Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction

Abstract

ObjectiveStenting is an established endoscopic therapy for malignant gastric outlet obstruction (mGOO). The choice of stent (covered vs uncovered) has been examined in prior randomised studies without clear results.DesignIn a multicentre randomised prospective study, we compared covered (CSEMS) with uncovered self-expandable metal stents (UCSEMS) in patients with mGOO; main outcomes were stent dysfunction and patient survival, with subgroup analyses of patients with extrinsic and intrinsic tumours.ResultsOverall survival was poor with no difference between groups (probability at 3 months 49.7% for covered vs 48.4% for uncovered stents; log-rank for overall survival p=0.26). Within that setting of short survival, the proportion of stent dysfunction was significantly higher for uncovered stents (35.2% vs 23.4%, p=0.01) with significantly shorter time to stent dysfunction. This was mainly relevant for patients with extrinsic tumours (stent dysfunction rates for uncovered stents 35.6% vs 17.5%, p<0.01). Subgrouping was also relevant with respect to tumour ingrowth (lower with covered stents for intrinsic tumours; 1.6% vs 27.7%, p<0.01) and stent migration (higher with covered stents for extrinsic tumours: 15.3% vs 2.5%, p<0.01).ConclusionsDue to poor patient survival, minor differences between covered and uncovered stents may be less relevant even if statistically significant; however, subgroup analysis would suggest to use covered stents for intrinsic and uncovered stents for extrinsic malignancies.

A pilot study of novel duodenal covered self-expandable metal stent fixation

“…Another important issue is that the rate of patients receiving chemotherapy varies in published articles. The chemotherapy regimen continues to change and evolve, and some prospective studies including RCTs excluded mGOO patients with poor performance status 10 , 17 . Patients with poor performance status tend to avoid receiving chemotherapy, so the rate of patients with mGOO receiving chemotherapy might be lower in real-world practice.…”

“… 24 2018 Retrospective 24 HANAROSTENT Pylorus/duodenum Kim’s Flare 12.5 16.7 99 Yamao et al . 10 2020 RCT 182 Flared-ComVi stent 36.3 12.1 NA All clinical trials (range) 1052 41.2 (11.4–78.6) 14.5 (6.0–32.3) Hori et al . , current study 2021 Consecutive 15 Flared-ComVi stent with OTSC fixation 26.7 6.7 84 C-SEMS covered self-expandable metal stent, NA not available (or no details), OTSC over-the-scope-clip, RCT randomized controlled trial.…”

“…Endoscopic duodenal SEMS placement may be selected because it is minimally invasive. Uncovered SEMSs (U-SEMSs) and covered SEMSs (C-SEMSs) (including partially covered SEMSs [PC-SEMSs]) are available, and RCTs 6 – 10 have revealed their clinical features. The main cause of stent dysfunction with U-SEMSs is tumor ingrowth via the mesh of the stent, which occurs in 16–44% 6 – 9 of cases.…”

Feasibility of Duodenal Covered Self-Expandable Metal Stent Fixation: A Pilot Study (With Video)

“…1A). Even with these ingenious improvements, previous studies using the C-SEMS ( ared-ComVi stent) 10,22 could not prevent stent migration with complete satisfaction. In comparison, although our pilot study included a limited number of cases, we observed favorable results (23.1% and 12.1% [ ared-ComVi stent only] vs 6.7% [ ared-ComVi stent with OTSC xation]).…”

“…Although this event fortuitously may not cause symptoms related to gastrointestinal obstruction, it potentially results in intestinal obstruction. Table 3 lists some published articles about endoscopic duodenal covered metal stenting for mGOO [6][7][8][9][10][11][14][15][16][17][18][19][20][21][22][23][24] . The literature review assessed more than 1000 cases of endoscopic duodenal C-SEMS stenting and found that chemotherapy was administered after C-SEMS placement in 41.2% (range 11.4-78.6%), and that stent migration occurred in 14.5% (range 6.0-32.3%) of cases.…”