Max Bittinger

A Randomized Prospective Comparison of Self-Expandable Plastic Stents and Partially Covered Self-Expandable Metal Stents in the Palliation of Malignant Esophageal Dysphagia

OBJECTIVES:Self-expanding metal stents (SEMS) provide effective palliation in patients with malignant dysphagia, although severe complications and mortality may result. We performed a prospective controlled trial to compare a new self-expanding polyester mesh stent (Polyflex) with SEMS (Ultraflex).METHODS:One hundred one patients with unresectable esophageal carcinoma were randomized to placement of a Polyflex (N = 47) or a partially covered Ultraflex (N = 54) stent. Patients with esophagogastric junction (EGJ) malignancy were excluded.RESULTS:Placement was successful in 46 (98%) patients with the Polyflex and 54 (100%) patients with the Ultraflex stent. In one patient, the Polyflex stent could not be placed. After 1 wk, dysphagia was improved by at least 1 grade in 100% of the Polyflex group and in 94% of the Ultraflex group. Major complications were observed in 48% of the Polyflex group and 33% of the Ultraflex group. Intraprocedural perforation occurred in 1 Polyflex and 1 Ultraflex patient. Two Polyflex patients had postprocedural hemorrhage. Twenty (44%) patients with a Polyflex stent and 18 (33%) with an Ultraflex stent had recurrent dysphagia because of tumor overgrowth, stent migration, hyperplastic granulomatous reaction, or food bolus impaction. Multivariate analysis showed a significantly higher complication rate with Polyflex than with Ultraflex stents (odds ratio 2.3, 95% CI 1.2–4.4). However, median survival was 134 days with Polyflex and 122 days with Ultraflex stents (P = NS).CONCLUSIONS:No difference was seen in palliation of dysphagia between the two stents. Significantly more complications, especially late stent migration, were observed in the Polyflex group.

Treatment of malignant gastroduodenal obstruction with a nitinol self-expanding metal stent: an international prospective multicentre registry.

BACKGROUND Duodenal stenting has become a broadly accepted first line of treatment for patients with advanced malignant gastroduodenal obstruction as these patients are difficult to treat and are poor surgical candidates. AIMS To document duodenal stent performance for palliative management of malignant gastroduodenal obstruction. METHODS Multicentre, single arm, prospective registry documenting peroral endoscopic duodenal stenting procedures in 202 patients. RESULTS Technical success achieved in 98% (CI, 95%, 99%) of stent placements. Increase of Gastric Outlet Obstruction Score by at least 1 point compared to baseline was achieved in 91% (CI, 86%, 95%) of patients persisting for a median of 184 days (CI, 109, 266). By day 5 (CI, 4, 6) after stent placement, 50% of patients experienced a score increase of at least 1 point. Improvement from 14% of patients at baseline tolerating soft solids or low residue/normal diet to 84% at 15 days, 86% at 30 days, 81% at 90 days, 79% at 180 days, and 70% at 270 days. Complications included stent ingrowth and/or overgrowth (12.4%), transient periprocedural symptoms (3%), bleeding (3%), stent migration (1.5%), and perforation (0.5%). CONCLUSIONS Safety and effectiveness of duodenal stenting for palliation of malignant gastroduodenal obstruction was confirmed in the largest international prospective series to date.

4730 Antibiotic prophylaxis in percutaneous endoscopic gastrostomy in patients with malignant tumors.

The use of ABP in reducing local wound infection rates after PEG insertion is controversial. Previous observations suggested that patients with malignant tumors are at high risk of developing local infections after receiving a PEG. Aim of this study was to test if patients with malignant tumors benefit from an ABP prior to PEG insertion. Methods: Prospective randomized study with 25 patients with malignant tumors receiving their first PEG (thread pull method). Group 1 received an ABP with 2g cefotiam i.v. prior to PEG insertion, group 2 received no ABP. The rate and severity of local infections in the 4 days after PEG insertion were estimated by a score (value 0-21) consisting of the following parameters: Signs of infection at the site of insertion (0-4), local pain (0-3), systemic complications (0-2), body temperature (0-4) and rise in blood leucocytes (0-4) and CRP (0-4) between day 0 and 4 after PEG insertion. Results: Local infections occurred in 11/25 pts (44%): in group 1 in 4/14 pts (29%) and in group 2 in 7/11 pts (63%). Severe local infections were not observed in group 1, but occurred in 5 pts in group 2 (3 purulent secretions, 2 erythemata with secretion). The mean score value in group 1 (2.5±0.8) was significantly lower (p=0.019, Mann-Whitney test) than in group 2 (5.9±1.1)(Fig). The PEG had to be removed due to local infection in 2 pts in group 2, but in none of group 1. Conclusion: Patients with malignant tumors have a high risk of developing local infections after PEG insertion. An antibiotic propylaxis with cefotiam is able to lower the rate and particularly the severity of local infections. It should be recommended in all patients with malignant tumors.