Pyloric Obstruction with Advanced Gastric Cancer: Stent vs. Bypass

In the past, conservative bypass surgery was usually performed for palliation of malignant obstruction of the gastrointestinal tract. However, endoscopic stenting was developed recently, and technical advances and clinical experience have made it possible to establish stent implantation as one of the main treatment options. There are several advantages in stent implantation over bypass surgery, such as high feasibility and technical success rate, non-invasiveness, rapid symptomatic response, short hospitalization, and cost-effect benefits. Complications, such as stent ingrowth, stent injury by bile or acid, and migration, may occur and early re-insertion is frequently needed. Recently, diverse novel stents which are powered to predict stent migration or ingrowth have been developed and are being used in the clinical setting. In general, stent implantation is known to be beneficial in patients who are expected to survive 6 months. In this review, we have compared the technical feasibility, clinical outcomes, complications, and cost-benefit between stent implantation and bypass surgery, and determined the optimal treatment strategy in malignant upper gastrointestinal obstruction.

Efficacy of Niti-S ComVi Stents for Palliation of Malignant Gastrointestinal Obstruction / 대한소화기내시경학회지

BACKGROUND/AIMS: Niti-S ComVi stents are flexible and retain the shape-memory of the original configuration. ComVi stents are effective in preventing tumor ingrowth because polytetrafluoroethylene is inserted between two stent wires. The aim of this study was to examine the efficacy of Niti-S ComVi stents for the palliation of a malignant gastrointestinal obstruction. METHODS: Between April 2004 and April 2006, 17 patients (20 cases) underwent Niti-S ComVi stenting, using a through-the- scope method. The technical and clinical success, complication, and outcome were analyzed. RESULTS: Stent insertion was technically successful in 18 cases (90%). Malposition to the afferent loop occurred in 2 cases. Symptomatic improvement was achieved in 14 cases (70%). The mean gastric outlet obstruction score was 0.2 before stenting and 1.6 after stenting. The complications encountered were stent migration (2 cases) and obstruction (5 cases), which were treated by re-stenting and balloon dilatation. Twelve patients died with a median survival of 67 days. Five patients were still alive with a median follow up of 151 days. The overall median stent patency time was 60 days. The mean waist diameter of the stents was expanded to 57% of full expansion immediately after deployment, and 77% after 36 hours. CONCLUSIONS: Niti-S ComVi stenting is an effective palliative technique for inoperable or postoperative recurrent tumors, and significantly improves the quality of life.

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.