Abstract
Duodenal self-expandable metal stents (SEMS) are designed for palliation and prompt relief of malignant gastric outlet obstruction (GOO). This mini-invasive endoscopic treatment is preferable to surgery due to its lower morbidity and mortality, shorter hospitalization, and earlier symptoms relief; furthermore endoscopic enteral stenting can be performed under conscious sedation, reducing the risk of general anesthesia in these already fragile patients. The stent placement technique is well established and should be performed in referral centers with adequate materials and equipment. Duodenal stents can be covered and uncovered. Nitinol stents have almost replaced other materials, being more flexible with a satisfactory axial and radial force. Common duodenal SEMS-related complications are recurrence of GOO symptoms due to stent clogging (tissue ingrowth/overgrowth and food impaction) and stent migration. These complications can be usually managed endoscopically. Perforation and bleeding are the most severe, but rare, complications. After stent placement, malignant GOO patients usually have improvement of the GOO symptoms with good resumption of fluids and solids. Choosing the most appropriate type of stent is arduous and should be done mainly in relation to the morphological aspects of the stricture. Endoscopic duodenal SEMS placement is indicated in symptomatic GOO patients suffering from unresectable malignancy or those inoperable due to advanced age or comorbidities. The absence of peritoneal carcinomatosis and multiple small bowel strictures is a key point for the clinical success of duodenal SEMS. Almost all symptomatic malignant GOO patients are candidates for the duodenal SEMS procedure; resolution of GOO, avoiding the need for a permanent naso-gastric or percutaneous endoscopic gastrostomy tube, significantly improves the patients’ quality of life and dignity, even if life expectancy is short. Endoscopic duodenal SEMS insertion, after an adequate training, is a reproducible, simple, safe, and cost-effective procedure.
Similar content being viewed by others
References
Lillemoe KD, Pitt HA. Palliation. Surgical and otherwise. Cancer. 1996;78(3 suppl.):605–614.
Jeurnink SM, van Eijck CH, Steyerberg EW, et al. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol. 2007;8:7–18.
Siddiqui A, Spechler SJ, Huerta S. Surgical bypass versus endoscopic stenting for malignant gastroduodenal obstruction: a decision analysis. Dig Dis Sci. 2007;52:276–281.
Truong S, Bohndorf V, Geller H, et al. Self-expanding metal stents for palliation of malignant gastric outlet obstruction. Endoscopy. 1992;24:433–435.
Hosono S, Ohtani H, Arimoto Y, et al. Endoscopic stenting vs. surgical gastroenterostomy for palliation of malignant gastroduodenal obstruction: a meta-analysis. J Gastroenterol. 2007;42:283–290.
Dormann A, Meisner S, Verin N, et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy. 2004;36:543–550.
Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc. 2004;60:1010–1017.
Van Hooft JE, Uitdehaag MJ, Bruno MJ, et al. Efficacy and safety of the new WallFlex enteral stent in palliative treatment of malignant gastric outlet obstruction (DUOFLEX study): a prospective multicenter study. Gastrointest Endosc. 2009;69:1059–1066.
Bae JI, Shin JH, Song HY, et al. Treatment of a benign anastomotic duodenojejunal stricture with a polytetrafluoroethylene-covered retrievable expandable nitinol stent. J Vasc Interv Radiol. 2004;15:769–772.
Van Heek NT, van Geenen RC, Busch OR, et al. Palliative treatment in “peri”-pancreatic carcinoma: stenting or surgical therapy? Acta Gastroenterol Belg. 2002;65:171–175.
Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc. 2010;71:490–499.
Laasch HU, Martin DF, Maetani I. Enteral stents in the gastric outlet and duodenum. Endoscopy. 2005;37:74–81.
Maetani I, Isayama H, Mizumoto Y. Palliation in patients with malignant gastric outlet obstruction with a newly designed enteral stent: a multicenter study. Gastrointest Endosc. 2007;66:355–360.
Kerker A, Hardt C, Schlief HE, et al. Combined sedation with midazolam/propofol for gastrointestinal endoscopy in elderly patients. BMC Gastroenterol. 2010;27:10–11.
Bell JK, Laasch HU, Wilbraham L, et al. Bispectral index monitoring for conscious sedation in intervention: better, safer, faster. Clin Radiol. 2004;59:1106–1113.
Mutignani M, Tringali A, Shah SG, et al. Combined endoscopic stent insertion in malignant biliary and duodenal obstruction. Endoscopy. 2007;39:440–447.
Topazian M, Baron TH. Endoscopic fenestration of duodenal stents using argon plasma to facilitate ERCP. Gastrointest Endosc. 2009;69:166–169.
Maetani I, Ukita T, Inoue H, et al. Knitted nitinol stent insertion for various intestinal stenoses using modified delivery system. Gastrointest Endosc. 2001;54:364–367.
Maetani I, Tada T, Shimura J, et al. Technical modifications and strategies for stenting gastric outlet strictures using esophageal endoprosthesis. Endoscopy. 2002;34:402–406.
Telford JJ, Carr-Locke DL, Baron TH. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study. Gastrointest Endosc. 2004;60:916–920.
Thumbe VK, Houghton AD, Smith MS. Duodenal perforation by a Wallstent. Endoscopy. 2000;32:495–497.
Isayama H, Nakai Y, Toyokawa Y, et al. Measurement of radial and axial forces of biliary self-expandable metallic stents. Gastrointest Endosc. 2009;70:37–44.
Stoeckel D, Pelton A, Duerig T. Self-expanding nitinol stents: material and design considerations. Eur Radiol. 2004;14:292–301.
Bethge N, Sommer A, Gross U, et al. Human tissue responses to metal stents implanted in vivo for the palliation of malignant stenoses. Gastrointest Endosc. 1996;43:596–602.
Vakil N, Gross U, Bethge N. Human tissue responses to metal stents. Gastrointest Endosc Clin N Am. 1999;9:359–365.
Kim GH, Kang DH, Lee DH, et al. Which types of stent, uncovered or covered, should be used in gastric outlet obstructions? Scand J Gastroenterol. 2004;39:1010–1014.
Song HY, Yang DH, Kuh JH, et al. Obstructing cancer of the gastric antrum: palliative treatment with covered metallic stents. Radiology. 1993;187:357–358.
Jung GS, Song HY, Kang SG, et al. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology. 2000;216:758–763.
Maetani I, Ukita T, Tomoko N, et al. Comparison of Ultraflex and Niti-S stents for palliation of unresectable malignant gastroduodenal obstruction. Dig Endosc. 2010;22:83–89.
Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol. 2002;97:72–78.
Jeurnink SM, Steyerberg EW, van’ t Hof G, et al. Gastrojejunostomy vs. stent placement in patients with malignant gastric outlet obstruction: a comparison in 95 patients. J Surg Oncol. 2007;96:389–396.
Schiefke I, Zabel-Langhennig A, Wiedmann M, et al. Self-expandable metallic stents for malignant duodenal obstruction caused by biliary tract cancer. Gastrointest Endosc. 2003;58:213–219.
Lee SM, Kang DH, Kim GH, et al. Self-expanding metallic stents for gastric outlet obstruction resulting from stomach cancer: a preliminary study with a newly designed double-layered pyloric stent. Gastrointest Endosc. 2007;66:1206–1210.
Lowe AS, Beckett CG, Jowett S, et al. Self-expandable metal stent placement for the palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol. 2007;62:738–744.
Yim HB, Jacobson BC, Saltzman JR, et al. Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc. 2001;53:329–332.
van Hooft J, Mutignani M, Repici A, et al. First data on the palliative treatment of patients with malignant gastric outlet obstruction using the WallFlex enteral stent: a retrospective multicenter study. Endoscopy. 2007;39:434–439.
Kim JH, Song HY, Shin JH, et al. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc. 2007;66:256–264.
Mittal A, Windsor J, Woodfield J, et al. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. Br J Surg. 2004;91:205–209.
Maetani I, Akatsuka S, Ikeda M, et al. Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy. J Gastroenterol. 2005;40:932–937.
Stawowy M, Kruse A, Mortensen FV, et al. Endoscopic stenting for malignant gastric outlet obstruction. Surg Laparosc Endosc Percutan Tech. 2007;17:5–9.
Tringali A, Mutignani M, Spera G, et al. Duodenal stent migration. Gastrointest Endosc. 2003;58:759.
Piesman M, Kozarek RA, Brandabur JJ, et al. Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial. Am J Gastroenterol. 2009;104:2404–2411.
Jeurnink SM, Polinder S, Steyerberg EW, et al. Cost comparison of gastrojejunostomy versus duodenal stent placement for malignant gastric outlet obstruction. J Gastroenterol. 2010;45:537–543.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Boškoski, I., Tringali, A., Familiari, P. et al. Self-expandable metallic stents for malignant gastric outlet obstruction. Adv Therapy 27, 691–703 (2010). https://doi.org/10.1007/s12325-010-0061-2
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12325-010-0061-2