<p>Efficacy and Adverse Effects of Self-Expandable Metal Stent Placement for Malignant Duodenal Obstruction: The Papilla of Vater as a Landmark</p>

Abstract

Self-expandable metal stents are used for malignant duodenal obstruction. Outcomes between stents placed above and below the papilla of Vater differ, and no study has investigated these differences. We evaluated the efficacy and adverse events of stent placement in these two locations and reported our experience with self-expandable metal stent placement in patients. Patients and Methods: We retrospectively analyzed the data of patients with unresectable metastatic cancers (n = 101), who underwent successful duodenal self-expandable metal stent placement between 2008 and 2018. Patients were divided into above and below the papilla of Vater groups. Patient demographics, technical and clinical outcomes, post-procedural morbidity, and stent patency were analyzed. Results: Overall, 71 and 30 patients had intestinal obstruction above (including the papilla itself) and below the papilla of Vater and underwent successful stenting. Common bile duct obstruction was more common in the above-papilla group. Procedure time was similar between the groups, if an appropriate endoscope could facilitate stent placement in the below-papilla group. Both groups achieved symptomatic relief. Median stent patency duration was not significantly different between the groups; three patients had severe gastrointestinal bleeding due to postoperative vascular-enteric fistula. Conclusion: Self-expandable metal stents can effectively relieve symptoms of duodenal obstructions located above and below the papilla of Vater. Duodenoscopes could facilitate stent placement if the obstruction is located below the papilla of Vater; if gastrointestinal bleeding occurs postoperatively, the possibility of vascular-enteric fistula formation should be considered.

Outcomes of patients with malignant duodenal obstruction after receiving self-expandable metallic stents: A single center experience

“…Despite these difficulties mentioned, Wu et al . disclosed an equal efficacy of stenting between the patients with duodenal obstruction levels above and below the major papilla, with no increased adverse events in the below papilla group [ 14 ]. However, the long-term outcomes following metallic stenting on different duodenal portions and predictors for prognosis were not analyzed in their study.…”

“…further compared the clinical outcomes between patients who received SEMS for the obstruction level above the major papilla (including papilla itself) and below the major papilla, with technical success rates of 100% and 93%, respectively. The clinical success rates were 100% in both the above-papilla and below-papilla groups [ 14 ]. Though these studies disclosed that palliative stenting in duodenal obstruction is clinically effective, factors that influence the prognosis in these patients remain unclear.…”

Malignant Gastric Outlet Obstruction Caused by Duodenal Cervix Metastasis in a Young Woman: Rendezvous Technique

“…Dormian et al [ 18 ] reported that SEMSs is technically successful in 97% of cases and clinically successful, measuredas the ability of a patient to tolerate oral intake, in 87%. However, SEMSs are associated inthe long term witha high risk of stent occlusion and migration;other complications reported are duodenal bleeding and perforation [ 19 ]. SEMSs should probably be considered the best option in patients with poor general condition and a theoretically short life expectancy;meanwhile, surgery still represents a first optionfor patients with a longer life expectancy.…”

“…According to the classification system, this case was a type II stenosis because of the involvement of the second part of the duodenum and papilla. In this case, anendoscopic procedure alonewould have beendifficult, so a biliary stenting through the mesh ofthe duodenal SEMS was used to resolve the double strictures using a procedure known as the rendezvous technique, an intervention thatcombines both endoscopic and percutaneous approaches [ 18 , 19 ].…”

Risk Factors of Duodenobiliary Reflux-Related Dysfunction of Covered Biliary Metal Stents after Treatment of Duodenal Stricture in Patients with Malignant Biliary and Duodenal Obstruction

“…Type III stenosis involves the third section of the duodenum, distal to, and without involvement of the papilla. We simplified the position of duodenal obstruction into two categories, namely the above-papilla type (comprising patients with duodenal obstruction from the bulb to the papilla of Vater itself) and the below-papilla type (comprising patients with duodenal obstruction below the papilla, including the lower part of the second section of the duodenum to the proximal jejunum) owing to different clinical backgrounds and technical challenges [23]. Logistic regression analysis determined that the events associated with duodenal obstruction below the papilla of Vater (type III in Mutignani's classification) were risk factors for DBR-related covered SEMS dysfunction.…”