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Malignant duodenal stenosis is a common presentation of inoperable metastatic pancreatic cancer. It can be observed in up to 15% of patients.[[1,2]] Inoperable primary duodenal and biliary cancers, along with lymphoma and metastatic spread of other malignancies, are other common causes of duodenal obstruction.[[3,4]] Common symptoms are abdominal pain, nausea, vomiting and weight loss, which significantly impact quality of life.[[5]] Often these patients are old with comorbidities and have advanced disease, and their median term of survival is only 3–6 months.[[6]] This precludes any definitive or even palliative surgical intervention because <40% of these patients are fit to undergo a surgical procedure.[[7]]

Duodenal stenting effectively relieves obstruction and is relatively less invasive in comparison to surgical interventions like gastroenterostomy.[[8]] Previous studies have shown that, in comparison to surgical therapy, endoscopic stenting significantly reduces length of stay post procedure and time to commencing free oral fluids and light diet.[[9]] However, the data in terms of safety of the procedure are lacking. Commonly reported complications of duodenal stenting in the literature are bleeding, perforation, pancreatitis and stent migration.[[2,10,11]] Previous radiotherapy is considered a risk factor for perforation post stenting in the upper gastrointestinal (GI) tract.[[12]]

The aim of this study was to review the complication rates of endoscopically placed duodenal stents for malignant duodenal obstruction and to determine factors associated with the complications.

Patients and methods

All patients who underwent duodenal stenting for malignant duodenal obstruction between 1 April 2010 and 31 of March 2020 at Middlemore Hospital in Auckland were identified by searching Provation MD database. All the endoscopic procedures at our center are reported using Provation MD, which is maintained by the department of gastroenterology. We searched for the keywords ‘prosthesis or stent’, ‘duodenal mass or tumour’ and ‘duodenal stenosis or stricture’. We reviewed the records of all patients who were positive for any of the criteria and then collated the database of patients who had palliative duodenal stenting for malignant duodenal obstruction.

Definitive surgery was contraindicated in these patients either due to advanced metastatic disease, lesions that were not resectable or significant patient comorbidities.

Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction.

Patients were excluded if the obstruction was due to a benign pathology. Patients with gastric-outlet obstruction were also excluded, as the aim of this study was specifically to study the complications of duodenal stents.

The data collected for each patient included age, gender, ethnicity, cause of the malignant duodenal obstruction, any complications associated with the stent, history of previous radiotherapy treatment and type of stent used.

Technical and clinical success of the stent was analysed as well. Technical success was defined as satisfactory positioning of the stent endoscopically and radiologically. Clinical success was defined as improvement in patient symptoms at the time of discharge or during outpatient clinic assessment post stent insertion.

Ethics approval was obtained for this study.

Data analysis

The data were analysed descriptively in terms of counts and proportions for categorical variables and means, with standard deviation for continuous variables. The complication rates are reported with 95% confidence intervals. Chi-square and fisher exact tests were carried out to test for a significant association in terms of the risk factors and complication rates. A p-value of less than 5% was considered as statistically significant.

Results

Between 1 April 2010 and 31 March 2020, 61 patients underwent palliative duodenal stenting. Median age was 65 years (range 40–96). There were 32 males and 29 female patients. Almost 40% of the patients were New Zealand European. All 61 cases of stenting were technically successful and all cases but one were clinically successful (Table 1).

Table 1: Demographics and clinical characteristics.

Pancreatic adenocarcinoma causing duodenal obstruction was the most common indication for palliative duodenal stenting during the study period (52%). This was followed by duodenal adenocarcinoma (21%). The ‘others’ category included four cases of metastatic colorectal carcinoma, three of gastric adenocarcinoma, two of metastatic renal cell carcinoma and one each of duodenal neuroendocrine tumour, metastatic cervical squamous cell carcinoma and small cell type extra-pulmonary neuroendocrine tumour (Figure 1).

Figure 1: Primary diagnosis by category.

Niti-S stent (TaeWoong) was the most commonly used stent (69%) during the study period, as shown in Figure 2.

Figure 2: Type of stent used by category.

Most cases (85%) had no complications. The complication rate was 15% with 95% confidence interval (5.9%, 23.7%). Out of the nine cases with complications (Table 2), five were stent migration, two were perforation and two were tumour ingrowth requiring re-stenting. Three out of the five stent migrations had non-obstructive lesions. Both the perforation cases had previous radiotherapy. Both cases of tumour ingrowth were late (>28 days) complications.

Table 2: Number of cases with or without complication and the type of complication involved.

Figure 3: Percentage of complications in each age group.

Figure 4: Percentage of complications in each ethnic group.

Figure 5: Percentage of complications with each involved stent type.

Figure 6: Number of complications in each category of primary diagnosis.

Figures 3–6 show the percentage of complications associated with age group, ethnicity, stent type and primary diagnosis.

Table 3: Counts and proportions of patient characteristics by complication.

* Fisher exact test used.

Discussion

Patients with duodenal obstructions often have symptoms of nausea, vomiting, abdominal bloating and constipation.[[5]] This results in dehydration, electrolyte imbalance, malnutrition and general deterioration.[[5,13]] As a result of these complications, palliative chemotherapy becomes extremely challenging and won’t necessarily be helpful in relieving symptoms.[[14]] Prompt relief of obstructions is required to palliate these symptoms and improve nutrition and quality of life.[[7,10,15]]

Palliative endoscopic duodenal stenting is a relatively less invasive procedure with acceptable efficacy has been reported.[[10]] It has been compared with palliative surgical intervention and provides relief of obstruction promptly. Gastrojejunostomy surgical bypass procedure is associated with a significant perioperative morbidity (up to 35%) and mortality (2%) and in a large group of patients (up to 31%) does not sufficiently relieve symptoms.[[9,16]] It is less expensive than gastrojejunostomy, surgical procedure performed for palliation with less hospital days.[[17]]

Previous studies have shown the complication rate of endoscopically placed duodenal stents is between 17% and 28%.[[11]] This is in keeping with our study, which showed a complication rate of 15%. Palliative duodenal stenting has been shown to have a higher reintervention rate in comparison with surgery, due to complications such as stent obstruction and migration.[[8,10]] Stent patency is particularly influenced by malignant stent obstruction (via tumour growth) in about 15–20% of patients.[[2,10,16]] We observed a lower rate of malignant stent obstruction (8%) in comparison to previous studies, and in our study all but one patient were successfully treated with re-stenting. Rates of reintervention were 16% for a combination of stent migration and stent obstruction.

Uncovered stents are usually complicated by tumour ingrowth through the stent mesh. On the other hand, covered stents are complicated by stent migration despite lowering the risk of tumour ingrowth. Rates of reintervention to treat complications don’t seem to differ significantly between the two types of stents.[[8]] Kim et al[[11]] showed that uncovered stents have a longer duration of stent patency and are more resistant to stent migration, making them preferable for patients with malignant duodenal obstruction.[[10]]

The higher complication rates identified in patients among the 60–69 age group, New Zealand Māori/Pacific Islander ethnic group, patients with the Niti- S stent and in those with duodenal adenocarcinoma as the primary diagnosis were not found to be statistically significant. This could be due to smaller numbers in our study. Larger studies are required to assess factors associated with complication rates.

Finally, no previous studies have commented on whether previous radiotherapy is a risk factor for bowel perforation in patients undergoing palliative duodenal stenting for malignant duodenal obstruction. However, it is considered a risk factor for perforation post stenting elsewhere in the upper GI tract.[[12]] In our study, seven patients in total had prior radiotherapy to chest or abdomen. Two of these patients subsequently developed a bowel perforation post duodenal stenting. Further studies are needed to assess whether prior radiotherapy is a risk factor for bowel perforation post duodenal stenting.

Conclusion

Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. Technical and clinical success is achieved in most patients and complication rates are low. Our results are similar to those in other published studies. This study could not adequately assess the factors associated with complications, due to smaller numbers. Larger studies are required to study this particular issue.

Summary

Abstract

BACKGROUND: Endoscopically placed duodenal stents are commonly performed procedures for palliation of obstruction due to malignancy. A relatively small number of studies highlight the potential complications of this procedure, and to date no data have been published in New Zealand specifically addressing this issue. We aimed to retrospectively review complications from duodenal stents at our center and factors associated with the complications. METHOD: We retrospectively reviewed our endoscopy reporting system, Provation MD, for patients who underwent endoscopic duodenal stenting between 1 April 2010 and 31 March 2020. We searched the system for the keywords ‘prosthesis or stent’, ‘duodenal mass or tumour’ and ‘duodenal stenosis or stricture’. Their clinical records were reviewed. Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction. Patients were excluded if the obstruction was due to a benign pathology or if the obstruction was proximal to duodenum. Patient demographics, the type of stent used and any stent-related complications were recorded. Previous radiotherapy to chest or abdomen was also recorded. RESULTS: We identified 61 patients who underwent palliative endoscopic duodenal stenting. The overall complication rate was 15% (9/61), with five cases of stent migration, two cases of perforation and two cases of late tumour ingrowth requiring re-stenting. Three out of five stent-migration cases had non-obstructive lesions. Both the cases of perforation had previous radiotherapy. CONCLUSION: Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. The complication rate was found to be higher among the 60–69 age group, the New Zealand Māori/Pacific Islander ethnic group, patients with Niti-S stent and those with duodenal adenocarcinoma as the primary diagnosis, but these higher rates were not found to be statistically significant. Larger studies are required to assess factors associated with complication rates.

Aim

Method

Results

Conclusion

Author Information

Anurag Sekra MBBS, MD, FRACP: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Vijay Dyavadi MBChB: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Qiuyu Jin MBChB: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Ravinder Ogra MBBS, MD, FRACP: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Anurag Sekra, Consultant Gastroenterologist and Interventional Endoscopist, Middlemore Hospital, Auckland

Correspondence Email

Anurag.Sekra@middlemore.co.nz

Competing Interests

Nil.

1. Sarr M, Cameron J, World Journal of Surgery, 1984, 8(6): 906–18

2. Graber I, et al. The efficacy and safety of duodenal stenting: A prospective multicentre study. Endoscopy, 2007; 39: 784–7

3. Vincent A, Herman J, Schulick R, Hruban RH, Goggins M. Pancreatic cancer. Lancet. 2011;378:607–20.

4. Patel T. Cholangiocarcinoma—controversies and challenges. Nat Rev Gastroenterol Hepatol. 2011;8:189–200

5. Jung GS, Song HY, Kang SG, Huh JD, Park SJ, Koo JY, Cho YD. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology. 2000;216:758–63

6. Baron TH. Management of simultaneous biliary and duodenal obstruction: the endoscopic perspective. Gut Liver. 2010;4 Suppl 1:S50–S56.

7. Moura EGH et al. Duodenal stenting for malignant gastric outlet obstruction: Prospective study. World J Gastroenterol. 2012 Mar 7; 18(9): 938–43

8. Bulut E et al. Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches. Diagn Interv Radiol. 2017 May(3): 211–6

9. Mittal A et al. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. British Journal of Surgery, 2004; 91: 205–9

10. Upchurch E et al. Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction. Cochrane Database Syst Rev. 2018 May; 2018 (5): CD012506

11. Kim JW et al. Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction. World J Gastroenterol. 2015 Feb 7; 21(5): 1580–7

12. Kristen J et al. Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy. GI Endoscopy. 1996; 43;3; 196-203

13. Bessoud B, de Baere T, Denys A, Kuoch V, Ducreux M, Precetti S, Roche A, Menu Y. Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents. J Vasc Interv Radiol. 2005;16:247–53

14. Johnston SD et al. Duodenal stents for malignant duodenal strictures. Ulster Med J. 2002 May; 71(1): 30–3.

15. Qureshi S et al. Malignant pyloro-duodenal obstruction: Role of self expandable metallic stents. JPMA. 2014 Jan; 64(1)

16. Larssen L et al. Treatment of malignant gastric outlet obstruction with stents: An evaluation of the reported variables for clinical outcome. BMC Gastroenterol. 2009; 9:45

17. Nassif T et al. Endoscopic palliation of malignant gastric outlet obstruction Using Self-Expandable metallic stents: Results of a Multicenter Study. Endoscopy 2003; 35(6):483–9

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Malignant duodenal stenosis is a common presentation of inoperable metastatic pancreatic cancer. It can be observed in up to 15% of patients.[[1,2]] Inoperable primary duodenal and biliary cancers, along with lymphoma and metastatic spread of other malignancies, are other common causes of duodenal obstruction.[[3,4]] Common symptoms are abdominal pain, nausea, vomiting and weight loss, which significantly impact quality of life.[[5]] Often these patients are old with comorbidities and have advanced disease, and their median term of survival is only 3–6 months.[[6]] This precludes any definitive or even palliative surgical intervention because <40% of these patients are fit to undergo a surgical procedure.[[7]]

Duodenal stenting effectively relieves obstruction and is relatively less invasive in comparison to surgical interventions like gastroenterostomy.[[8]] Previous studies have shown that, in comparison to surgical therapy, endoscopic stenting significantly reduces length of stay post procedure and time to commencing free oral fluids and light diet.[[9]] However, the data in terms of safety of the procedure are lacking. Commonly reported complications of duodenal stenting in the literature are bleeding, perforation, pancreatitis and stent migration.[[2,10,11]] Previous radiotherapy is considered a risk factor for perforation post stenting in the upper gastrointestinal (GI) tract.[[12]]

The aim of this study was to review the complication rates of endoscopically placed duodenal stents for malignant duodenal obstruction and to determine factors associated with the complications.

Patients and methods

All patients who underwent duodenal stenting for malignant duodenal obstruction between 1 April 2010 and 31 of March 2020 at Middlemore Hospital in Auckland were identified by searching Provation MD database. All the endoscopic procedures at our center are reported using Provation MD, which is maintained by the department of gastroenterology. We searched for the keywords ‘prosthesis or stent’, ‘duodenal mass or tumour’ and ‘duodenal stenosis or stricture’. We reviewed the records of all patients who were positive for any of the criteria and then collated the database of patients who had palliative duodenal stenting for malignant duodenal obstruction.

Definitive surgery was contraindicated in these patients either due to advanced metastatic disease, lesions that were not resectable or significant patient comorbidities.

Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction.

Patients were excluded if the obstruction was due to a benign pathology. Patients with gastric-outlet obstruction were also excluded, as the aim of this study was specifically to study the complications of duodenal stents.

The data collected for each patient included age, gender, ethnicity, cause of the malignant duodenal obstruction, any complications associated with the stent, history of previous radiotherapy treatment and type of stent used.

Technical and clinical success of the stent was analysed as well. Technical success was defined as satisfactory positioning of the stent endoscopically and radiologically. Clinical success was defined as improvement in patient symptoms at the time of discharge or during outpatient clinic assessment post stent insertion.

Ethics approval was obtained for this study.

Data analysis

The data were analysed descriptively in terms of counts and proportions for categorical variables and means, with standard deviation for continuous variables. The complication rates are reported with 95% confidence intervals. Chi-square and fisher exact tests were carried out to test for a significant association in terms of the risk factors and complication rates. A p-value of less than 5% was considered as statistically significant.

Results

Between 1 April 2010 and 31 March 2020, 61 patients underwent palliative duodenal stenting. Median age was 65 years (range 40–96). There were 32 males and 29 female patients. Almost 40% of the patients were New Zealand European. All 61 cases of stenting were technically successful and all cases but one were clinically successful (Table 1).

Table 1: Demographics and clinical characteristics.

Pancreatic adenocarcinoma causing duodenal obstruction was the most common indication for palliative duodenal stenting during the study period (52%). This was followed by duodenal adenocarcinoma (21%). The ‘others’ category included four cases of metastatic colorectal carcinoma, three of gastric adenocarcinoma, two of metastatic renal cell carcinoma and one each of duodenal neuroendocrine tumour, metastatic cervical squamous cell carcinoma and small cell type extra-pulmonary neuroendocrine tumour (Figure 1).

Figure 1: Primary diagnosis by category.

Niti-S stent (TaeWoong) was the most commonly used stent (69%) during the study period, as shown in Figure 2.

Figure 2: Type of stent used by category.

Most cases (85%) had no complications. The complication rate was 15% with 95% confidence interval (5.9%, 23.7%). Out of the nine cases with complications (Table 2), five were stent migration, two were perforation and two were tumour ingrowth requiring re-stenting. Three out of the five stent migrations had non-obstructive lesions. Both the perforation cases had previous radiotherapy. Both cases of tumour ingrowth were late (>28 days) complications.

Table 2: Number of cases with or without complication and the type of complication involved.

Figure 3: Percentage of complications in each age group.

Figure 4: Percentage of complications in each ethnic group.

Figure 5: Percentage of complications with each involved stent type.

Figure 6: Number of complications in each category of primary diagnosis.

Figures 3–6 show the percentage of complications associated with age group, ethnicity, stent type and primary diagnosis.

Table 3: Counts and proportions of patient characteristics by complication.

* Fisher exact test used.

Discussion

Patients with duodenal obstructions often have symptoms of nausea, vomiting, abdominal bloating and constipation.[[5]] This results in dehydration, electrolyte imbalance, malnutrition and general deterioration.[[5,13]] As a result of these complications, palliative chemotherapy becomes extremely challenging and won’t necessarily be helpful in relieving symptoms.[[14]] Prompt relief of obstructions is required to palliate these symptoms and improve nutrition and quality of life.[[7,10,15]]

Palliative endoscopic duodenal stenting is a relatively less invasive procedure with acceptable efficacy has been reported.[[10]] It has been compared with palliative surgical intervention and provides relief of obstruction promptly. Gastrojejunostomy surgical bypass procedure is associated with a significant perioperative morbidity (up to 35%) and mortality (2%) and in a large group of patients (up to 31%) does not sufficiently relieve symptoms.[[9,16]] It is less expensive than gastrojejunostomy, surgical procedure performed for palliation with less hospital days.[[17]]

Previous studies have shown the complication rate of endoscopically placed duodenal stents is between 17% and 28%.[[11]] This is in keeping with our study, which showed a complication rate of 15%. Palliative duodenal stenting has been shown to have a higher reintervention rate in comparison with surgery, due to complications such as stent obstruction and migration.[[8,10]] Stent patency is particularly influenced by malignant stent obstruction (via tumour growth) in about 15–20% of patients.[[2,10,16]] We observed a lower rate of malignant stent obstruction (8%) in comparison to previous studies, and in our study all but one patient were successfully treated with re-stenting. Rates of reintervention were 16% for a combination of stent migration and stent obstruction.

Uncovered stents are usually complicated by tumour ingrowth through the stent mesh. On the other hand, covered stents are complicated by stent migration despite lowering the risk of tumour ingrowth. Rates of reintervention to treat complications don’t seem to differ significantly between the two types of stents.[[8]] Kim et al[[11]] showed that uncovered stents have a longer duration of stent patency and are more resistant to stent migration, making them preferable for patients with malignant duodenal obstruction.[[10]]

The higher complication rates identified in patients among the 60–69 age group, New Zealand Māori/Pacific Islander ethnic group, patients with the Niti- S stent and in those with duodenal adenocarcinoma as the primary diagnosis were not found to be statistically significant. This could be due to smaller numbers in our study. Larger studies are required to assess factors associated with complication rates.

Finally, no previous studies have commented on whether previous radiotherapy is a risk factor for bowel perforation in patients undergoing palliative duodenal stenting for malignant duodenal obstruction. However, it is considered a risk factor for perforation post stenting elsewhere in the upper GI tract.[[12]] In our study, seven patients in total had prior radiotherapy to chest or abdomen. Two of these patients subsequently developed a bowel perforation post duodenal stenting. Further studies are needed to assess whether prior radiotherapy is a risk factor for bowel perforation post duodenal stenting.

Conclusion

Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. Technical and clinical success is achieved in most patients and complication rates are low. Our results are similar to those in other published studies. This study could not adequately assess the factors associated with complications, due to smaller numbers. Larger studies are required to study this particular issue.

Summary

Abstract

BACKGROUND: Endoscopically placed duodenal stents are commonly performed procedures for palliation of obstruction due to malignancy. A relatively small number of studies highlight the potential complications of this procedure, and to date no data have been published in New Zealand specifically addressing this issue. We aimed to retrospectively review complications from duodenal stents at our center and factors associated with the complications. METHOD: We retrospectively reviewed our endoscopy reporting system, Provation MD, for patients who underwent endoscopic duodenal stenting between 1 April 2010 and 31 March 2020. We searched the system for the keywords ‘prosthesis or stent’, ‘duodenal mass or tumour’ and ‘duodenal stenosis or stricture’. Their clinical records were reviewed. Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction. Patients were excluded if the obstruction was due to a benign pathology or if the obstruction was proximal to duodenum. Patient demographics, the type of stent used and any stent-related complications were recorded. Previous radiotherapy to chest or abdomen was also recorded. RESULTS: We identified 61 patients who underwent palliative endoscopic duodenal stenting. The overall complication rate was 15% (9/61), with five cases of stent migration, two cases of perforation and two cases of late tumour ingrowth requiring re-stenting. Three out of five stent-migration cases had non-obstructive lesions. Both the cases of perforation had previous radiotherapy. CONCLUSION: Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. The complication rate was found to be higher among the 60–69 age group, the New Zealand Māori/Pacific Islander ethnic group, patients with Niti-S stent and those with duodenal adenocarcinoma as the primary diagnosis, but these higher rates were not found to be statistically significant. Larger studies are required to assess factors associated with complication rates.

Aim

Method

Results

Conclusion

Author Information

Anurag Sekra MBBS, MD, FRACP: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Vijay Dyavadi MBChB: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Qiuyu Jin MBChB: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Ravinder Ogra MBBS, MD, FRACP: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Anurag Sekra, Consultant Gastroenterologist and Interventional Endoscopist, Middlemore Hospital, Auckland

Correspondence Email

Anurag.Sekra@middlemore.co.nz

Competing Interests

Nil.

1. Sarr M, Cameron J, World Journal of Surgery, 1984, 8(6): 906–18

2. Graber I, et al. The efficacy and safety of duodenal stenting: A prospective multicentre study. Endoscopy, 2007; 39: 784–7

3. Vincent A, Herman J, Schulick R, Hruban RH, Goggins M. Pancreatic cancer. Lancet. 2011;378:607–20.

4. Patel T. Cholangiocarcinoma—controversies and challenges. Nat Rev Gastroenterol Hepatol. 2011;8:189–200

5. Jung GS, Song HY, Kang SG, Huh JD, Park SJ, Koo JY, Cho YD. Malignant gastroduodenal obstructions: treatment by means of a covered expandable metallic stent-initial experience. Radiology. 2000;216:758–63

6. Baron TH. Management of simultaneous biliary and duodenal obstruction: the endoscopic perspective. Gut Liver. 2010;4 Suppl 1:S50–S56.

7. Moura EGH et al. Duodenal stenting for malignant gastric outlet obstruction: Prospective study. World J Gastroenterol. 2012 Mar 7; 18(9): 938–43

8. Bulut E et al. Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches. Diagn Interv Radiol. 2017 May(3): 211–6

9. Mittal A et al. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. British Journal of Surgery, 2004; 91: 205–9

10. Upchurch E et al. Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction. Cochrane Database Syst Rev. 2018 May; 2018 (5): CD012506

11. Kim JW et al. Comparison between uncovered and covered self-expandable metal stent placement in malignant duodenal obstruction. World J Gastroenterol. 2015 Feb 7; 21(5): 1580–7

12. Kristen J et al. Prior radiation and chemotherapy increase the risk of life-threatening complications after insertion of metallic stents for esophagogastric malignancy. GI Endoscopy. 1996; 43;3; 196-203

13. Bessoud B, de Baere T, Denys A, Kuoch V, Ducreux M, Precetti S, Roche A, Menu Y. Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents. J Vasc Interv Radiol. 2005;16:247–53

14. Johnston SD et al. Duodenal stents for malignant duodenal strictures. Ulster Med J. 2002 May; 71(1): 30–3.

15. Qureshi S et al. Malignant pyloro-duodenal obstruction: Role of self expandable metallic stents. JPMA. 2014 Jan; 64(1)

16. Larssen L et al. Treatment of malignant gastric outlet obstruction with stents: An evaluation of the reported variables for clinical outcome. BMC Gastroenterol. 2009; 9:45

17. Nassif T et al. Endoscopic palliation of malignant gastric outlet obstruction Using Self-Expandable metallic stents: Results of a Multicenter Study. Endoscopy 2003; 35(6):483–9

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

Malignant duodenal stenosis is a common presentation of inoperable metastatic pancreatic cancer. It can be observed in up to 15% of patients.[[1,2]] Inoperable primary duodenal and biliary cancers, along with lymphoma and metastatic spread of other malignancies, are other common causes of duodenal obstruction.[[3,4]] Common symptoms are abdominal pain, nausea, vomiting and weight loss, which significantly impact quality of life.[[5]] Often these patients are old with comorbidities and have advanced disease, and their median term of survival is only 3–6 months.[[6]] This precludes any definitive or even palliative surgical intervention because <40% of these patients are fit to undergo a surgical procedure.[[7]]

Duodenal stenting effectively relieves obstruction and is relatively less invasive in comparison to surgical interventions like gastroenterostomy.[[8]] Previous studies have shown that, in comparison to surgical therapy, endoscopic stenting significantly reduces length of stay post procedure and time to commencing free oral fluids and light diet.[[9]] However, the data in terms of safety of the procedure are lacking. Commonly reported complications of duodenal stenting in the literature are bleeding, perforation, pancreatitis and stent migration.[[2,10,11]] Previous radiotherapy is considered a risk factor for perforation post stenting in the upper gastrointestinal (GI) tract.[[12]]

The aim of this study was to review the complication rates of endoscopically placed duodenal stents for malignant duodenal obstruction and to determine factors associated with the complications.

Patients and methods

All patients who underwent duodenal stenting for malignant duodenal obstruction between 1 April 2010 and 31 of March 2020 at Middlemore Hospital in Auckland were identified by searching Provation MD database. All the endoscopic procedures at our center are reported using Provation MD, which is maintained by the department of gastroenterology. We searched for the keywords ‘prosthesis or stent’, ‘duodenal mass or tumour’ and ‘duodenal stenosis or stricture’. We reviewed the records of all patients who were positive for any of the criteria and then collated the database of patients who had palliative duodenal stenting for malignant duodenal obstruction.

Definitive surgery was contraindicated in these patients either due to advanced metastatic disease, lesions that were not resectable or significant patient comorbidities.

Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction.

Patients were excluded if the obstruction was due to a benign pathology. Patients with gastric-outlet obstruction were also excluded, as the aim of this study was specifically to study the complications of duodenal stents.

The data collected for each patient included age, gender, ethnicity, cause of the malignant duodenal obstruction, any complications associated with the stent, history of previous radiotherapy treatment and type of stent used.

Technical and clinical success of the stent was analysed as well. Technical success was defined as satisfactory positioning of the stent endoscopically and radiologically. Clinical success was defined as improvement in patient symptoms at the time of discharge or during outpatient clinic assessment post stent insertion.

Ethics approval was obtained for this study.

Data analysis

The data were analysed descriptively in terms of counts and proportions for categorical variables and means, with standard deviation for continuous variables. The complication rates are reported with 95% confidence intervals. Chi-square and fisher exact tests were carried out to test for a significant association in terms of the risk factors and complication rates. A p-value of less than 5% was considered as statistically significant.

Results

Between 1 April 2010 and 31 March 2020, 61 patients underwent palliative duodenal stenting. Median age was 65 years (range 40–96). There were 32 males and 29 female patients. Almost 40% of the patients were New Zealand European. All 61 cases of stenting were technically successful and all cases but one were clinically successful (Table 1).

Table 1: Demographics and clinical characteristics.

Pancreatic adenocarcinoma causing duodenal obstruction was the most common indication for palliative duodenal stenting during the study period (52%). This was followed by duodenal adenocarcinoma (21%). The ‘others’ category included four cases of metastatic colorectal carcinoma, three of gastric adenocarcinoma, two of metastatic renal cell carcinoma and one each of duodenal neuroendocrine tumour, metastatic cervical squamous cell carcinoma and small cell type extra-pulmonary neuroendocrine tumour (Figure 1).

Figure 1: Primary diagnosis by category.

Niti-S stent (TaeWoong) was the most commonly used stent (69%) during the study period, as shown in Figure 2.

Figure 2: Type of stent used by category.

Most cases (85%) had no complications. The complication rate was 15% with 95% confidence interval (5.9%, 23.7%). Out of the nine cases with complications (Table 2), five were stent migration, two were perforation and two were tumour ingrowth requiring re-stenting. Three out of the five stent migrations had non-obstructive lesions. Both the perforation cases had previous radiotherapy. Both cases of tumour ingrowth were late (>28 days) complications.

Table 2: Number of cases with or without complication and the type of complication involved.

Figure 3: Percentage of complications in each age group.

Figure 4: Percentage of complications in each ethnic group.

Figure 5: Percentage of complications with each involved stent type.

Figure 6: Number of complications in each category of primary diagnosis.

Figures 3–6 show the percentage of complications associated with age group, ethnicity, stent type and primary diagnosis.

Table 3: Counts and proportions of patient characteristics by complication.

* Fisher exact test used.

Discussion

Patients with duodenal obstructions often have symptoms of nausea, vomiting, abdominal bloating and constipation.[[5]] This results in dehydration, electrolyte imbalance, malnutrition and general deterioration.[[5,13]] As a result of these complications, palliative chemotherapy becomes extremely challenging and won’t necessarily be helpful in relieving symptoms.[[14]] Prompt relief of obstructions is required to palliate these symptoms and improve nutrition and quality of life.[[7,10,15]]

Palliative endoscopic duodenal stenting is a relatively less invasive procedure with acceptable efficacy has been reported.[[10]] It has been compared with palliative surgical intervention and provides relief of obstruction promptly. Gastrojejunostomy surgical bypass procedure is associated with a significant perioperative morbidity (up to 35%) and mortality (2%) and in a large group of patients (up to 31%) does not sufficiently relieve symptoms.[[9,16]] It is less expensive than gastrojejunostomy, surgical procedure performed for palliation with less hospital days.[[17]]

Previous studies have shown the complication rate of endoscopically placed duodenal stents is between 17% and 28%.[[11]] This is in keeping with our study, which showed a complication rate of 15%. Palliative duodenal stenting has been shown to have a higher reintervention rate in comparison with surgery, due to complications such as stent obstruction and migration.[[8,10]] Stent patency is particularly influenced by malignant stent obstruction (via tumour growth) in about 15–20% of patients.[[2,10,16]] We observed a lower rate of malignant stent obstruction (8%) in comparison to previous studies, and in our study all but one patient were successfully treated with re-stenting. Rates of reintervention were 16% for a combination of stent migration and stent obstruction.

Uncovered stents are usually complicated by tumour ingrowth through the stent mesh. On the other hand, covered stents are complicated by stent migration despite lowering the risk of tumour ingrowth. Rates of reintervention to treat complications don’t seem to differ significantly between the two types of stents.[[8]] Kim et al[[11]] showed that uncovered stents have a longer duration of stent patency and are more resistant to stent migration, making them preferable for patients with malignant duodenal obstruction.[[10]]

The higher complication rates identified in patients among the 60–69 age group, New Zealand Māori/Pacific Islander ethnic group, patients with the Niti- S stent and in those with duodenal adenocarcinoma as the primary diagnosis were not found to be statistically significant. This could be due to smaller numbers in our study. Larger studies are required to assess factors associated with complication rates.

Finally, no previous studies have commented on whether previous radiotherapy is a risk factor for bowel perforation in patients undergoing palliative duodenal stenting for malignant duodenal obstruction. However, it is considered a risk factor for perforation post stenting elsewhere in the upper GI tract.[[12]] In our study, seven patients in total had prior radiotherapy to chest or abdomen. Two of these patients subsequently developed a bowel perforation post duodenal stenting. Further studies are needed to assess whether prior radiotherapy is a risk factor for bowel perforation post duodenal stenting.

Conclusion

Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. Technical and clinical success is achieved in most patients and complication rates are low. Our results are similar to those in other published studies. This study could not adequately assess the factors associated with complications, due to smaller numbers. Larger studies are required to study this particular issue.

Summary

Abstract

BACKGROUND: Endoscopically placed duodenal stents are commonly performed procedures for palliation of obstruction due to malignancy. A relatively small number of studies highlight the potential complications of this procedure, and to date no data have been published in New Zealand specifically addressing this issue. We aimed to retrospectively review complications from duodenal stents at our center and factors associated with the complications. METHOD: We retrospectively reviewed our endoscopy reporting system, Provation MD, for patients who underwent endoscopic duodenal stenting between 1 April 2010 and 31 March 2020. We searched the system for the keywords ‘prosthesis or stent’, ‘duodenal mass or tumour’ and ‘duodenal stenosis or stricture’. Their clinical records were reviewed. Patients were included if they had a duodenal stent inserted to relieve a malignant duodenal obstruction. Patients were excluded if the obstruction was due to a benign pathology or if the obstruction was proximal to duodenum. Patient demographics, the type of stent used and any stent-related complications were recorded. Previous radiotherapy to chest or abdomen was also recorded. RESULTS: We identified 61 patients who underwent palliative endoscopic duodenal stenting. The overall complication rate was 15% (9/61), with five cases of stent migration, two cases of perforation and two cases of late tumour ingrowth requiring re-stenting. Three out of five stent-migration cases had non-obstructive lesions. Both the cases of perforation had previous radiotherapy. CONCLUSION: Duodenal stenting can be performed safely in most patients with malignant duodenal obstruction. The complication rate was found to be higher among the 60–69 age group, the New Zealand Māori/Pacific Islander ethnic group, patients with Niti-S stent and those with duodenal adenocarcinoma as the primary diagnosis, but these higher rates were not found to be statistically significant. Larger studies are required to assess factors associated with complication rates.

Aim

Method

Results

Conclusion

Author Information

Anurag Sekra MBBS, MD, FRACP: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Vijay Dyavadi MBChB: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Qiuyu Jin MBChB: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand. Ravinder Ogra MBBS, MD, FRACP: Department of Gastroenterology, Middlemore Hospital, Auckland, New Zealand.

Acknowledgements

Correspondence

Dr Anurag Sekra, Consultant Gastroenterologist and Interventional Endoscopist, Middlemore Hospital, Auckland

Correspondence Email

Anurag.Sekra@middlemore.co.nz

Competing Interests

Nil.

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