INDICATIONS AND RESULTS OF ENTERAL STENT PLACEMENT<br />G.Vanbiervliet, M.D <br />Endoscopy Unit, L’Archet 2 Hospital, Nic...
To relieve obstruction with an expandable metallic material restoring the flow of digestive contents…<br />Malignantgastri...
Benign conditions ?!<br />was made possible by the membrane of the covered stent<br />[Silicone or PTFE]<br />=> possibili...
MalignantGastricOutlet Obstruction <br />10 to 25% of patients withpancreatic cancer => duodenal obstruction<br />Espinel ...
MalignantGastricOutlet Obstruction <br />Whenshouldwe insert a duodenal stent ?<br />Level of oral intakeassessed by GOO S...
Most frequentprimaryendpointused in studies
70% of patients includedwith GOOSS [0 – 1] in the samestudies</li></ul>Adler DH et Baron TH - Am J Gastroenterol 2002 <br />
MalignantGastricOutlet Obstruction <br />But itis not enough….<br />Large capacity of the stomach to distend !! <br />naus...
 Four types of strictures<br />Type I : antrum / duodenal bulb <br />/ upperduodenalgenu<br />Type II : second part of the...
And somecriticaltechnical points in the gastro duodenal stenting<br />Avoid aspiration by emptyingstomachwithnasogastric t...
Manage the biliary obstruction<br />The Golden rules :<br /><ul><li>During the gastro duodenal stenting, try to avoidcover...
Manage biliary obstruction<br />Our experience in 18 patients with biliary symptomsafterduodenal stenting…<br />Duodenal s...
Results: the example<br />« Duoflex » study – Malignant GOO<br />51 patients with prospective follow up<br />Technicalsucc...
Results: metaanalysis and review<br />From 1996 to 2005<br />versus GJJ<br />2 randomized trials<br />6 comparative studie...
Results: comparingwith surgery<br />SUSTENT Study - Jeurnink et al. Gastrointestendosc 2010 <br />Prospective and Randomiz...
Results : comparingwith the surgery<br />Stent providesfasterresults in oral intake<br />GJJ has better long-termresults (...
Covered or uncovered stent ?<br />134 patients treated for malignant gastric outlet obstruction<br />Stent migration was t...
Predictivefactors of survival<br />Prospective observational multicentric study of 105 patients with gastric outlet obstru...
The future ?<br />To combine the safety of the duodenal stent with the long-term efficacy of a surgicalbypass<br />Endosco...
The future ?<br />The NOTES ?<br />Using the endoscope to create a truegastrojejunalanastomosis !!<br />With a double work...
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Endoscopy in Gastrointestinal Oncology - Slide 11 - G. Vanbiervliet - Indications and results of enteral stent placement

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Endoscopy in Gastrointestinal Oncology - Slide 11 - G. Vanbiervliet - Indications and results of enteral stent placement

  1. 1. INDICATIONS AND RESULTS OF ENTERAL STENT PLACEMENT<br />G.Vanbiervliet, M.D <br />Endoscopy Unit, L’Archet 2 Hospital, Nice, France<br />Centre<br />Hospitalier<br />Universitaire de Nice<br />
  2. 2. To relieve obstruction with an expandable metallic material restoring the flow of digestive contents…<br />Malignantgastricoutlet obstruction…<br />Advanced and/or unresectableGastric,<br />Pancreatic,<br />Duodenal,<br />Hepato biliary<br />Metastaticmalignancies<br />Benign conditions<br />Stricture,<br />Perforation,<br />Fistula…<br />
  3. 3. Benign conditions ?!<br />was made possible by the membrane of the covered stent<br />[Silicone or PTFE]<br />=> possibility of retrieval and limited local tissue reaction<br />Hanarostent (M.I.tech) – Niti-S (Taewoong)<br />Certainlyveryuseful in management of perforation and leak, in unfrequentbenignduodenalstricture<br />But... No large seriesreported and limited data about the long termefficacy<br />Risk of migration (avoid by anchoringwith clips ?)<br />Wait for prospective (certainlymulticentric) evaluation<br />Small et al. GIE 2007; Lung et al. W J SurgOncol 2009<br />
  4. 4. MalignantGastricOutlet Obstruction <br />10 to 25% of patients withpancreatic cancer => duodenal obstruction<br />Espinel et al Surgendosc 2006; Jeurnink et al. J Gastroenterol 2010; Huang et al. W J Gastroenterol 2007; Lindsay et al. Aliment Pharmacol<br />Ther 2004; Jeurnink et al. J Surg Onc 2007; Shaw et al. Br J Surg 2010; van Hooft et al. GIE 2009; Jeurnink et al. GIE 2010<br />
  5. 5. MalignantGastricOutlet Obstruction <br />Whenshouldwe insert a duodenal stent ?<br />Level of oral intakeassessed by GOO Scoring System <br />0 = no oral intake<br /> 1 = liquidsonly<br /> 2 = soft solids<br /> 3 = Low-residue or full diet<br /><ul><li>Reflecting the reduction in quality of life
  6. 6. Most frequentprimaryendpointused in studies
  7. 7. 70% of patients includedwith GOOSS [0 – 1] in the samestudies</li></ul>Adler DH et Baron TH - Am J Gastroenterol 2002 <br />
  8. 8. MalignantGastricOutlet Obstruction <br />But itis not enough….<br />Large capacity of the stomach to distend !! <br />nausea, vomiting, deshydratation and weightloss<br />=> associatedwith the malignantdisease and itstreatment<br />Malignant GOO isoftenclinicallydetectedat an advanced stage<br />Gastricmotilitydisturbances<br />Reduction of the efficacy of the stent ?<br />in doubt, remember upper endoscopy <br />and contrast study !!<br />
  9. 9. Four types of strictures<br />Type I : antrum / duodenal bulb <br />/ upperduodenalgenu<br />Type II : second part of the duodenum<br /> (involvement of papilla)<br />Type III : Third and farther part of duodenum<br />Type IV : Gastro jejunalanastomosis<br />/ distal enteral stenosis<br />
  10. 10. And somecriticaltechnical points in the gastro duodenal stenting<br />Avoid aspiration by emptyingstomachwithnasogastric tube / <br />oro tracheal intubation with optimal sedation<br />Be sure that the patient has only one stricture…(Previouscomputedtomography)<br />Assess the strictureduring the stenting procedure<br />Use the right endoscope witha large workingchannel(3.8 mm)<br />Coloscope (distal stricture) – duodenoscope (bettervizualisation)<br />Use the fluoroscopic control, hydrophilic guidewire for accessand <br />stiffer for stent insertion<br />Avoid dilation to prevent the perforation risk<br />Manage previous biliary obstruction, alreadytreated, <br />concomitant or future conditions in pancreatic or ampullarymalignantdisease<br />
  11. 11. Manage the biliary obstruction<br />The Golden rules :<br /><ul><li>During the gastro duodenal stenting, try to avoidcovering the papilla (allowingretrogradeaccess)</li></ul> [more easywith type 1 and 3 of duodenalstrictures]<br /><ul><li>Always control the biliary tract whenprevious biliary stent in place => New stent in case of partial or completedysfunction</li></ul>ERCP isdifficult but possible if papillacovered and biliary obstruction occursduring the follow up<br />Transhepaticapproach and hepaticogastrostomyunder EUS guidance are available<br />
  12. 12. Manage biliary obstruction<br />Our experience in 18 patients with biliary symptomsafterduodenal stenting…<br />Duodenal stent<br />Duodenal stent<br />Success 5/5<br />Biliary stent<br />Group II (n=2): <br />Papilla under duodenal stent<br />Group I (n=3)<br />Biliary stent under the duodenal stent<br />Duodenal stent<br />Success in 12/13<br />Dilation and argon<br />on the meshes<br />Duodenal stent<br />Biliary stent<br />Biliary stent<br />Group IV (n=2): <br />Papilla covered by duodenal stent<br />Group III (n=11): <br />Biliary metallic stent covered by duodenal stent<br />Vanbiervliet et al. GECB 2004<br />
  13. 13. Results: the example<br />« Duoflex » study – Malignant GOO<br />51 patients with prospective follow up<br />Technicalsuccess of 98% (50/51)<br />Clinicalsuccessat 1 week of 84% (43/51)<br />Medianpatencywas307 days<br />6 tumor over or ingrowth (median of 121 days)<br />One migration<br />No perforation<br />p = .02<br />p < .001<br />van Hooft et al. <br />GastrointestEndosc 2009<br />
  14. 14. Results: metaanalysis and review<br />From 1996 to 2005<br />versus GJJ<br />2 randomized trials<br />6 comparative studies<br />Early major complications<br />= migration<br />Late major complications<br />= dysfunction<br /> 13 j<br />Jeurnink et al BMC Gastroenterology 2007<br />
  15. 15. Results: comparingwith surgery<br />SUSTENT Study - Jeurnink et al. Gastrointestendosc 2010 <br />Prospective and Randomizedstudy<br />21 patients withuncovered stent (Wallflex)<br />18 patients with gastrojejunostomy (often open way)<br />Primaryendpoint<br />* = ns<br />p < .01<br />p = .02<br />p = .02<br />
  16. 16. Results : comparingwith the surgery<br />Stent providesfasterresults in oral intake<br />GJJ has better long-termresults (> 2 months)<br />But… smallnumber of patients<br />isendoscopicreintervention invasive ? (no difference in quality of life betweenboth groups)<br />Costeffectiveness in the stent group<br />Solution ?<br /> > A covered stent ?<br /> > Independent predictivefactors of survival in case of malignantgastricoutlet obstruction ? <br />
  17. 17. Covered or uncovered stent ?<br />134 patients treated for malignant gastric outlet obstruction<br />Stent migration was the most common cause of failure in covered stents (73.7%), while tumor ingrowth was the most common cause in uncovered stents (52.2%)<br />Prevention of the migration by anchoring the proximal end of the stent ? (No migration in a prospective study of 25 patients)<br />Bang S et al. Hepatogastroenterology 2008; Kim ID et al. Scand J Gastroenterol 2010<br />
  18. 18. Predictivefactors of survival<br />Prospective observational multicentric study of 105 patients with gastric outlet obstruction<br />Multivariate analysis of survival – final model prediction<br /> => short survival => stent placement ?<br />van Hooft et al. Scand J Gastroenterol 2010<br />
  19. 19. The future ?<br />To combine the safety of the duodenal stent with the long-term efficacy of a surgicalbypass<br />Endoscopic gastroentericanastomosis by using Magnetic Anastomosis ?<br />18 patients with GOO and a GOOSS score of 0 or 1 in 78%<br />12 /13 patients withsuccessfulldeployment of the stent<br />…But 3 migrations with one death (perforation)<br />Improve the design of the stent to reduce the risk of migration<br />van Hooft et al. GastrointestEndosc 2010<br />
  20. 20. The future ?<br />The NOTES ?<br />Using the endoscope to create a truegastrojejunalanastomosis !!<br />With a double workingchannel and the equipmentcurrentlyavailable in anyendoscopy suite…<br />
  21. 21. The future ?<br />
  22. 22. Conclusion<br />An effective, safe palliative treatment for malignant GOO<br />Must obtain more data on long termefficacy for benign conditions<br />Betterresults in patients with short life prognosis<br />Try to reduce the reintervention rate withcovered stent ?<br />A new randomizedstudywithit ?<br />Trust the new devices !!<br />

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