title: Palliation of malignant gastric outlet obstruction with simultaneous endoscopic insertion of afferent and efferent jejunal limb enteral stents in patients with recurrent malignancy.
abstract: BACKGROUND
  Patients with prior pancreaticobiliary or distal gastric cancer treated surgically may have local anastomotic recurrence with obstruction of the afferent and efferent jejunal limbs. This report describes the efficacy and safety of simultaneous endoscopic insertion of self-expanding metal stents into the afferent and efferent jejunal limbs in patients with gastric outlet obstruction (GOO) of post-surgical anatomy for palliation of recurrent malignancy.
  
  
  METHODS
  Patients were identified from an endoscopic database at a specialized cancer center between September 2007 and March 2014. Technical success was defined as single-session insertion of afferent and efferent jejunal limb enteral stents. Clinical success was defined as immediate symptom relief and ability to advance diet. A durable response was defined as symptom relief of at least 60 days or until hospice placement or death.
  
  
  RESULTS
  Twenty-three patients were identified who underwent insertion of two 22-mm-diameter uncovered duodenal stents. Stent length varied from 60 to 120 mm. Stents were placed under endoscopic and fluoroscopic guidance. Three patients required balloon dilation to facilitate stent insertion. Average procedure time was 58.8 min (range 28-120). Technical success was achieved in 23/24 (96%) patients. Clinical success was achieved in 19/23 (83%) patients. Following initial stent insertion and prior to subsequent re-intervention, 11/19 (58%) patients had a durable response with a median duration of 70 days (range 4-315). Eight (42%) patients underwent subsequent re-intervention at a median of 22 days (range 11-315). Five patients had stent revision and were able to tolerate oral intake. Two patients had percutaneous endoscopic gastrostomy/jejunostomy insertion. One patient required surgical diversion for persistent obstruction. Complications included stent migration and post-stent insertion bacteremia due to food bolus obstruction.
  
  
  CONCLUSIONS
  Recurrent malignant GOO in patients with post-surgical anatomy treated with simultaneous endoscopic enteral stenting of afferent and efferent jejunal limbs has a high rate of technical and clinical success and low rate of complications and provides effective palliation.
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
authors.forename: Isaac
authors.initials: I
authors.lastname: Soo
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
authors.forename: Hans
authors.initials: H
authors.lastname: Gerdes
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
authors.forename: Arnold J
authors.initials: AJ
authors.lastname: Markowitz
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
authors.forename: Robin B
authors.initials: RB
authors.lastname: Mendelsohn
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
authors.forename: Emmy
authors.initials: E
authors.lastname: Ludwig
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA.
authors.forename: Pari
authors.initials: P
authors.lastname: Shah
authors.affiliation: Gastroenterology and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, USA. schattnm@mskcc.org.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schattner
mesh_terms: D000230:Adenocarcinoma / Q000150:complications* / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001661:Biliary Tract Neoplasms / Q000150:complications / Q000601:surgery; D004067:Digestive System Neoplasms / Q000150:complications* / Q000601:surgery; D016099:Endoscopy, Gastrointestinal; D005260:Female; D005500:Follow-Up Studies; D017219:Gastric Outlet Obstruction / Q000209:etiology / Q000628:therapy*; D006801:Humans; D007583:Jejunum; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000150:complications*; D010166:Palliative Care / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000150:complications / Q000601:surgery; D012189:Retrospective Studies; D000069322:Self Expandable Metallic Stents; D013274:Stomach Neoplasms / Q000150:complications / Q000601:surgery; D016896:Treatment Outcome
keywords: Endoscopic palliation; Enteral stent; Gastric cancer; Gastrojejunostomy; Malignant gastric outlet obstruction; Pancreaticobiliary cancer