1) Enteral stents are used to relieve obstruction of the digestive tract from malignant or benign causes by restoring flow. 2) For malignant gastric outlet obstruction, stents provide effective short term relief of symptoms and allow for improved oral intake compared to surgery, but surgery may have better long term results. 3) Managing concurrent biliary obstruction when stenting the duodenum is important to prevent complications, and may require placing a biliary stent through the enteral stent.

1. INDICATIONS AND RESULTS OF ENTERAL STENT PLACEMENT G.Vanbiervliet, M.D Endoscopy Unit, L’Archet 2 Hospital, Nice, France Centre Hospitalier Universitaire de Nice

2. To relieve obstruction with an expandable metallic material restoring the flow of digestive contents… Malignantgastricoutlet obstruction… Advanced and/or unresectableGastric, Pancreatic, Duodenal, Hepato biliary Metastaticmalignancies Benign conditions Stricture, Perforation, Fistula…

3. Benign conditions ?! was made possible by the membrane of the covered stent [Silicone or PTFE] => possibility of retrieval and limited local tissue reaction Hanarostent (M.I.tech) – Niti-S (Taewoong) Certainlyveryuseful in management of perforation and leak, in unfrequentbenignduodenalstricture But... No large seriesreported and limited data about the long termefficacy Risk of migration (avoid by anchoringwith clips ?) Wait for prospective (certainlymulticentric) evaluation Small et al. GIE 2007; Lung et al. W J SurgOncol 2009

4. MalignantGastricOutlet Obstruction 10 to 25% of patients withpancreatic cancer => duodenal obstruction Espinel et al Surgendosc 2006; Jeurnink et al. J Gastroenterol 2010; Huang et al. W J Gastroenterol 2007; Lindsay et al. Aliment Pharmacol Ther 2004; Jeurnink et al. J Surg Onc 2007; Shaw et al. Br J Surg 2010; van Hooft et al. GIE 2009; Jeurnink et al. GIE 2010

6. Most frequentprimaryendpointused in studies

7. 70% of patients includedwith GOOSS [0 – 1] in the samestudiesAdler DH et Baron TH - Am J Gastroenterol 2002

8. MalignantGastricOutlet Obstruction But itis not enough…. Large capacity of the stomach to distend !! nausea, vomiting, deshydratation and weightloss => associatedwith the malignantdisease and itstreatment Malignant GOO isoftenclinicallydetectedat an advanced stage Gastricmotilitydisturbances Reduction of the efficacy of the stent ? in doubt, remember upper endoscopy and contrast study !!

9. Four types of strictures Type I : antrum / duodenal bulb / upperduodenalgenu Type II : second part of the duodenum (involvement of papilla) Type III : Third and farther part of duodenum Type IV : Gastro jejunalanastomosis / distal enteral stenosis

10. And somecriticaltechnical points in the gastro duodenal stenting Avoid aspiration by emptyingstomachwithnasogastric tube / oro tracheal intubation with optimal sedation Be sure that the patient has only one stricture…(Previouscomputedtomography) Assess the strictureduring the stenting procedure Use the right endoscope witha large workingchannel(3.8 mm) Coloscope (distal stricture) – duodenoscope (bettervizualisation) Use the fluoroscopic control, hydrophilic guidewire for accessand stiffer for stent insertion Avoid dilation to prevent the perforation risk Manage previous biliary obstruction, alreadytreated, concomitant or future conditions in pancreatic or ampullarymalignantdisease

12. Manage biliary obstruction Our experience in 18 patients with biliary symptomsafterduodenal stenting… Duodenal stent Duodenal stent Success 5/5 Biliary stent Group II (n=2): Papilla under duodenal stent Group I (n=3) Biliary stent under the duodenal stent Duodenal stent Success in 12/13 Dilation and argon on the meshes Duodenal stent Biliary stent Biliary stent Group IV (n=2): Papilla covered by duodenal stent Group III (n=11): Biliary metallic stent covered by duodenal stent Vanbiervliet et al. GECB 2004

13. Results: the example « Duoflex » study – Malignant GOO 51 patients with prospective follow up Technicalsuccess of 98% (50/51) Clinicalsuccessat 1 week of 84% (43/51) Medianpatencywas307 days 6 tumor over or ingrowth (median of 121 days) One migration No perforation p = .02 p < .001 van Hooft et al. GastrointestEndosc 2009

14. Results: metaanalysis and review From 1996 to 2005 versus GJJ 2 randomized trials 6 comparative studies Early major complications = migration Late major complications = dysfunction 13 j Jeurnink et al BMC Gastroenterology 2007

15. Results: comparingwith surgery SUSTENT Study - Jeurnink et al. Gastrointestendosc 2010 Prospective and Randomizedstudy 21 patients withuncovered stent (Wallflex) 18 patients with gastrojejunostomy (often open way) Primaryendpoint * = ns p < .01 p = .02 p = .02

16. Results : comparingwith the surgery Stent providesfasterresults in oral intake GJJ has better long-termresults (> 2 months) But… smallnumber of patients isendoscopicreintervention invasive ? (no difference in quality of life betweenboth groups) Costeffectiveness in the stent group Solution ? > A covered stent ? > Independent predictivefactors of survival in case of malignantgastricoutlet obstruction ?

17. Covered or uncovered stent ? 134 patients treated for malignant gastric outlet obstruction Stent migration was the most common cause of failure in covered stents (73.7%), while tumor ingrowth was the most common cause in uncovered stents (52.2%) Prevention of the migration by anchoring the proximal end of the stent ? (No migration in a prospective study of 25 patients) Bang S et al. Hepatogastroenterology 2008; Kim ID et al. Scand J Gastroenterol 2010

18. Predictivefactors of survival Prospective observational multicentric study of 105 patients with gastric outlet obstruction Multivariate analysis of survival – final model prediction => short survival => stent placement ? van Hooft et al. Scand J Gastroenterol 2010

19. The future ? To combine the safety of the duodenal stent with the long-term efficacy of a surgicalbypass Endoscopic gastroentericanastomosis by using Magnetic Anastomosis ? 18 patients with GOO and a GOOSS score of 0 or 1 in 78% 12 /13 patients withsuccessfulldeployment of the stent …But 3 migrations with one death (perforation) Improve the design of the stent to reduce the risk of migration van Hooft et al. GastrointestEndosc 2010

20. The future ? The NOTES ? Using the endoscope to create a truegastrojejunalanastomosis !! With a double workingchannel and the equipmentcurrentlyavailable in anyendoscopy suite…

21. The future ?

22. Conclusion An effective, safe palliative treatment for malignant GOO Must obtain more data on long termefficacy for benign conditions Betterresults in patients with short life prognosis Try to reduce the reintervention rate withcovered stent ? A new randomizedstudywithit ? Trust the new devices !!