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BACKGROUND Malignancies-related esophagogastric junction (EGJ) obstruction is usually diagnosed in inoperable status with poor clinical outcomes. Metallic stent placement at EGJ could improve dysphagia for these patients. However, studies regarding the outcomes in these patients receiving metallic stents are still limited. This study aimed to investigate the outcomes of metallic stent placement in malignant EGJ obstruction. METHODS Forty-one patients with inoperable malignant EGJ obstruction receiving metallic stent placement were retrospectively enrolled. The clinical outcomes between different stents and deployment techniques were analyzed. RESULTS The overall technical success rate was 97.6% and clinical success rate was 92.1%. The median overall survival time was 77 (4-893) days, and the patency time was 71 (4-893) days, respectively. Post-stent radiotherapy significantly prolonged survival and stent patency. Between patients receiving uncovered or partially covered metal stents, there was no difference in procedure-related complications, survival time and stent patency time. Moreover, the clinical outcomes in patients receiving duodenal stents for malignant EGJ obstruction is not inferior to those receiving esophageal stents. CONCLUSION This study provides crucial information for endoscopists to establish individualized stenting strategies for malignant EGJ obstruction.

Deployment of bare metal duodenal stents for individuals with gastric outlet obstructions (GOOs) is a well-characterized measure to improve the quality of life. However, these interventions are palliative in nature and are associated with known complications. We present an unfortunate case of a previously not well described, albeit not surprising, a complication of stent placement. The individual underwent duodenal stent placement due to obstructive metastatic disease and subsequently presented for gastrointestinal (GI) bleed. It was determined that an aortoduodenal fistula acutely developed and, despite heroic efforts, the patient ultimately expired.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard procedure for malignant jaundice palliation; however, it can be challenging when a duodenal self-expandable metal stent (SEMS) is already in place. Patients and methods The primary aim of our study was to evaluate the technical feasibility of the placement of a lumen apposing metal stent (LAMS) through the mesh (TTM) of duodenal stents. The secondary aims were to evaluate clinical outcomes and adverse events (AEs) related to the procedures. Results Data from 23 patients (11 F and 12 M; mean age: 69.5 ± 11 years old) were collected. In 17 patients (73.9 %) TTM LAMS placement was performed as first intention, while in six patients (26.1 %) it was performed after a failed ERCP. Thirteen patients (56.5 %) underwent the procedure due to advanced pancreatic head neoplasia. One technical failure was experienced (4.3 %). The TTM LAMS placement led to a significant decrease in the serum levels of bilirubin, ALP, GGT, WBC and CRP. No cases of duodenal SEMS occlusion occurred and no other AEs were observed during the follow-up. Conclusions Concomitant malignant duodenal and biliary obstruction is a challenging condition. Palliation of jaundice using TTM LAMS in patients already treated with duodenal stent is associated to promising technical and clinical outcomes.

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with a preexisting duodenal stent covering the papilla is particularly challenging. The aim of this study was to describe a multicenter experience of performing ERCP in patients with biliary obstruction in whom the papilla was obscured by a preexisting duodenal stent. A total of 38 patients with preexisting duodenal stents obscuring the papilla underwent ERCP. Endoscopic biliary cannulation was successful in 13 patients (34.2 %). In 12 of these 13 patients (92.3 %), endoscopic therapy was performed during the same procedure and achieved clinical success with relief of jaundice in all cases (100 %). The most commonly utilized procedure in patients in whom ERCP failed was EUS-guided biliary drainage (EGBD; n = 13 /22, 59.1 %), followed by percutaneous transhepatic biliary drainage (n = 9 /22, 40.9 %). Three patients in whom ERCP failed either did not consent to further intervention or were transferred to other centers. Thus, ERCP was technically challenging in our cohort of patients with preexisting duodenal stents, but was nonetheless successful in about one third of cases. Overall, when performed by experts, endoscopic biliary drainage (via ERCP or EGBD) can be successfully achieved in the majority of patients with indwelling duodenal stents.

Patients with malignant pancreatobiliary neoplasm sometimes manifest duodenal obstruction and biliary stricture synchronously or metachronously. In this paper, we reviewed our experience with and technique for combined endoscopic duodenal stent placement and endoscopic ultrasonography (EUS)-guided biliary drainage. Between May 2007 and September 2009, this combined technique was performed on seven patients with distal biliary strictures and duodenal obstructions. The clinical success rate of the procedure, complications, patency periods of duodenal stents and patency periods of biliary stents were retrospectively evaluated. Clinical success was achieved in all seven cases for both procedures. Complications related to EUS-biliary drainage, namely localized peritonitis due to bile leakage, occurred in two cases. Both patients recovered without additional interventions. Occlusion of a duodenal stent was observed in one patient, but additional intervention could not be performed due to sepsis. Occlusion of both a duodenal stent and a biliary stent was also observed in one patient, and this was resolved with the insertion of an additional duodenal stent and a biliary stent exchange. In conclusion, combined duodenal stent placement and EUS-guided biliary drainage is a therapeutic option in case of failed endoscopic retrograde cannulation of malignant strictures with a malignant duodenal obstruction.

The purpose of this study is to evaluate the efficacy of palliation of malignant biliary and duodenal obstruction with combined metallic stenting under fluoroscopy guidance. A retrospective analysis of 9 patients (6 men and 3 women) who underwent biliary and duodenal stenting was performed. The mean age of patients was 61 years (range: 42–80 years). The causes of obstruction were pancreatic carcinoma in 7 patients, cholangiocellular carcinoma in one, and duodenal carcinoma in the other. Biliary and duodenal stents were placed simultaneously in 4 patients. In other 5 patients dudodenal stents were placed after biliary stenting when the duodenal obstruction symptoms have developed. In two patients duodenal stents were advanced via transgastric approach. Technical success rate was 100 %. After percutaneous biliary drainage and stenting bilirubin levels decreased to normal levels in 6 patients and in remaining 3 patients mean reduction of 71% in bilirubin levels was achieved. Tumoral ingrowth occurred in one patient and percutaneous biliary restenting was performed 90 days after the initial procedure. Of the 9 patients, 6 patients were able to tolerate solid diet, whereas 2 patients could tolerate liquid diet and one patient did not show any improvement. Mean survival periods were 111 and 73 days after biliary and duodenal stenting, respectively. Combined biliary and duodenal stent placement which can be performed under fluoroscopic guidance without assistance of endoscopy is feasible and an effective method of palliation of malignant biliary and duodenal obstructions. If transoral and endoscopic approaches fail, percutaneous gastrostomy route allows duodenal stenting.

Duodenal stenting has been gradually established in recent years because it is less invasive than standard surgical procedures and produces a rapid therapeutic response. For palliation of both duodenal and biliary stenoses, double stenting may be performed. Duodenal stents offer a great advantage in allowing endoscopic retrograde cholangiopancreatography (ERCP) without the need for balloon dilation. When biliary stent dysfunction occurs, the patient undergoes diagnostic and/or therapeutic ERCP across the duodenal stent. We encountered a duodenal stent fracture in a patient who required repeated ERCPs for stent dysfunction. Duodenal stent fractures have not previously been reported. The damaged stent was successfully repaired by using a cutting wire filament and placing another duodenal stent coaxially with the first. Clinicians should be aware of the possibility of stent fracture following endoscopic procedures, such as an ERCP, that require passage through the stent. The procedure described in this report would be of significant benefit if a gastrointestinal stent is fractured and occluded by a broken part.

Duodenal stents are frequently used for palliating malignant gastric outlet obstruction. Successful stent placement relieves obstructive symptoms, is cost effective, and has a relatively low complication rate. However, enteral stents have the potential of migrating distally and rarely, even lead to bowel perforation. We present a rare case of a duodenal stent placed as a palliative measure for gastric outlet obstruction due to unresectable pancreatic cancer that migrated distally after a gastrojejunostomy resulting in small bowel perforation.

Introduction Stent placement for malignant gastric outflow obstruction (GOO) is recommended for palliative management for patients with unresectable disease. Gastrojejunostomy is an alternative but may not be appropriate due to poor performance status and prognosis. Endoscopic SEMS for GOO is less invasive and has been shown to be safe and effective method for relieving symptoms of GOO. Previously reported endoscopic success rate of GOO stenting is 92–100%. 1 Our aim was to assess the safety and efficacy of pyloric and duodenal stents (SEMS) for gastric outflow obstruction caused by malignancy. Method Retrospective audit between Jan 2012 to Dec 2014, reviewing medical notes and electronic patient records. All procedures were performed using Through the Scope (TTS) technique and fluoroscopic guidance. End-points were technical success (correct SEMS placement confirmed radiologically and endoscopically at time of procedure) and clinical success (resolution of obstructive symptoms, resumption of oral diet). Results 63 patients were identified (median age 71 years). 50 patients (79%) had malignant stricture due to primary cancers (gastric 33%, pancreatic 25%). 13 patients had GOO from metastases (20%). Median ASA grade was 3. Procedural Success 4 patients did not require stent placement when evaluated endoscopically. Of the remaining 59 patients 55 were stented successfully (93.2%). In 4 patients stents could not be deployed as stricture could not be traversed with wire or cannula. Of the 55 patients who were stented clinical success was 96% (2 patients needed repeat procedure within one week). 13 patients (25%) required further interventions due to stent blockage from tumour ingrowth or food debris and all successfully managed with restenting. The mean time for further intervention 98 day. 83 procedures were carried in total with an overall success rate of 95.2%. There were no major complications reported, no perforation or procedure related mortality. Two patient had stent migrated proximally into stomach and one patient needed repeat procedure due to lack of stent expansion, all managed with successful restenting. Survival 78% were alive at 30 days, 32% were alive at 6 month with 4 patients yet to reach 6 month end point, 33% alive at 1 year. Conclusion Stenting for GOO is a safe procedure and avoids the need for surgical gastroenterojejunostomy in over 93% of palliative patients. Stent dysfunction can happen due to tumour overgrowth, food debris or stent migration. In our study all 25% of patients needing reintervention within 4 months were successfully managed with restenting. Disclosure of interest None Declared. Reference Gaidos JKJ. Treatment of malignant gastric outlet obs truction with endoscopically placed self -expandable metal stents. World J Gastroenterol 2009;15(35):4365–4371