Covered Metal Stent after Dysfunction of Uncovered Stents for Palliation of Gastrointestinal Malignant Obstruction

Abstract

<b><i>Background:</i></b> Self-expanding metal stents (SEMS) have been used for the palliative treatment of malignant gastrointestinal tract obstruction. However, restenosis or incomplete expansion of a first stent is a frequent complication, and the effectiveness of reintervention with placement of a second stent is still controversial. <b><i>Objective:</i></b> To evaluate the clinical outcomes of covered SEMS (cSEMS) placement after dysfunction of uncovered SEMS (uSEMS) by the stent-in-stent technique. <b><i>Patients and Methods:</i></b> We retrospectively studied a consecutive series of patients receiving palliative treatment for malignant gastrointestinal obstruction with cSEMS placement after uSEMS dysfunction in a tertiary center from January 2013 to August 2018. Technical and clinical success, time of patency, and adverse events were analyzed. <b><i>Results:</i></b> Twelve patients were included; their mean age was 60 ± 9 years. Eleven patients had gastric outlet obstruction, and 1 patient had compression of the transverse colon due to gastric neoplasia. In 5 cases, there was absence of early clinical success with uSEMS and stent dysfunction in 7 cases (median patency time: 81 days). There was 100% technical success and 91.7% clinical success after cSEMS placement. There were no adverse events nor need for reintervention. The median patency time after placement of both stents was 163 days (vs. 71 days with the initial stent). <b><i>Conclusion:</i></b> cSEMS placement after uSEMS dysfunction is technically feasible and a clinically effective treatment for patients with recurrent malignant gastrointestinal obstruction, with good stent patency in the medium/long term. This approach seems to be safe and without increase in adverse effects.

Stent-in-Stent for Malign Obstruction: Should We Go Back to a Place Where We Were Happy?

“…Reports on the use of gastroduodenal SEMS after first stent dysfunction are limited. In this issue of GE Portuguese Journal of Gastroenterology , Patita et al [7] aim to bring new light on the efficacy and safety in the placement of a second SEMS using the stent-in-stent technique. This technique involves the insertion of a stent into the stenotic portion of the prior stent [8].…”

“…Authors report their retrospective series in patients with malignant strictures, mostly gastric outlet obstruction, providing objective data, including technical and clinical success rates, adverse events, and stent patency. Patita et al [7] describe a well characterized series of 12 patients (11 with malign gastric outlet obstruction), with the particularity that all had disfunction of an uncovered stent, which was treated with the deployment of a new covered stent. This study confirms what has been known to gastroenterologists: in experienced hands, stent-in-stent technique has a high rate of technical and clinical success, and a low rate of procedural adverse events.…”

“…Prolonged gastric obstruction causes dilation of the stomach and weakening of the muscle wall, impairing gastric emptying even when luminal patency is reestablished. Another factor may be gastroparesis caused by chemo- or radiotherapy (present in 11/12 patients in the study by Patita et al [7]) or tumor infiltration of neural plexuses. Furthermore, advancing malignancy deteriorates patient condition and causes significant anorexia.…”

“…Furthermore, advancing malignancy deteriorates patient condition and causes significant anorexia. Finally, obstruction distal to the stent is common with peritoneal carcinomatosis (present in 6/12 patients in the study by Patita et al [7]). As a result, when patients do not improve after SEMS placement or show obstructive symptoms after initial improvement, it is important to exclude these different factors.…”

“…Previous studies described adverse events related to SEMS deployment such as bleeding and perforation in 4.6 and 1.9% of the cases, respectively, in the context of malign gastric outlet obstruction [9]. The study by Patita et al [7] corroborates more recent studies, showing that stent-in-stent deployment in this context is associated with no or negligible adverse events [10]. This highlights the value of specialized teams in this setting and the safety of the technique.…”