Arno J. Dormann

BACKGROUND AND STUDY AIMS: The current standard approach to the management of malignant gastric outlet obstruction mainly involves bypass surgery, which is associated with significant rates of mortality and morbidity. Recently, metal stents have emerged as a new therapeutic option. The aim of the present study was to review the currently published evidence on the effectiveness and safety of this form of endoscopic treatment. MATERIALS AND METHODS: A systematic review of the published data was carried out by searching medline, embase, and abstracts from the major gastroenterological conferences from January 1992 to September 2003. A total of 136 relevant publications were identified (case series, single case reports, letters and editorials, or reviews). The systematic review included 32 case series from a total of 46 publications identified as reporting primary clinical data. Abstracts and single case reports were not taken into account. Analysis of these 32 case series included data on technical success (successful stent placement and deployment), clinical success (relief of symptoms such as nausea and vomiting, and/or improvement of food intake), and complications. Pooled results were calculated from the 32 studies (10 of which were prospective). RESULTS: Stent insertion was attempted in 606 patients with malignant symptomatic gastroduodenal obstruction; 94 % of the patients were unable to take food orally or were mainly ingesting liquids. Stent placement and deployment were successful in 589 of the patients (97 %). Clinical success was achieved in 526 patients in the group in which technical success was reported (89 %; 87 % of the entire group undergoing stenting). Disease-related factors accounted for the majority of clinical failures. Oral intake became possible in all of the patients in whom a successful procedure was carried out, with 87 % taking soft solids or a full diet, with final resolution of symptoms occurring after a mean of 4 days. There was no procedure-related mortality. Severe complications (bleeding and perforation) were observed in seven patients (1.2 %). Stent migration was reported in 31 patients (5 %). Stent obstruction occurred in 104 cases (18 %), mainly due to tumor infiltration. The mean survival period was 12.1 weeks. CONCLUSIONS: Published evidence from case series suggests that gastroduodenal stenting offers good palliation and is a safe and effective treatment option in patients with a short remaining lifespan. However, patient selection for this intervention continues to be an issue requiring thorough consideration, and studies comparing the method with surgery are needed.

BACKGROUND AND STUDY AIMS: Self-expandable metallic covered stents (SEMS) are widely used for the palliation of esophageal cancer. In the long term, a drawback of these stents is the occurrence of nontumoral occlusion at their proximal or distal parts. New self-expanding plastic stents (SEPS) may combine the advantages of SEMS with those of previously used plastic stents. Our aim was to study prospectively the implantation of such stents in a series of patients with fairly long life expectancy, focusing on safety, feasibility and long-term effectiveness. PATIENTS AND METHODS: Between June 1999 and December 2000, in a prospective cohort study, 33 patients were treated with Polyflex stents for palliation of esophageal stenoses, and were followed up until death. The inclusion criteria demanded the presence of a nonresectable or nonoperable, histologically proven, malignant stricture of the esophagus causing significant dysphagia. RESULTS: Stent insertion was successful in all cases. The mean duration of follow-up of the patients was 149.7 days (range 25 - 469). A complete follow-up until death was documented for all patients (n = 33). During the entire follow-up, no stent occlusion was observed which was caused by either nontumoral or tumoral ingrowth, or by nontumoral overgrowth. Stent occlusions were caused only by tumoral overgrowth, and occurred at a rate of 12.1 % (n = 4). The stent migration rate was 6.0 % (n = 2), and the re-intervention rate overall was 21.1 % (n = 7). CONCLUSIONS: These results show that SEPS are effective for the palliation of dysphagia in patients with esophageal malignancies. The immediate results are similar to those observed with SEMS, and the observed low rate of late obstruction suggests that their long-term efficacy might be superior to that of SEMS. This device warrants evaluation in a controlled prospective trial.

OBJECTIVE: The aim of this study was to determine the efficacy of antibiotic prophylaxis in percutaneous endoscopic gastrostomy (PEG). METHODS: An open prospective, randomised, multicenter study was conducted in 141 patients; 72 received ceftriaxone 1 g i.v. 30 min preintervention, and 69 received no study medication. A standardized protocol was followed for PEG preparation, insertion, and aftercare; all patients received a 15-Fr gastrostomy tube. Follow-up of local and systemic infection and clinical course was continued to postintervention day 10. An aggregate erythema and exudation score >3 or the presence of pus was taken as indicative of peristomal infection. The pharmacoeconomics of antibiotic use were also examined. RESULTS: In no-prophylaxis patients, wound infection rates were 25% on day 4 and 26.4% on day 10, versus 10.1% (p = 0.03) and 14.5% (p = 0.10), respectively, in prophylaxis patients. Results were disproportionally better in tumor patients: systemic infection rates were 16.7% versus 5.8% in no-prophylaxis versus prophylaxis patients (p = 0.045), and overall infection rates 38.9% versus 17.4%, respectively (p = 0.046). Pneumonia was more frequent in patients with underlying neurological disease. Antibiotic costs were the same in both groups (p = 0.792). CONCLUSIONS: Single dose ceftriaxone 1 g is an effective prophylaxis against local and systemic infection after PEG.