ideal technique, in which a sustained bypass can be created through a minimally invasive approach. The goal of this review is to describe the technical aspects as well as the clinical data of endoscopic bypass. RECENT FINDINGS A review of this novel technique is timely given recent developments of several accessories and techniques that allow for safer and easier endoscopic bypass including the advent of the lumen apposing stent, a specialized double-balloon enteric tube, the EUS-assisted technique, and the natural orifice transluminal surgery approach. In addition, accumulating and promising data have emerged supporting the endoscopic approach to gastric bypass. SUMMARY Endoscopic bypass is a novel and developing field of therapeutic endoscopy with improving technique and promising clinical data. This review will help to shed light on the current status and future direction of this intricate endoscopic modality.
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Lopera JE, Gregorio MAD, Laborda A, Casta?o R. Enteral stents: Complications and their management. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii160005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Jorge E. Lopera
- Department of Radiology, UT Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Alicia Laborda
- Minimally Invasive Techniques Research Group (GITMI), University of Zaragoza, Zaragoza, Spain
| | - Rodrigo Casta?o
- Gastrohepatology Group, Universidad de Antioquia, Medell?n, Colombia
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Kozarek RA. Endoscopic approaches to afferent and Roux-en-Y limb obstruction. GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Richard A. Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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Kobayashi S, Ueno M, Kameda R, Moriya S, Irie K, Goda Y, Tezuka S, Yanagida N, Ohkawa S, Aoyama T, Morinaga S, Morimoto M. Duodenal stenting followed by systemic chemotherapy for patients with pancreatic cancer and gastric outlet obstruction. Pancreatology 2016; 16:1085-1091. [PMID: 27424479 DOI: 10.1016/j.pan.2016.07.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/13/2016] [Accepted: 07/09/2016] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Endoscopic duodenal stenting has recently been proposed as a substitute for surgical gastrojejunostomy for the treatment of gastric outlet obstruction. We aimed to evaluate the efficacy and safety of duodenal stenting followed by systemic chemotherapy for patients with advanced pancreatic cancer with gastric outlet obstruction. METHODS This was a single-center, retrospective cohort study, conducted at an academic medical center, of 71 patients with advanced pancreatic cancer and gastric outlet obstruction (mean age: 67.6 years; range: 31-92 years) who underwent duodenal stenting with or without subsequent chemotherapy. Overall survival, duration of oral intake of foods, the rate of introduction of chemotherapy, progression-free survival, and adverse events were evaluated. RESULTS Stent placement was technically successful in 69 (97%) patients. Thirty-six (51%) patients were treated with chemotherapy: 17 with gemcitabine alone, 15 with S-1 alone, 3 with FOLFIRINOX, and 1 with paclitaxel. Median progression-free survival and overall survival after chemotherapy were 2.6 months (95% confidence interval: 1.3-3.9 months) and 4.7 months (95% confidence interval: 2.6-6.8 months), respectively. Cases of grade 3 anemia were frequently observed during chemotherapies following duodenal stenting (32%). Tumor stage, performance status, neutrophil-to-lymphocyte ratio, and introduction of chemotherapy were independent prognostic factors for survival (hazard ratios of 3.73, 2.21, 2.69, and 1.85 with p-values of <0.001, 0.010, <0.001, and 0.045, respectively). CONCLUSIONS The findings of this study suggest that endoscopic duodenal stenting is an advantageous treatment in advanced pancreatic cancer patients with gastric outlet obstruction regarding its safety and smooth conduction of subsequent chemotherapies.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan.
| | - Makoto Ueno
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Ryo Kameda
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Satoshi Moriya
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Kuniyasu Irie
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshihiro Goda
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Shun Tezuka
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Naoki Yanagida
- Department of Gastroenterology, Yamato Municipal Hospital, Yamato, Japan
| | - Shinichi Ohkawa
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Toru Aoyama
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Soichiro Morinaga
- Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama, Japan
| | - Manabu Morimoto
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
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Oh SY, Kozarek RA. Management of gastroduodenal stent-related complications. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii150008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Stephen Y. Oh
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
| | - Richard A. Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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van Halsema EE, Rauws EAJ, Fockens P, van Hooft JE. Self-expandable metal stents for malignant gastric outlet obstruction: A pooled analysis of prospective literature. World J Gastroenterol 2015; 21:12468-81. [PMID: 26604654 PMCID: PMC4649130 DOI: 10.3748/wjg.v21.i43.12468] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 07/17/2015] [Accepted: 10/12/2015] [Indexed: 02/06/2023] Open
Abstract
AIM To provide an overview of the clinical outcomes of self-expandable metal stent (SEMS) placement for malignant gastric outlet obstruction (MGOO). METHODS A systematic literature search was performed in PubMed of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success, defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs (PCSEMSs) and uncovered SEMSs (UCSEMSs) using Fisher's exact test. RESULTS A total of 19 studies, including 1281 patients, were included in the final analysis. Gastric (42%) and pancreatic (37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients, mainly caused by re-obstruction (12.6%) and stent migration (4.3%), and was comparable between PCSEMSs and UCSEMSs (21.2% vs 19.1%, respectively, P = 0.412). Re-obstruction was more common with UCSEMSs (14.9% vs 5.1%, P < 0.001) and stent migration was more frequent after PCSEMS placement (10.9% vs 2.2%, P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients, including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies. CONCLUSION The clinical outcomes in this large population showed that enteral stent placement was feasible, effective and safe. Therefore, stent placement is a valid treatment option for the palliation of MGOO.
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Gerritsen A, Wennink RAW, Busch ORC, Borel Rinkes IHM, Kazemier G, Gouma DJ, Molenaar IQ, Besselink MGH. Feeding patients with preoperative symptoms of gastric outlet obstruction after pancreatoduodenectomy: Early oral or routine nasojejunal tube feeding? Pancreatology 2015; 15:548-553. [PMID: 26235830 DOI: 10.1016/j.pan.2015.07.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/03/2015] [Accepted: 07/05/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Early oral feeding is currently considered the optimal routine feeding strategy after pancreatoduodenectomy (PD). Some have suggested that patients with preoperative symptoms of gastric outlet obstruction (GOO) who undergo PD have such a high risk of developing delayed gastric emptying that these patients should rather receive routine postoperative tube feeding. The aim of this study was to determine whether clinical outcomes after PD in these patients differ between postoperative early oral feeding and routine tube feeding. METHODS We analyzed a consecutive multicenter cohort of patients with preoperative symptoms of GOO undergoing PD (2010-2013). Patients were categorized into two groups based on the applied postoperative feeding strategy (dependent on their center's routine strategy): early oral feeding or routine nasojejunal tube feeding. RESULTS Of 497 patients undergoing PD, 83 (17%) suffered from preoperative symptoms of GOO. 49 patients received early oral feeding and 29 patients received routine tube feeding. Time to resumption of adequate oral intake (primary outcome; 14 vs. 12 days, p = 0.61) did not differ between these two feeding strategies. Furthermore, overall complications and length of stay were similar in both groups. Of the patients receiving early oral feeding, 24 (49%) ultimately required postoperative tube feeding. In patients with an uncomplicated postoperative course, early oral feeding was associated with shorter time to adequate oral intake (8 vs. 12 days, p = 0.008) and shorter hospital stay (9 vs. 13 days, p < 0.001). CONCLUSION Also in patients with preoperative symptoms of GOO, early oral feeding can be considered the routine feeding strategy after PD.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Roos A W Wennink
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier R C Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Geert Kazemier
- Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Dirk J Gouma
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc G H Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
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