Search Results (55)

Pancreatic cancer is an aggressive malignancy, with a current 5-year survival rate in the United States of approximately 13.3%. Although the current standard for resectable pancreatic cancer most commonly includes neoadjuvant chemotherapy prior to a curative resection, surgery, in the majority of patients, has historically been palliative. The latter interventions include open or laparoscopic bypass of the bile duct or stomach in cases of obstructive jaundice or gastric outlet obstruction, respectively. Non-surgical interventional therapies started with percutaneous transhepatic biliary drainage (PTBD), both as a palliative maneuver in unresectable patients with obstructive jaundice and to improve liver function in patients whose surgery was delayed. Likewise, interventional radiologic techniques included the placement of plastic and ultimately self-expandable metal stents (SEMSs) through PTBD tracts in patients with unresectable cancer as well as percutaneous cholecystostomy in patients who developed cholecystitis in the context of malignant obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) and stent placement (plastic/SEMS) were subsequently used both preoperatively and palliatively, and this was followed by, or undertaken in conjunction with, endoscopic gastro-duodenal SEMS placement for gastric outlet obstruction. Although endoscopic ultrasound (EUS) was initially used to cytologically diagnose and stage pancreatic cancer, early palliation included celiac block or ablation for intractable pain. However, it took the development of lumen-apposing metal stents (LAMSs) to facilitate a myriad of palliative procedures: cholecystoduodenal, choledochoduodenal, gastrohepatic, and gastroenteric anastomoses for cholecystitis, obstructive jaundice, and gastric outlet obstruction, respectively. In this review, we outline these procedures, which have variably supplanted surgery for the palliation of pancreatic cancer in this rapidly evolving field. Full article

The diagnosis of colorectal cancer in more advanced stages, especially in younger patients where the diagnosis usually occurs because of obstructive complications, has prompted the development of less invasive, more rapid and well tolerated methods of decompression as an alternative to the standard surgical approach. As such, self-expanding metal stents (SEMSs) have gained wide acceptance for the palliative alleviation of obstructive symptoms in patients with advanced colorectal cancer. The purpose of this study was to evaluate SEMS placement against various forms of palliative surgical procedures in terms of effectiveness, morbidity, mortality and oncologic results. We conducted a systematic search of PubMed, Web of Science, Cochrane Library and Medline for articles describing patients with incurable locally advanced obstructive colorectal cancer who underwent surgery or self-expanding metal stent placement as a palliative procedure for the alleviation of symptoms. Eighteen studies (1606 patients) were included in a pooled meta-analysis. In the surgery group the clinical success was slightly higher (98.62% vs. 94.92%; OR = 0.35, 95%CI [0.16–0.73], p = 0.005) and the late complications rate was lower (13.9% vs. 24.0%; OR = 3.01, 95%CI [2.06–4.39], p < 0.00001). The SEMS placement was associated with a lower early complication (11.3% vs. 28.1%; OR = 0.34, 95%CI [0.19–0.58], p = 0.0001) and a shorter length of hospital stay (SMD = −1.94, 95%CI [−2.76, −1.12], p < 0.00001). In terms of the oncologic results, surgery was significantly associated with an increased overall survival regardless of the type of procedure (OR = 1.24, 95%CI [1.08–1.42], p = 0.002). Although having lower early morbidity and mortality rates, SEMS placement was associated with an increased chance of late complications and a worse overall survival, thus making them avoidable when patients have longer life expectancies. Due to the lower early complications rates, SEMSs might still have a place in the management of selected cases with bowel obstruction. Full article

Background: Over the last two decades, therapy for benign esophageal strictures has shifted from empirical dilatations and surgery to evidence-based and complex endoscopic and surgical procedures, aiming to achieve long-term esophageal patency. Aim: The purpose of our study is to provide descriptive evidence regarding the appropriate tailored medical, endoscopic, and surgical management of benign esophageal strictures. Methods: This retrospective study includes patients with benign esophageal strictures; the data collected encompass the complete patient profiles, detailed etiologic and anatomic workups of the strictures, comprehensive imaging, as well as management and follow-up details. Technical and clinical success rates, adverse events, stricture patency, and the need for additional therapy have been evaluated. Results: Most of the strictures (80.2%) were complex, requiring advanced techniques for management. The primary treatment involved endoscopic dilation, performed with Savary-Gillard bougie dilators in 76.7% of cases and pneumatic balloon dilators in 23.3% of cases. Clinical success was achieved in 95.3% of patients, with a significant improvement in the Ogilvie dysphagia score. Patients with caustic strictures required repeated dilations over the years, compared to shorter intervals for peptic strictures. Adverse events were minimal (e.g., perforation 2.3% and bleeding 4.7%) and managed predominantly endoscopically. Refractory strictures (16.3%) required advanced interventions, including fully covered self-expandable metallic stents (fc-SEMS) and corticosteroid injections. Conclusions: Both our data and the current literature support the use of tailored endoscopic strategies as the first-choice options for managing benign esophageal strictures. Our results strongly suggest against one-size-fits-all therapeutic alternatives. Full article

Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients’ quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings. Full article

Background: Endoscopic self-expandable metallic stent (SEMS) placement is a widely accepted treatment for malignant left-sided colorectal obstruction (LSO) because of its lower invasiveness and quicker symptomatic relief compared to surgery. However, SEMS placement for ileocecal valve obstruction (ICVO) has not been established due to its technical difficulties. Methods: This single-center retrospective study compared the clinical outcomes of patients who underwent SEMS placement for ICVO (ICVO group, n = 13) and LSO (LSO group, n = 146). Particularly in cases with severe small-intestine dilation, we applied a “Two-Step Strategy”, which involved long intestinal tube insertion followed by SEMS placement to ensure safety and overcome technical challenges. Results: Patients in the ICVO group were significantly more likely to undergo SEMS placement with the Two-Step Strategy compared to those in the LSO group (76.9% vs. 6.9%, p < 0.001). Both groups achieved similarly high technical and clinical success rates (100% vs. 98.6%, p = 1.000; 92.3% vs. 88.4%, p = 1.000), and the incidence of adverse events also showed no significant difference between the groups (7.7% vs. 13.0%; p = 1.000). Furthermore, the median time to recurrent colorectal obstruction and survival time after SEMS placement did not differ between patients with palliative stenting for ICVO and LSO (not reached vs. 430 days, p = 0.586; 119 days vs. 200 days, p = 0.303). Conclusions: SEMS placement for malignant ICVO is as safe and effective as it is for malignant LSO, and the Two-Step Strategy might be useful in ICVO cases. Full article

Colorectal cancer (CRC) is a leading cause of cancer mortality, with many patients presenting with malignant colorectal obstruction (MCO). Self-expandable metal stents (SEMSs) have emerged as a minimally invasive key intervention, both as a bridge to surgery (BTS) in curative setting sand for palliation in advanced disease. This review aims to provide an evidence-based analysis of SEMS indications, contraindications, and efficacy across curative and palliative contexts, with focus on long-term outcomes. Based on data from recent trials and guidelines, we examine SEMS placement outcomes, focusing on specific scenarios, including BTS for left-sided MCO, chemotherapy (with angiogenic agents) safety during stent therapy, the optimal timing between SEMS placement and surgery, and oncological outcomes. We also discuss the use of SEMSs in challenging contexts such as proximal colon obstruction and extracolonic obstruction, and the relevant technical considerations. Findings indicate that using a SEMS in the BTS setting reduces emergency surgery needs, minimizes complications, and decreases stoma formation. Long-term oncologic outcomes, particularly recurrence, are still debated, but recent evidence shows that SEMS placement is safe, without worsening long term outcomes. Palliative SEMS placement shows high efficacy in symptom relief with manageable adverse events. Success depends on patient selection and technical expertise, with multidisciplinary approaches essential for optimal outcomes. Full article

Self-Expanding Metallic (SEM) Y stents are a newer form of stent that is gaining popularity outside the USA, but still has limited data, especially in a community medicine setting. This study analyzed efficacy and complication rates in 14 patients who had a SEM Y stent placed between August 2022 and June 2024 at Harris Methodist Hospital in Fort Worth, Texas for either central airway obstruction (CAO) or fistulae. Of the 14 patients, 11 were requiring supplemental oxygen or mechanical ventilation prior to stent placement. Post-stenting 42.9% had decreased oxygen requirements, 21.4% unchanged, 14.3% increased, and 21.4% remained on room air. Complications included mucus plugging (42.9%), infection (35.7%), and granulation tissue (14.3%). There was no statistically significant correlation between gender/age and complications (p = 0.879/0.490, respectively). Complication rates were similar when compared to silicone Y stents based on literature review. In conclusion, SEM Y stents are a safe and effective alternative stent intended for palliative treatment with similar success and complications that can be easily and effectively implemented in a community hospital, with the added benefit of being able to be placed with flexible bronchoscopy. Full article

Background/Objectives: Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) often requires fistula dilation owing to the placement of a large diameter of the delivery stent. The recently developed delivery devices, which are as thin as 5.9/6.0 Fr, may save the need for fistula dilation. Therefore, we investigated whether large fistula dilation would be required or not in the case of this newly developed thin-diameter delivery stents. Methods: We conducted a retrospective study involving 33 patients implemented with a self-expandable metal stent (SEMS) during EUS-HGS. The patients were categorized based on the delivery device diameter into thin (n = 13; delivery device diameter: 5.9/6.0 Fr) and thick (n = 20; delivery device diameter: 8.5 Fr) groups. We compared the initial rate of success, technical success, and clinical success between the thin and thick groups. The initial rate of success was defined as successful stent placement without a balloon or large diameter mechanical dilation. Results: The rate of the initial stenting success was significantly higher in the thin group (100% [13/13]) compared with that in the thick group (65.0% [13/20]) (p = 0.027). In the thick group, seven cases with technical difficulty in terms of stent placement could be successfully completed with additional fistula dilation with a 9 Fr bougie dilator or 4 mm balloon dilator; this resulted in a technical success of 100% in both groups ultimately. The rate of clinical success was 100% and 95.0% in the thin and thick groups, respectively (p = 1.00). Conclusions: Thin delivery stents may facilitate stent placement without the need for a balloon fistula or large-diameter mechanical dilation. Full article

Background/Objectives: Covered self-expandable metallic stents (CSEMS) are commonly used to treat malignant distal biliary obstructions. A 10-mm CSEMS carries the risk of obstructing the pancreatic and cystic duct orifices by adhering to the bile duct; therefore, postoperative pancreatitis and cholecystitis are reported to occur at a certain frequency. We have adopted a new drainage technique for malignant distal biliary obstruction called ‘‘double-slim SEMS stenting” (DSS), where two small-diameter CSEMS are placed side-by-side. We aimed to compare the efficacy and safety of biliary drainage using DSS with those of conventional CSEMS. Methods: In total, 50 patients who underwent endoscopic biliary drainage for malignant distal biliary obstructions between April 2019 and March 2022 at Hyogo Medical University Hospital were enrolled. Patients were divided into DSS and Conventional groups, and the technical success rate, clinical success rate, adverse events, success rate for reintervention, recurrent biliary obstruction (RBO) rate, and time to RBO (TRBO) were evaluated. Results: There were no significant differences in patient characteristics between the DSS (n = 20) and Conventional groups (n = 30). The technical and clinical success rates were 100% in the DSS group. The incidence of adverse events was not significantly different between the two groups (DSS/Conventional: 10.0% [2/20]/20.0% [6/30]) (p = 0.34). No acute cholecystitis was observed in the DSS group. The incidence rates of RBO were 30% (6/20) and 43% (13/30) in the DSS and Conventional groups, respectively (p = 0.92). The median TRBO in the DSS group was 378 days, while the TRBO in the Conventional group was 195 days (p = 0.03), resulting in significantly longer TRBO in the DSS group. Conclusions: DSS emerges as a viable and safe approach for biliary drainage in malignant distal biliary obstruction, demonstrating a lower incidence of adverse events and longer TRBO compared to conventional CSEMS. Full article

Background: Although several reports have compared the outcomes of self-expandable metallic stent (SEMSs) and transanal decompression tube (TDT) placement for malignant colorectal obstruction (MCO), few studies have compared the radiation exposure (RE) associated with these two procedures. Consequently, we aimed to compare the RE of SEMS and TDT placements for MCO using propensity score matching (PSM) in a multi-center, prospective observational study. Methods: This study investigated the clinical data of 236 patients who underwent SEMS or TDT placement. The air kerma at the patient entrance reference point (K_a,r: mGy) and air kerma–area product (P_KA; Gycm²) were measured and compared between SEMS and TDT groups after PSM. Results: After PSM, 61 patients were identified in each group. The median K_a,r in the SEMS group was significantly greater than that in the TDT group (77.4 vs. 55.6 mGy; p = 0.025) across the entire cohort. With respect to subgroup analyses by location, in the rectum, the median K_{a, r} and P_KA were significantly greater in the SEMS group than in the TDT group (172.9 vs. 34.6 mGy; p = 0.001; and 46.0 vs. 18.1 Gycm²; p = 0.006, respectively). However, in the colon, the RE parameters did not significantly differ between the two groups. Conclusions: TDT might be a more suitable option for decompression in patients with malignant rectal obstruction due to its lower RE and technical advantages. Conversely, SEMS placement is recommended as the first decompression method to treat malignant colonic obstruction, in line with the current guidelines. Full article

Background: Recently, there has been a significant increase in the utilization of self-expandable metallic stents (SEMSs) for treating malignant colorectal obstructions through colorectal stenting. The mechanical properties of SEMSs are usually considered to affect clinical outcomes of patients with malignant colorectal obstructions. Methods: This single-arm, prospective, multicenter study of SEMS with a lower axial force and high axial force zero-border included 200 patients with malignant colorectal obstruction. Technical and clinical success, stent patency, and adverse events associated with SEMS placement were evaluated. Results: One patient was excluded, and 199 patients were evaluated. The treatment intent was bridge-to-surgery in 129 and palliation in 70 patients. Technical and clinical success rates were 99.5% and 97.0%, respectively. The percentage of the ColoRectal Obstruction Scoring System scores of 3 or higher improved significantly from 19.2% before placement to 93.9% after placement. Clinical success was not achieved in five patients due to insufficient stent expansion in four patients and stent occlusion in one patient. Only one patient underwent emergency surgery for perforation of the proximal colon, far from where the stent was placed; the rescue procedure was not performed, despite no improvement in proximal dilatation due to insufficient stent expansion. Among the palliation cohort, 15 patients received chemotherapy, including molecular-targeted agents such as bevacizumab. There were no fatal cases related to stent placement. Conclusions: For management of malignant colorectal obstruction, this newly developed SEMS with low axial force and a high axial force zero-border showed high technical and clinical success rates, and an extremely low perforation rate (0.5%). Full article

Inflammation of the bile ducts and surrounding tissues can impede bile flow from the liver into the intestines. If this occurs, a plastic or self-expanding metal (SEM) stent is placed to restore bile drainage. United States (US) Food and Drug Administration (FDA)-approved plastic biliary stents are less expensive than SEMs but have limited patency and can occlude bile flow if placed spanning a duct juncture. Recently, we investigated the effects of variations to post-processing and autoclaving on a commercially available stereolithography (SLA) resin in an effort to produce a suitable material for use in a biliary stent, an FDA Class II medical device. We tested six variations from the manufacturer’s recommended post-processing and found that tripling the isopropanol (IPA) wash time to 60 min and reducing the time and temperature of the UV cure to 10 min at 40 °C, followed by a 30 min gravity autoclave cycle, yielded a polymer that was flexible and non-cytotoxic. In turn, we designed and fabricated customizable, SLA 3D-printed polymeric biliary stents that permit bile flow at a duct juncture and can be deployed via catheter. Next, we generated an in silico stent 3-point bend test to predict displacements and peak stresses in the stent designs. We confirmed our simulation accuracy with experimental data from 3-point bend tests on SLA 3D-printed stents. Unfortunately, our 3-point bend test simulation indicates that, when bent to the degree needed for placement via catheter (~30°), the peak stress the stents are predicted to experience would exceed the yield stress of the polymer. Thus, the risk of permanent deformation or damage during placement via catheter to a stent printed and post-processed as we have described would be significant. Moving forward, we will test alternative resins and post-processing parameters that have increased elasticity but would still be compatible with use in a Class II medical device. Full article

Esophagectomy, while a pivotal treatment for esophageal cancer, is not without adverse events. Among these, anastomotic leak (AL) is the most feared complication, threatening patient lives and incurring significant healthcare costs. The management of AL is complex and lacks standardization. Given the high morbidity and mortality rates associated with redo-surgery, which poses risks for already fragile patients, various endoscopic treatments have been developed over time. Self-expandable metallic stents (SEMSs) were the most widely used treatment until the early 2000s. The mechanism of action of SEMSs includes covering the wall defect, protecting it from secretions, and promoting healing. In 2010, endoscopic vacuum therapy (EVT) emerged as a viable alternative for treating ALs, quickly gaining acceptance in clinical practice. EVT involves placing a dedicated sponge under negative pressure inside or adjacent to the wall defect, aiming to clear the leak and promote granulation tissue formation. More recently, the VAC-Stent entered the scenario of endoscopic treatment of post-esophagectomy ALs. This device combines a fully covered SEMS with an integrated EVT sponge, blending the ability of SEMSs to exclude defects and maintain the patency of the esophageal lumen with the capacity of EVT to aspirate secretions and promote the formation of granulation tissue. Although the literature on this new device is not extensive, early results from the application of VAC-Stent have shown promising outcomes. This review aims to synthesize the preliminary efficacy and safety data on the device, thoroughly analyze its advantages over traditional techniques and disadvantages, explore areas for improvement, and propose future directions. Full article

Anastomotic insufficiencies are severe complications of abdominal surgery, often leading to prolonged hospitalization, serious tissue inflammation, and even sepsis, along with the need for recurrent surgery. Current non-surgical treatments such as self-expanding metal stents (SEMSs) and endoscopic vacuum therapy (EVT) have limitations, including stent migration or perforation. This review evaluates the effectiveness of the VacStent GI^TM (Möller Medical GmbH, Fulda, Germany), a novel medical device combining SEMS and negative-pressure wound therapy in treating gastrointestinal leaks. Data were gathered from four prospective studies and compared with existing treatments. Studies on the VacStent GI^TM application demonstrate technical success and competitive closure rates in upper gastrointestinal leaks, with minimal complications reported. Comparative analyses with SEMS and EVT reveal promising and most importantly equally good outcomes while maintaining the possibility for sustained enteral nutrition and reducing the risk of stent migration. The VacStent GI^TM presents a promising alternative to current non-surgical treatments. Ongoing research aims to validate its efficacy in lower gastrointestinal leaks and comprehensively establish its role in leak management. Further investigation is necessary to confirm these findings and optimize treatment protocols. Future usages of the VacStent GI^TM in colonic anastomotic insufficiencies promise an effective approach and might be able to lower the rates of necessary implementations of a stoma. Full article

Esophageal cancer is a complex and challenging tumor to treat, with esophageal stenting being used as a palliative measure to improve the quality of life of patients. Self-expandable metal stents (SEMS), self-expandable plastic stents (SEPS), and biodegradable stents are the most commonly used types of stents. However, complications can arise, such as migration, bleeding, and perforation. To address issues of migration, this study developed a novel 3D printed bioinspired esophageal stent utilizing a highly flexible and ductile TPU material. The stent was designed to be self-expanding and tubular with flared ends to provide secure anchorage at both the proximal and distal ends of the structure. Suction cups were strategically placed around the shaft of the stent to prevent migration. The stent was evaluated through compression–recovery, self-expansion, and anti-migration tests to evaluate its recovery properties, self-expansion ability, and anchoring ability, respectively. The results indicated that the novel stent was able to recover its shape, expand, keep the esophagus open, and resist migration, demonstrating its potential for further research and clinical applications. Finite element analysis (FEA) was leveraged to analyze the stent’s mechanical behavior, providing insights into its structural integrity, self-expansion capability, and resistance against migration. These results, supported by FEA, highlight the potential of this innovative stent for further research and its eventual application in preclinical settings. Full article