title: Self-expandable metal stent placement for malignant duodenal obstruction distal to the bulb.
abstract: OBJECTIVE
  Self-expandable metal stents (SEMS) are widely used for the palliative management of malignant proximal gastroduodenal obstruction because of its low morbidity and mortality rates compared with surgical bypass. However, stent placement for duodenal obstruction beyond the first part of the duodenum is considered technically difficult and is not routinely performed. We report our experience with SEMS placement for these patients.
  
  
  METHODS
  Between 2006 and 2015, 51 patients with unresectable or metastatic malignancy underwent SEMS placements under combined endoscopic and fluoroscopic guidance. Eighteen patients had intestinal obstruction distal to the duodenal bulb. Their demographics, technical and clinical outcomes, periprocedural morbidity and mortality, length of hospital stay, further interventions and overall survival were analysed.
  
  
  RESULTS
  Out of the 18 cases, nine cases of intestinal obstruction were due to primary malignancy of the pancreas, three due to gastric malignancy, three from other locoregional cancers and three were the result of metastases. In 12 patients, the obstruction involved the second part (D2), in four the third part (D3) and in two the fourth part (D4) of the duodenum. A front-facing therapeutic gastroscope was used to visualize the duodenum before the stricture was crossed under direct vision and fluoroscopic guidance, with a catheter and guidewire, and a through-the-scope SEMS deployed using an 'over-the-wire' technique. Technical success rate was 89%. The mean gastric outlet obstruction scores improved from 0.63 to 2.57 (P<0.0001). Four patients died within 30 days of the procedure, although none of the deaths were procedure related. The median length of postprocedural hospital stay was 4 days and the median overall survival was 58 days.
authors.affiliation: aDepartment of Radiology, Castle Hill Hospital, Hull and East Yorkshire NHS Trust, Cottingham bThe Queen's Centre for Oncology and Haematology, Hull and York Medical School, Castle Hill Hospital, Hull, UK cDepartment of Diagnostic Radiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong.
authors.forename: Keith Wan Hang
authors.initials: KW
authors.lastname: Chiu
authors.forename: Abdul
authors.initials: A
authors.lastname: Razack
authors.forename: Anthony
authors.initials: A
authors.lastname: Maraveyas
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D004067:Digestive System Neoplasms / Q000150:complications*; D004380:Duodenal Obstruction / Q000209:etiology / Q000473:pathology / Q000628:therapy*; D005260:Female; D005471:Fluoroscopy / Q000379:methods; D005773:Gastroscopy / Q000379:methods; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010166:Palliative Care / Q000379:methods; D015641:Radiography, Interventional / Q000379:methods; D000069322:Self Expandable Metallic Stents