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CC BY-NC-ND 4.0 · Endosc Int Open 2024; 12(03): E367-E376
DOI: 10.1055/a-2261-2833
Original article

Incidence and factors associated with stent dysfunction and pancreatitis after gastroduodenal stenting for malignant gastric outlet obstruction

Daiki Yamashige
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Susumu Hijioka 
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Yoshikuni Nagashio
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Yuta Maruki
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Soma Fukuda 
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Shin Yagi
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Kohei Okamoto
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Hidenobu Hara
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Yuya Hagiwara
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Daiki Agarie
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Tetsuro Takasaki
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Mark Chatto
2   Department of Gastroenterology, Makati Medical Center, Makati City, Philippines (Ringgold ID: RIN37571)
,
Akihiro Ohba
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Shunsuke Kondo
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Chigusa Morizane
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Hideki Ueno
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Miyuki Sone
3   Department of Diagnostic Radiology, National Cancer Center Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
,
Yutaka Saito
4   Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
,
Takuji Okusaka
1   Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital Japan, Chuo-ku, Japan (Ringgold ID: RIN13874)
› Author AffiliationsSupported by: National Cancer Center Research and Development Fund 2022-A-16
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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.

Keywords

Endoscopy Upper GI Tract - Malignant strictures - Dilation, injection, stenting - Pancreatobiliary (ERCP/PTCD) - Strictures

Supplementary Material



Publication History

Received: 24 September 2023

Accepted after revision: 13 December 2023

Accepted Manuscript online:
05 February 2024

Article published online:
07 March 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Tendler DA. Malignant gastric outlet obstruction: bridging another divide. Am J Gastroenterol 2002; 97: 4-6 DOI: 10.1111/j.1572-0241.2002.05391.x. (PMID: 11808968)
    CrossrefPubMedGoogle Scholar
  • 2 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Ahmed O, Lee JH, Thompson CC. et al. AGA clinical practice update on the optimal management of the malignant alimentary tract obstruction: expert review. Clin Gastroenterol Hepatol 2021; 19: 1780-1788 DOI: 10.1016/j.cgh.2021.03.046. (PMID: 33813072)
    CrossrefPubMedGoogle Scholar
  • 4 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 DOI: 10.1038/ajg.2009.409. (PMID: 19707192)
    CrossrefPubMedGoogle Scholar
  • 5 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 DOI: 10.1016/j.gie.2009.09.042. (PMID: 20003966)
    CrossrefPubMedGoogle Scholar
  • 6 Chandrasegaram MD, Eslick GD, Mansfield CO. et al. Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction. Surg Endosc 2012; 26: 323-329 DOI: 10.1007/s00464-011-1870-3. (PMID: 21898024)
    CrossrefPubMedGoogle Scholar
  • 7 Jang S, Stevens T, Lopez R. et al. Superiority of gastrojejunostomy over endoscopic stenting for palliation of malignant gastric outlet obstruction. Clin Gastroenterol Hepatol 2019; 17: 1295-1302.e1
    CrossrefPubMedGoogle Scholar
  • 8 Mintziras I, Miligkos M, Wächter S. et al. Palliative surgical bypass is superior to palliative endoscopic stenting in patients with malignant gastric outlet obstruction: systematic review and meta-analysis. Surg Endosc 2019; 33: 3153-3164
    CrossrefPubMedGoogle Scholar
  • 9 Yamao K, Kitano M, Chiba Y. et al. Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction. Gut 2021; 70: 1244-1252 DOI: 10.1136/gutjnl-2020-320775. (PMID: 33223499)
    CrossrefPubMedGoogle Scholar
  • 10 Hori Y, Naitoh I, Hayashi K. et al. Predictors of outcomes in patients undergoing covered and uncovered self-expandable metal stent placement for malignant gastric outlet obstruction: a multicenter study. Gastrointest Endosc 2017; 85: 340-348.e1
    CrossrefPubMedGoogle Scholar
  • 11 Sasaki T, Isayama H, Nakai Y. et al. Predictive factors of solid food intake in patients with malignant gastric outlet obstruction receiving self-expandable metallic stents for palliation. Dig Endosc 2012; 24: 226-230
    CrossrefPubMedGoogle Scholar
  • 12 Reijm AN, Zellenrath PA, van der Bogt RD. et al. Self-expandable duodenal metal stent placement for the palliation of gastric outlet obstruction over the past 20 years. Endoscopy 2022; 54: 1139-1146 DOI: 10.1055/a-1838-5642. (PMID: 35483885)
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Tringali A, Costa D, Anderloni A. et al. Covered versus uncovered metal stents for malignant gastric outlet obstruction: a systematic review and meta-analysis. Gastrointest Endosc 2020; 92: 1153-1163.e9
    CrossrefPubMedGoogle Scholar
  • 14 Yamao K, Kitano M, Kayahara T. et al. Factors predicting through-the-scope gastroduodenal stenting outcomes in patients with gastric outlet obstruction: a large multicenter retrospective study in West Japan. Gastrointest Endosc 2016; 84: 757-763.e6
    CrossrefPubMedGoogle Scholar
  • 15 Hamada T, Hakuta R, Takahara N. et al. Covered versus uncovered metal stents for malignant gastric outlet obstruction: systematic review and meta-analysis. Dig Endosc 2017; 29: 259-271 DOI: 10.1111/den.12786. (PMID: 27997723)
    CrossrefPubMedGoogle Scholar
  • 16 Amateau SK, Wolfgang CL, Khashab MA. Pancreaticobiliary obstruction following duodenal stent placement. Endoscopy 2012; 44 (Suppl. 02) E17-E18 DOI: 10.1055/s-0031-1291500. (PMID: 22396255)
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Lou GC, Yang JM, Ke JJ. et al. Acute pancreatitis induced by placement of a duodenal stent. Endoscopy 2013; 45 (Suppl. 02) E256-E257
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 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 DOI: 10.1111/j.1572-0241.2002.05423.x. (PMID: 11808972)
    CrossrefPubMedGoogle Scholar
  • 19 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
    CrossrefPubMedGoogle Scholar
  • 20 Austin PC, Fine JP. Practical recommendations for reporting Fine-Gray model analyses for competing risk data. Stat Med 2017; 36: 4391-4400 DOI: 10.1002/sim.7501. (PMID: 28913837)
    CrossrefPubMedGoogle Scholar
  • 21 Okuwaki K, Kida M, Yamauchi H. et al. Randomized controlled exploratory study comparing the usefulness of two types of metallic stents with different axial forces for the management of duodenal obstruction caused by pancreatobiliary cancer. J Hepatobiliary Pancreat Sci 2016; 23: 289-297
    CrossrefPubMedGoogle Scholar
  • 22 Sato T, Hara K, Mizuno N. et al. Gastroduodenal stenting with Niti-S stent: long-term benefits and additional stent intervention. Dig Endosc 2015; 27: 121-129
    CrossrefPubMedGoogle Scholar
  • 23 Oh SY, Edwards A, Mandelson M. et al. Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: comparison of pancreatic cancer and nonpancreatic cancer. Gastrointest Endosc 2015; 82: 460-468.e2
    CrossrefPubMedGoogle Scholar
  • 24 Sasaki T, Isayama H, Nakai Y. et al. Clinical outcomes of secondary gastroduodenal self-expandable metallic stent placement by stent-in-stent technique for malignant gastric outlet obstruction. Dig Endosc 2015; 27: 37-43 DOI: 10.1111/den.12321. (PMID: 24995858)
    CrossrefPubMedGoogle Scholar
  • 25 Sasaki T, Ishibashi R, Yoshida S. et al. Comparing the mechanical properties of a self-expandable metallic stent for colorectal obstruction: proposed measurement method of axial force using a new measurement machine. Dig Endosc 2021; 33: 170-178 DOI: 10.1111/den.13671. (PMID: 32196766)
    CrossrefPubMedGoogle Scholar
  • 26 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 DOI: 10.1016/j.gie.2008.09.032. (PMID: 19249766)
    CrossrefPubMedGoogle Scholar
  • 27 Ko HK, Song HY, Shin JH. et al. Fate of migrated esophageal and gastroduodenal stents: experience in 70 patients. J Vasc Interv Radiol 2007; 18: 725-732 DOI: 10.1016/j.jvir.2007.02.030. (PMID: 17538134)
    CrossrefPubMedGoogle Scholar
  • 28 Lee PH, Moore R, Raizada A. et al. Small bowel perforation after duodenal stent migration: an interesting case of a rare complication. World J Radiol 2011; 3: 152-154 DOI: 10.4329/wjr.v3.i6.152. (PMID: 21860709)
    CrossrefPubMedGoogle Scholar
  • 29 Moxey PW, Khan AZ, Karanjia ND. A case of small-bowel perforation caused by a migrated duodenal stent. Endoscopy 2007; 39: E54 DOI: 10.1055/s-2006-944903. (PMID: 17323276)
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Shi-Yi L, Ai-Wu M, Yi-Ping J. et al. Placement of duodenal stents across the duodenal papilla may predispose to acute pancreatitis: a retrospective analysis. Diagn Interv Radiol 2012; 18: 360-364 DOI: 10.4261/1305-3825.DIR.5045-11.1. (PMID: 22399365)
    CrossrefPubMedGoogle Scholar
  • 31 van Wanrooij RLJ, Vanella G, Bronswijk M. et al. Endoscopic ultrasound-guided gastroenterostomy versus duodenal stenting for malignant gastric outlet obstruction: an international, multicenter, propensity score-matched comparison. Endoscopy 2022; 54: 1023-1031 DOI: 10.1055/a-1782-7568. (PMID: 35325931)
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Ge PS, Young JY, Dong W. et al. EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction. Surg Endosc 2019; 33: 3404-3411 DOI: 10.1007/s00464-018-06636-3. (PMID: 30725254)
    CrossrefPubMedGoogle Scholar
  • 33 Chen YI, Kunda R, Storm AC. et al. EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc 2018; 87: 1215-1221 DOI: 10.1016/j.gie.2017.07.030. (PMID: 28750837)
    CrossrefPubMedGoogle Scholar
  • 34 Bronswijk M, Vanella G, van Malenstein H. et al. Laparoscopic versus EUS-guided gastroenterostomy for gastric outlet obstruction: an international multicenter propensity score-matched comparison (with video). Gastrointest Endosc 2021; 94: 526-536.e2
    CrossrefPubMedGoogle Scholar