Iruru Maetani

Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy

BackgroundIn patients with gastric outlet obstruction (GOO), palliative enteral stenting is a less invasive procedure compared with gastroenterostomy. Most diseases analyzed in previous studies of such stenting were pancreaticobiliary malignancies.MethodsWe reviewed the medical records of patients with GOO secondary to gastric cancer who were admitted to our institution between September 1994 and September 2004. The outcome of stent placement for GOO was compared with the outcome in patients who underwent palliative open gastrojejunostomy during the same period. Enrolled patients from both groups displayed symptomatic GOO. Patients with recurrent gastric cancer were excluded from this study.ResultsTwenty-two patients underwent palliative enteral stenting, and 22 patients were subjected to surgical gastrojejunostomy (bypass). There were no significant differences between the two groups regarding patient baseline characteristics. Technical success and clinical success were obtained in 100% and 77.3%, respectively, of both groups. The operating time was shorter in the stent group (30 vs 118 min; P < 0.0001). The time from the procedure to the resumption of food intake was shorter in the stent group than in the bypass group (2 days vs 8 days; P < 0.0001). An improvement in performance score after the procedure was observed in both groups (stent group; P = 0.0264; bypass group; P = 0.0235). No significant differences were observed regarding the possibility of discharge. In patients discharged, the median postoperative hospital stays were 19 days and 28 days (P = 0.0558). The median survival periods were 65 days and 90 days. Minor complications were observed in 1 patient in the stent group and in 4 in the bypass group. No mortality or severe complications were observed for either group.ConclusionsSelf-expandable metallic stent placement is a safe and efficacious procedure for palliation, with shorter operating time and more prompt restoration of oral intake, compared to surgical alternatives in patients with GOO caused by gastric cancer.

Metallic stents for gastric outlet obstruction: reintervention rate is lower with uncovered versus covered stents, despite similar outcomes

BACKGROUND Self-expandable metallic stents (SEMSs) are widely used for palliation of malignant gastric outlet obstruction (GOO). A common complication of their use, however, is stent obstruction caused by tumor ingrowth or hyperplasia. The covered SEMS was designed to prevent these problems. OBJECTIVE We compared the performance of uncovered and covered SEMSs in patients with GOO. DESIGN A retrospective study, single center. SETTING A tertiary-referral center. PATIENTS Sixty patients with symptomatic malignant GOO. INTERVENTIONS All patients received an uncovered or covered knitted nitinol stent by using the over-the-wire placement procedure. MAIN OUTCOME MEASUREMENT Comparison of the clinical outcome, complications, and the reintervention rate between uncovered and covered stents. RESULTS Thirty-one patients (mean [+/-SEM] age 72.2 +/- 2.1 years; 16 men) received uncovered SEMSs, and 29 (mean [+/-SEM] age 70.6 +/- 1.7 years; 17 men) received covered SEMSs. The technical success rate was 100% in both groups. No difference in clinical success was seen (90.3% uncovered group vs 86.2% covered group). Regarding early complications (<1 week), one mild case of pancreatitis from the stent covering the papilla occurred in each group. Late complications included reobstruction, migration, bleeding, stent fracture, and perforation. The occurrence of reobstruction did not differ between the 2 groups (3.2% uncovered group vs 10.3% covered group). No difference in migration (0% uncovered group vs 6.9% covered group) was seen. The uncovered group required less frequent reinterventions for stent reobstruction, migration, or stent fracture (3.2% uncovered group vs 20.7% covered group, P = .0490). The uncovered group had 2 major late complications: bleeding and perforation. All 60 patients died, with a median survival time of 51 days and 62 days, respectively. LIMITATIONS Small-sized, single-center, retrospective study. CONCLUSIONS In palliation for malignant GOO, covered stents were associated with a more frequent need for reintervention than uncovered stents, despite similar outcomes and complications. These results require confirmation in a larger randomized comparison.

PEG with introducer or pull method: a prospective randomized comparison.

BACKGROUND PEG by the conventional pull method has the potential drawback of being associated with a higher frequency of wound infection, presumably caused by contamination of the gastrostomy catheter as it passes through the oral cavity. This study investigated the occurrence of peristomal wound infection after PEG placement by using the pull and introducer techniques. METHODS Between September 1999 and May 2002, consecutive patients with dysphagia for whom PEG was recommended were enrolled in the study and randomly assigned to two groups: PEG with the introducer method (Group I) or PEG with the pull method (Group II). The peristomal area of each patient was evaluated on a daily basis for one week after PEG. Erythema and exudate were scored on a scale from 0 to 4 and induration on a scale of 0 to 3. Criteria for infection were a maximum combined score of 8 or higher, or the presence of microscopic and microbiologic evidence of suppurating exudate. In each group, the endoscope was passed once during the procedure, and an antibiotic (piperacillin) was given prophylactically. All procedures were performed by one investigator with the assistance of another physician. RESULTS Of the 60 patients enrolled, 30 were assigned to each group. PEG was successful in all patients. One patient was excluded from each group because of death (Group I, stroke; Group II, myocardial infarction) within one week of the procedure. Therefore, 58 patients, 29 in each group, were evaluated. There was no significant difference between the groups in terms of clinical parameters (age, gender, disease, performance score, mode of previous feeding, and recent antibiotic exposure). The occurrence of peristomal infection within one week of PEG was lower in Group I (introducer method) (0 vs. 9; p = 0.00094). The mean daily combined scores in Group I were significantly lower than those in Group II. Median of maximum parameter scores in Group I were significantly lower than those in Group II. There were no procedure-related mortalities or clinically significant wound infections that required surgical intervention. CONCLUSIONS The risk of peristomal wound infection after PEG is lower with the introducer method compared with the pull method.

Clinical outcome of endoscopic resection for nonampullary duodenal tumors

BACKGROUND AND STUDY AIMS Compared with any other location in the gastrointestinal tract, the duodenum presents the most challenging site for endoscopic resection. The aim of this study was to analyze the clinical outcomes of duodenal endoscopic resection and to assess the feasibility of the technique as a therapeutic procedure. PATIENTS AND METHODS A total of 113 consecutive patients with 121 nonampullary duodenal tumors underwent endoscopic resection by endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), or polypectomy between January 2000 and September 2013. Long-term outcomes were investigated in patients with more than 1 year follow-up. RESULTS The median tumor size was 12 mm (range 3 - 50 mm). Lesions consisted of 63 adenocarcinomas/high-grade intraepithelial neoplasias (53 %) and 57 adenomas/low-grade intraepithelial neoplasias (48 %). Endoscopic resection included 106 EMRs (87 %), 8 ESDs (7 %), and 7 polypectomies (6 %). En bloc resection was achieved in 77 lesions (64 %), and 43 lesions (35 %) underwent piecemeal resection; one procedure was discontinued due to perforation. There were 14 cases of delayed bleeding after EMR (12 %), 1 perforation (1 %) during ESD, and 1 delayed perforation (1 %) after ESD, which required emergency surgery. Of the 76 patients who were followed for more than 1 year, none of the patients died from a primary duodenal neoplasm, and there were no local recurrences during the 51-month median follow-up period (range 12 - 163 months). CONCLUSIONS Duodenal endoscopic resection was feasible as a therapeutic procedure, but it should only be performed by highly skilled endoscopists because of its technical difficulty. Piecemeal resection by EMR is acceptable for small lesions, based on these excellent long-term outcomes.

Peroral insertion techniques of self-expanding metal stents for malignant gastric outlet and duodenal stenoses

Self-expanding metal stents (EMS) have gained widespread popularity for the palliative treatment of various stenoses in blood vessels, biliary ducts, bronchi, and the gastrointestinal tract. Regarding stenoses of the upper gastrointestinal tract, EMS insertion for gastric outlet and duodenal stenoses is considerably more difficult than for esophageal stenoses. We describe a reliable EMS insertion technique for malignant gastric outlet and duodenal stenoses.

Comparison of partially covered nitinol stents with partially covered stainless stents as a historical control in a multicenter study of distal malignant biliary obstruction: the WATCH study

BACKGROUND Covered self-expandable metal stents (CSEMSs) were developed to prevent tumor ingrowth, but stent migration is one of the problems with CSEMSs. OBJECTIVE To evaluate a new, commercially available CSEMS with flared ends and low axial force compared with a commercially available CSEMS without the anti-migration system and high axial force. DESIGN Multicenter, prospective study with a historical cohort. SETTING Twenty Japanese referral centers. PATIENTS This study involved patients with unresectable distal malignant biliary obstruction. INTERVENTION Placement of a new, commercially available, partially covered SEMS. MAIN OUTCOME MEASUREMENTS Recurrent biliary obstruction rate, time to recurrent biliary obstruction, stent-related complications, survival. RESULTS Between April 2009 and March 2010, 141 patients underwent partially covered nitinol stent placement, and between May 2001 and January 2007, 138 patients underwent placement of partially covered stainless stents as a historical control. The silicone cover of the partially covered nitinol stents prevented tumor ingrowth. There were no significant differences in survival (229 vs 219 days; P = .250) or the rate of recurrent biliary obstruction (33% vs 38%; P = .385) between partially covered nitinol stents and partially covered stainless stents. Stent migration was less frequent (8% vs 17%; P = .019), and time to recurrent biliary obstruction was significantly longer (373 vs 285 days; P = .007) with partially covered nitinol stents. Stent removal was successful in 26 of 27 patients (96%). LIMITATIONS Nonrandomized, controlled trial. CONCLUSION Partially covered nitinol stents with an anti-migration system and less axial force demonstrated longer time to recurrent biliary obstruction with no tumor ingrowth and less stent migration.

Wire-guided selective cannulation of the bile duct with a sphincterotome: a prospective randomized comparative study with the standard method

Abstract Objective. Wire-guided cannulation (WGC) is expected to reduce the incidence of post-ERCP pancreatitis (PEP). Our aim was to compare the incidence of PEP and the success rate of deep biliary cannulation using WGC or the standard cannulation method with contrast injection (STD). Material and methods. A total of 172 cases with an intact papilla were randomized into the STD group (n = 86) and the WGC group (n = 86). First a trainee endoscopist attempted the cannulation and if it was not successful, an expert endoscopist tried. When the cannulation was not successful within 10 min, the other method was conducted as a second attempt. The primary endpoint was the incidence of PEP and the secondary endpoint was the success rate of selective cannulation. Results. In successful cases, PEP occurred in 6.5% in the STD group and 3.0% in the WGC group in the first attempt. Overall rate of PEP was 6.0% (3, mild; 1, moderate and 1, severe) in the STD group and 2.3% (2, mild) in the WGC group, which were not significantly different. Selective cannulation rate in the first attempt was 73.8% in the STD group and 77.9% in the WGC group. After a crossover, the cannulation was successful in the second attempt in 36.4% and 42.1% and finally in 95.2% and 100% by the STD and WGC method, respectively. Conclusions. The incidence of PEP tended to be lower in the WGC method compared to the STD method. In addition, all cases of pancreatitis in the WGC group were mild. The success rate of cannulation was comparable between two groups.

Japanese multicenter estimation of wallflex duodenal stent for unresectable malignant gastric outlet obstruction

This retrospective study estimated the efficacy and safety of the WallFlex duodenal stent for malignant gastric outlet obstruction (GOO) in Japan.

Self-expandable metallic stent placement as palliative treatment of obstructed colorectal carcinoma

BackgroundStent placement in palliation of unresectable colon cancer is an alternative to surgical treatment. The through-the-scope stent for the exclusive treatment of colorectal cancer is not available in Japan. This report describes the use of an esophageal stent and the technical modifications required for its success in the treatment of colorectal strictures. We describe various technical strategies for colorectal stent placement and report on the outcomes.MethodsMedical records of patients who underwent palliative colonic stenting between June 1997 and March 2003 were reviewed retrospectively, and the clinical outcome was evaluated.ResultsInsertion of a metallic esophageal stent was attempted in 12 patients (mean age, 73.0 years; 5 male, 7 female). Location of the stricture was in the rectum in 4 patients and in the sigmoid, descending, or transverse segments of the colon in 5, 1, and 2 patients, respectively. Two patients had recurrent colon cancer after surgery. The remaining 10 patients did not undergo surgery. Stent placement was technically successful in 11 patients, giving a technical success rate of 92%. Following successful stent placement, all but 1 patient obtained clinical success, generating a clinical success rate of 83%. Late complications occurred in 4 patients and included 2 migrations, 2 bleeds, and 1 obstruction. The complication rate of the procedure was 33.3%. There was no mortality or severe complications. The median survival period was 120 days.ConclusionsStent placement can be considered safe and effective palliation for unresectable colorectal cancer. With technical modification of an esophageal stent, this procedure is now feasible.

Reduced Risk of Peristomal Infection of Direct Percutaneous Endoscopic Gastrostomy in Cancer Patients: Comparison with the Pull Percutaneous Endoscopic Gastrostomy Procedure

BACKGROUND Although pull percutaneous endoscopic gastrostomy (Pull-PEG) is a commonly used procedure, peristomal infection and tumor implantation are considered unavoidable complications of this procedure as the instrument passes through the oral cavity. A novel extracorporeal PEG technique, Direct-PEG, has been developed to reduce the risk of peristomal infection and implantation. STUDY DESIGN The Direct-PEG procedure was performed on 87 patients from April 2006 to April 2007 in a single, high-volume cancer center in Japan. To compare the surgical outcomes of Direct-PEG and Pull-PEG, the clinical outcomes of Direct-PEG, such as peristomal infection, were retrospectively collected and compared with those of 64 patients having Pull-PEG procedures from April 2005 to March 2006. RESULTS The mean operation time for the Direct-PEG group (13+/-1 minutes) was comparable to that for the Pull-PEG group (12+/-1 minutes), and the mean visual analogue pain score during surgery was lower for the Direct-PEG group (3.5+/-1.7) than for the Pull-PEG group (24.6+/-3.6; p < 0.001). The incidence of peristomal infection was lower in the Direct-PEG group (1%) than in the Pull-PEG group (9%; p=0.001). Although the most common major underlying disease in the groups was oropharyngeal or esophageal tumor, tumor implantation was not observed in either group. CONCLUSIONS Direct-PEG may be superior to the Pull-PEG method for a high-volume cancer center because of reduced risks of infection.