Open Access
CC BY-NC-ND 4.0 · Endosc Int Open 2025; 13: a24872722
DOI: 10.1055/a-2487-2722
Original article

Predictive factors for long-term patency in duodenal stenting for malignant gastric outlet obstruction

David Razzaz
1   Surgery and Oncology, Capio St Gorans Hospital, Stockholm, Sweden (Ringgold ID: RIN59560)
,
Stefan Linder
2   Department of Clinical Science Intervention and Technology, Karolinska Institute, Stockholm, Sweden (Ringgold ID: RIN27106)
,
Alexander Waldthaler
3   Department of Medicine, Karolinska Institute, Stockholm, Sweden (Ringgold ID: RIN27106)
,
Marcus Holmberg*
1   Surgery and Oncology, Capio St Gorans Hospital, Stockholm, Sweden (Ringgold ID: RIN59560)
,
Poya Ghorbani*
2   Department of Clinical Science Intervention and Technology, Karolinska Institute, Stockholm, Sweden (Ringgold ID: RIN27106)
› Author Affiliations
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Abstract

Background and study aims

Malignant gastric outlet obstruction (GOO) occurs often late during disseminated disease, requiring palliation. Placement of duodenal self-expandable metal stents (SEMS) is a common method for relieving malignant GOO but recurrent obstruction is common, warranting reintervention. The aim of the present study was to identify predictive factors for stent patency at 3 months and survival. Also, stent patency rate and adverse events after duodenal stenting were analyzed.

Patients and methods

This was a retrospective observational single-center study including all patients with malignant GOO receiving duodenal SEMS for palliation (2008–2021). Logistic regression for stent patency (3 months) and Cox regression for survival were undertaken.

Results

Overall, 198 patients were included. The most common malignancies were pancreatic adenocarcinoma (40%), gastric adenocarcinoma (18%), and cholangiocarcinoma (13%). Uncovered SEMS were used in 88% of patients and the reintervention rate was 44%. The stent patency rate was 63% in 188 patients with clinical success. Predictors of stent patency at 3 months were jaundice, semi- or fully-covered stents, and chemotherapy prior to stenting. Median survival was 81 days (interquartile range 40–241) after stenting. In Cox regression, predictors for overall survival at 6 months were absence of jaundice and stent patency at 3 months. Stent dysfunction was the most common cause of reintervention and was managed by repeated stent (76%) or dilation (11%).

Conclusions

Treatment of malignant GOO with duodenal SEMS is effective but the reintervention rate is high. Predictors of stent patency were jaundice, semi- or fully-covered SEMS, and chemotherapy. Survival was impaired by jaundice and stent dysfunction.

* Shared last authorship.




Publication History

Received: 05 May 2024

Accepted after revision: 25 October 2024

Accepted Manuscript online:
25 November 2024

Article published online:
29 January 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Bibliographical Record
David Razzaz, Stefan Linder, Alexander Waldthaler, Marcus Holmberg, Poya Ghorbani. Predictive factors for long-term patency in duodenal stenting for malignant gastric outlet obstruction. Endosc Int Open 2025; 13: a24872722.
DOI: 10.1055/a-2487-2722
 
  • References

  • 1 van Halsema EE. Self-expandable metal stents for malignant gastric outlet obstruction: A pooled analysis of prospective literature. WJG 2015; 21: 12468
  • 2 Brimhall B, Adler DG. Enteral stents for malignant gastric outlet obstruction. Gastrointest Endosc Clin North Am 2011; 21: 389-403
  • 3 Del Nero L, Sheijani AD, De Ceglie A. et al. A meta-analysis of endoscopic stenting versus surgical treatment for malignant gastric outlet obstruction. World J Surg 2023; 47: 1519-1529
  • 4 Upchurch E, Ragusa M, Cirocchi R. Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction. Cochrane Database Syst Rev 2018; 5: CD012506
  • 5 Jeurnink SM, Steyerberg EW, van Hooft JE. et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 2010; 71: 490-499
  • 6 Suzuki O, Shichinohe T, Yano T. et al. Laparoscopic modified Devine exclusion gastrojejunostomy as a palliative surgery to relieve malignant pyloroduodenal obstruction by unresectable cancer. Am J Surg 2007; 194: 416-418
  • 7 Lang S, Stevens T, Lopez R. et al. Superiority of gastrojejunostomy over endoscopic stenting for palliation of malignant gastric outlet obstruction. Clin Gastroenterol Hepatol 2019; 17: 1295-1302.e1
  • 8 Kumagai K, Rouvelas I, Ernberg A. et al. A systematic review and meta-analysis comparing partial stomach partitioning gastrojejunostomy versus conventional gastrojejunostomy for malignant gastroduodenal obstruction. Langenbecks Arch Surg 2016; 401: 777-785
  • 9 Chandan S, Khan SR, Mohan BP. et al. EUS-guided gastroenterostomy versus enteral stenting for gastric outlet obstruction: Systematic review and meta-analysis. Endosc Int Open 2021; 09: E496-E504
  • 10 Van Wanrooij RLJ, Bronswijk M, Kunda R. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54: 310-332
  • 11 Yamao K, Kitano M, Kayahara T. et al. Factors predicting through-the-scope gastroduodenal stenting outcomes in patients with gastric outlet obstruction: a large multicenter retrospective study in West Japan. Gastrointest Endosc 2016; 84: 757-763.e6
  • 12 Kobayashi S, Ueno M, Kameda R. et al. Duodenal stenting followed by systemic chemotherapy for patients with pancreatic cancer and gastric outlet obstruction. Pancreatology 2016; 16: 1085-1091
  • 13 Kobayashi S, Ueno M, Nagashima S. et al. Association between time to stent dysfunction and the anti-tumour effect of systemic chemotherapy following stent placement in patients with pancreaticobiliary cancers and malignant gastric outlet obstruction: a retrospective cohort study. BMC Cancer 2021; 21: 576
  • 14 Hodo Y, Takatori H, Komura T. et al. Prognostic impact of clinical outcome after endoscopic gastroduodenal stent placement for malignant gastric outlet obstruction: a multicenter retrospective cohort study using a time-dependent analysis. Therap Adv Gastroenterol 2023; 16
  • 15 Takamatsu Y, Fujimori N, Miyagahara T. et al. The Glasgow Prognostic Score and stricture site can predict prognosis after endoscopic duodenal stent placement for malignant gastric outlet obstruction. Sci Rep 2022; 12: 9746
  • 16 von Elm E, Altman DG, Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol 2008; 61: 344-349
  • 17 Statement on ASA Physical Status Classification System. https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system
  • 18 ECOG Performance Status Scale. ECOG-ACRIN Cancer Research Group. https://ecog-acrin.org/resources/ecog-performance-status/
  • 19 Mutignani M, Tringali A, Shah SG. et al. Combined endoscopic stent insertion in malignant biliary and duodenal obstruction. Endoscopy 2007; 39: 440-447
  • 20 Tamura T, Mamoru T, Terai T. et al. Gastrojejunostomy versus endoscopic duodenal stent placement for gastric outlet obstruction in patients with unresectable pancreatic cancer: a propensity score-matched analysis. Surg Endosc 2023; 37: 1890-1900
  • 21 Larssen L, Medhus AW, Hauge T. Treatment of malignant gastric outlet obstruction with stents: An evaluation of the reported variables for clinical outcome. BMC Gastroenterol 2009; 9: 45
  • 22 Hori Y, Naitoh I, Hayashi K. et al. Predictors of outcomes in patients undergoing covered and uncovered self-expandable metal stent placement for malignant gastric outlet obstruction: a multicenter study. Gastrointest Endosc 2017; 85: 340-348.e1
  • 23 Jung K, Ahn JY, Jung H-Y. et al. Outcomes of endoscopically inserted self-expandable metal stents in malignancy according to the type of stent and the site of obstruction. Surg Endosc 2016; 30: 4001-4010
  • 24 Reijm AN, Zellenrath PA, van der Bogt RD. et al. Self-expandable duodenal metal stent placement for the palliation of gastric outlet obstruction over the past 20 years. Endoscopy 2022; 54: 1139-1146
  • 25 Yoshida Y, Fukutomi A, Tanaka M. et al. Gastrojejunostomy versus duodenal stent placement for gastric outlet obstruction in patients with unresectable pancreatic cancer. Pancreatology 2017; 17: 983-989
  • 26 Tringali A, Costa D, Anderloni A. et al. Covered versus uncovered metal stents for malignant gastric outlet obstruction: a systematic review and meta-analysis. Gastrointest Endosc 2020; 92: 1153-1163.e9
  • 27 Hamada T, Hakuta R, Takahara N. et al. Covered versus uncovered metal stents for malignant gastric outlet obstruction: Systematic review and meta-analysis. Digest Endosc 2017; 29: 259-271
  • 28 Miyabe K, Hayashi K, Nakazawa T. et al. Safety and benefits of self-expandable metallic stents with chemotherapy for malignant gastric outlet obstruction: SEMS and chemotherapy for MGOO. Digestive Endoscopy 2015; 27: 572-581
  • 29 Kim C, Park S, Choi I. et al. Effect of chemotherapy on the outcome of self-expandable metallic stents in gastric cancer patients with malignant outlet obstruction. Endoscopy 2012; 44: 807-812
  • 30 Grunwald D, Cohen J, Bartley A. et al. The location of obstruction predicts stent occlusion in malignant gastric outlet obstruction. Therap Adv Gastroenterol 2016; 9: 815-822
  • 31 Mendelsohn RB, Gerdes H, Markowitz AJ. et al. Carcinomatosis is not a contraindication to enteral stenting in selected patients with malignant gastric outlet obstruction. Gastrointest Endosc 2011; 73: 1135-1140
  • 32 Wei T-H, Ye B-W, Wu P-S. et al. Outcomes of patients with malignant duodenal obstruction after receiving self-expandable metallic stents: A single center experience. PLoS ONE 2022; 17: e0268920
  • 33 Jang JK, Song H-Y, Kim JH. et al. Tumor overgrowth after expandable metallic stent placement: experience in 583 patients with malignant gastroduodenal obstruction. Am J Roentgenol 2011; 196: W831-W836
  • 34 Yamashige D, Hijioka S, Nagashio Y. et al. Incidence and factors associated with stent dysfunction and pancreatitis after gastroduodenal stenting for malignant gastric outlet obstruction. Endosc Int Open 2024; 12: E367-E376
  • 35 Jue TL, Storm AC, Naveed M. et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc 2021; 93: 309-322.e4
  • 36 Oliveira JF de, Franco MC, Rodela G. et al. Endoscopic ultrasound-guided gastroenterostomy (gastroenteric anastomosis). Int J Gastrointest Intervention 2022; 11: 112-118