The vanishing stent: Repeated fracture and dissolution of nitinol gastric stents in a long term cancer survivor

Nitinol self expandable metal stents are increasingly utilised for malignant obstruction in the proximal gastrointestinal tract. We describe a case in which repeated fracture of proximal duodenal stents with dissolution of the nitinol wire skeleton and covering membranes occurred in a long term cancer survivor. This necessitated placement of 4 stents for symptom control and to allow oral feeding until the patient's death 20 months after the initial stent was inserted. Fracture of gastric and duodenal stents has rarely been described previously, some incidences of which were considered due to mechanical causes. Dissolution of stent metal skeletons has not previously been recognised in gastroduodenal stents but has been described in an oesophageal stent subject to reflux of gastric content and a biochemical mechanism has been proposed. With modern oncological treatment the prospect of patients outliving their stents is increasing and the need for repeat procedures should form part of the consent process.

Comprehensive management of cholangiocarcinoma: Part II. Treatment

Cholangioarcinoma is a rare but dreadful malignancy which poses much difficulties in the management. If detected early with only localized disease, curative resection is possible. However, most patients present in the late stages of the disease, which are managed with endoscopic biliary drainage and/or chemoradiation. Liver transplantation offers a possibility for cure in the distal and the perihilar tumors for selected candidates. Local treatments, such as hepatic artery-based therapies, brachytherapy, and photodynamic therapy, may offer some benefit in cases of the advanced disease. In this review, we will assess the role of preoperative biliary drainage, how best to drain biliary obstruction, and the intricate details of various treatments that are currently available.

Self-expandable metal stent placement for recurrent cancer in a surgically-altered stomach

Gastric cancer is one of the most common malignancies and most frequent causes of cancer-related death worldwide. Radical surgical resection accomplished by total or distal gastrectomy represents the mainstay of curative treatment for gastric cancer; however, recurrent cancer still occurs in a significant amount of cases. Patients with recurrent cancer are generally incurable and often experience debilitating symptoms, such as nausea, vomiting, dysphagia, dehydration, and malnutrition, because of malignant gastric-outlet, duodenal, and jejunal obstructions. Consequently, such patients experience progressive deterioration of quality of life. If bypass surgery has not already been performed, it is not usually appropriated in the context of recurrent cancer and is associated with a high risk of morbidity and mortality. Endoscopic or fluoroscopic self-expandable metal stent placement represents an effective and safe method for palliative treatment of recurrent cancer in patients with the surgically-altered stomach. Therefore, it should be considered as the first-line option. Importantly, accurate knowledge of the surgically-altered anatomy and stricture location are critical to achieve successful treatment outcomes.

Through the keyhole: Radiological management of malignant gastric outflow obstruction beyond the pylorus

This review article presents the radiological options for management of malignant gastric outflow obstruction distal to the pylorus. We place these options in context with surgical and endoscopic alternatives and recommend their use, particularly in those institutions where endoscopic alternatives may not be readily available.

The obstructed afferent loop: Percutaneous options

Endoscopic drainage can be considered the treatment of choice in benign and malignant obstruction of the distal biliary tree, with percutaneous intervention reserved for cases of difficult access or complex hilar strictures. However in patients with altered anatomy due to pancreatico-duodenectomy gastrectomy, or Bilroth II reconstruction, endoscopy can be exceptionally challenging and often impossible. Surgery remains the gold standard for benign causes of obstruction of a bilio-enteric anastomosis or afferent loop, and percutaneous management remains controversial. Novel endoscopic techniques such as double balloon enteroscopy and endoscopic ultrasound guided procedures can overcome some of the anatomical challenges, but a percutaneous approach is a more established technique for cases of malignant obstruction of a bilio-enteric anastomosis or afferent loop. The altered anatomy presents unique challenges which must be fully contemplated and understood before intervention should occur, to avoid the risk of permanent external drainage.

Enteral stents: Complications and their management

The treatment of malignant colonic and gastric outlet obstruction with self-expanding metallic stents (SEMS) is an established technique that can be performed by radiologic or a combination of radiologic and endoscopic guidance. The procedure is very effective to relieve the obstructive symptoms of advanced malignancies, with important clinical benefits and significant improvement in quality of life for the patients. Despite much advancement in the designs of SEMS, enteral stent placement is still associated with some significant early and late complications. Stent dysfunction mainly caused by tumor ingrowth/over growth, and stent migration when covered stent are used, are relatively common complications and many times require reinterventions.

Fluoroscopic Management of Complications after Colorectal Stent Placement

Colorectal self-expanding metal stents have been widely used as a bridge to surgery in patients with acute malignant colonic obstruction by allowing a single-stage operation, or as a definitive palliative procedure in patients with inoperable tumors. Colonic stents are placed under either fluoroscopic or combined endoscopic and fluoroscopic guidance, with similar technical-success and complication rates. Placement of colonic stents is a very safe procedure with a low procedure-related mortality rate, but serious complications can develop and reinterventions are not uncommon. Most of the complications can be treated by minimally invasive or conservative techniques, while surgical interventions are required for most patients with perforation.

Prótesis metálicas autoexpandibles en lesiones malignas de la unión esofagogástrica

Introducción: Los adenocarcinomas de esófago y cardias están incrementando su incidencia. El pronóstico es pobre con índices de sobrevida bajos. La disfagia es el síntoma que causa mayor molestia al paciente, repercutiendo en su estado nutricional y calidad de vida. El tratamiento de los tumores de la unión esofagogastrica es poco satisfactorio haciéndose los diagnósticos en etapas avanzadas. Las prótesis esofágicas son utilizadas como terapia paliativa primaria o en recidiva tras otras formas de tratamiento. Materiales y Métodos: Se incluyeron 13 pacientes entre enero 2002 a Diciembre 2006 con lesiones malignas avanzadas de la unión esofagogastrica no susceptibles a otro tipo de tratamiento. Previa dilatación de la estenosis maligna se procedió a colocar prótesis autoexpandibles en la unión esofagogastrica. Resultados: El adenocarcinoma fue la variedad histológica más frecuente. Se logra la colocación de las prótesis en 11 casos en la primera sesión. Sangramiento y dolor torácico se asociaron a la dilatación con bujías. En un paciente se presento migración de la prótesis al estómago (7,6%). Conclusiones: En nuestra serie no hay complicaciones asociadas a la colocación de la prótesis, ni mortalidad atribuible al procedimiento. Las prótesis metálicas autoexpandibles son un excelente instrumento en el manejo de la disfagia en lesiones malignas avanzadas de la unión esofagogastrica.

Introduction: The incidence of adenocarcinomas in esophagus and the esophagogastric junction are increasing all over the world. Prognosis is poor with low survival indexes. Dysphagia is the symptom that causes most nuisances to patients, affecting their nutritional state and quality of life. The treatment of tumors of the esophagogastric junction is not very satisfactory given that diagnoses are usually made at advanced stages. Stents are used as primary palliative therapy or in case of relapse after other treatment forms such as surgery or radiochemotherapy. Materials and Methods: 13 patients were included in the study between January 2002 and December 2006, all with advanced lesions at the GE junction which was not susceptible to other types of treatment. After dilation of the malignant stenosis we proceeded to place Expandable Metal Stents in the GE junction. Results: 84,6% of the tumors were adenocarcinomas. The placement of the stents was achieved in 11 cases in the first session. Bleeding and thoracic pain were associated with the dilation. Only one patient presented stent migration to the stomach (7,6%). Conclusions: In our series there were no complications associated with the placement of the stent, and no mortality caused by the procedure. The Expandable Metal Stents are an excellent instrument in the handling of dysphagia in malignant advanced lesions of the esophagogastric junction.

Uncovered Self-expandable Metal Stents (SEMS) for Gastric Outlet Obstruction Caused by Stomach Cancer / 대한소화기내시경학회지

BACKGROUND/AIMS: The use of self-expandable metal stents (SEMS) is a safe and efficacious method for palliating malignant gastric outlet obstruction. However, few reports have assessed clinical outcome after the insertion of SEMS for malignant gastric outlet obstruction caused by stomach cancer. The aim of this study was to assess the usefulness of uncovered SEMS in patients with malignant gastric outlet obstruction caused by stomach cancer. METHODS: We evaluated 62 patients with gastric outlet obstruction caused by stomach cancer treated by the implantation of uncovered SEMS. A total of 62 patients (43 males, 19 females) were treated between August 2000 and March 2007. A scoring system was used to grade the ability to eat. RESULTS: Stent implantation was successful in 61 (98.4%) patients. Relief of obstructive symptoms was achieved in 49 (80.3%) patients. The mean survival duration was 143 days. The mean stent patency time was 103.5 days. An improvement in the ability to eat using the scoring system was statistically significant (p<0.05). CONCLUSIONS: Endoscopic placement of uncovered SEMS is a safe and effective treatment for the palliation of patients with inoperable malignant gastric outlet obstruction caused by stomach cancer.

The Usefulness of Clip Application in Preventing Migration of Self-expandable Metal Stent in Patients with Malignant Gastrointestinal Obstruction / 대한소화기학회지

BACKGROUND/AIMS: Management of malignant gastrointestinal obstruction presents a significant challenge. Recently, self-expandable metal stent (SEMS) has emerged as an effective, safe, and less invasive alternative for the treatment of malignant intestinal obstruction. Accordingly, we reviewed our experience in SEMS insertion with hemoclip placement. METHODS: Between June 2004 and December 2005, a total of 40 SEMS were tried to place in 38 patients with malignant intestinal obstruction. Two stents were placed again due to recurrent obstruction and delayed stent migration after initial stent placement. We analyzed the technical and clinical success rates and complications. RESULTS: Total stent placement was successful in 38/40 (95%). In 2 cases, stent placement was failed due to complete obstruction. Twenty-eight stents for palliation of malignant intestinal stenosis, 9 stents for one-staged operation for malignant colonic obstruction, and 1 stent for management of tracheoesophageal fistula were placed. Stent migration occurred in 6/38 (15.8%). Early stent migration rate was significantly lower in the clipping group (0/19, 0%) than in the non-clipping group (5/19, 26.3%, p=0.04). Recurrent obstruction occurred in 2/38 (6.1%) due to tumor ingrowth and in 1/38 (2.6%) due to hard food materials. CONCLUSIONS: Application of the clips reduce early stent migration in patients with malignant gastrointestinal obstruction.

Effectiveness of Through-the-scope Self-expandable Metal Stent in Malignant Upper Gastrointestinal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Self-expandable metal stents (SEMS) have been used in the palliation of malignant obstruction. The purpose of this study was to evaluate the effectiveness, safety, and outcome of SEMS using through-the-scope (TTS) method in the patients with malignant upper gastrointestinal obstruction including recurrent gastric cancer after gastrectomy. METHODS: Thirty one patients (36 stents) were treated with SEMS between October 2000 and June 2004; nineteen had inoperable malignant gastric outlet obstruction, ten had recurrent gastric cancer after gastrectomy, and two had metastatic duodenal cancer. We analyzed the technical and clinical success, complication, and outcome. RESULTS: The technical success rate was 88.8% (32/36 stents) in total cases; 95.0% (19/20) in malignant gastric outlet obstruction, 84.6% (11/13) in recurrent gastric cancer after gastrectomy, and 66.7% (2/3) in metastatic duodenal cancer. The success rate of dietary intake was 86.1% (31/36 stents). Complications occurred in 7 of 36 stents (19.4%), including stent migration (1 patient), aspiration pneumonia (1 patient), and recurrent obstruction (5 patients). The mean survival duration period was 118.1+/-180.2 days and mean patency period was 92.2+/-89.9 days. CONCLUSIONS: SEMS using TTS is an effective, safe, and less invasive palliative treatment in malignant upper gastrointestinal obstruction including recurrent gastric cancer after surgery.

Silicone - Covered Self - Expandable Metal Stents for the Palliation of Malignant Esophageal Obstruction and Esophagorespiratory Fistulas / 대한소화기내시경학회지

BACKGROUND: Esophageal cancer can induce progressive dysphagia and occasionally develop esophagorespiratory fistulas. Surgically incurable disease is present in over 60% of patients at the time of presentation and in such a means, relief of dysphagia is one of the important treatment modes in the majority of these patients. Implantation of stents is widely used for improvement of dysphagia and sealing of esophagorespiratary fistulas. METHODS: Silicone-covered self-expandable metal stents were used in 19 consecutive patients with malignant esophageal obstruction (n=14) or esophageal obstruction with esophagorespiratory fistulas (n=5). RESULTS: The stents were successfully inserted in all patients. Dysphagia improved in 18 of 19 patients (95%). All fistulas were sealed and symptoms due to bronchial aspiration disappeared. Complications occurred during follow-up including chest pain (11 patients), aspiration pneumonia (4 patients), reflux esophagitis (2 patients), stent migration (2 patients), tumor overgrowth (2 patients) and hemorrhage (1 patient). Three of the 4 patients with aspirtion pneumonias and a patient with hemorrhage suffered from dysfunction of upper esophageal sphincter after implantation of stents in upper esophageal carcinoma. But, Tumor ingrowth and perforation did not occur. Two patients died of massive hemorrhage and respiratory failure caused by aspiration pneumonia. CONCLUSION: These results suggest that implantation of silicone-covered self-expandable metal stents is a rapid and effective procedure for the palliative treatment of malignant esophageal obstruction and esophagorespiratory fistulas.