Gastroduodenal obstruction

Very recently four larger series totalling 119 patients with gastroduodenal obstruction treated with uncovered stents were published by Pinto et al. (2001), Yim et al. (2001), Razzaq et al. (2001) and Adler and Baron (2000a) (Table 3.1). 

Other types of stents such as the Strecker tantalum stent (SoLT and Papp 1993), the Strecker Nitinol stent (Strecker et al. 1995) or modified and covered Gianturco stents (Song et al. 1993) have been used only occasionally and not much experience exists with these stents. Recently, however, two series of 19 and 24 patients have been published advocating covered metallic expandable stents for prevention of tumour ingrowth after stenting for gastroduodenal obstruction (Jung et al. 2000 Park et al. 2001). 

Stent fracture has only been reported in one series with modified covered Z-stents (Park et al. 2001) but not with any other stent designs implanted in gastroduodenal obstruction. 

Gastroduodenal Enteric gram-negative bacilli, gram-positive cocci, oral anaerobes Cefazolin 1 g x 1 High-risk patients only (obstruction, hemorrhage, malignancy, acid suppression therapy, morbid obesity) IA... 

In the VIGOR study, 8076 patients with rheumatoid arthritis were randomly assigned to receive rofecoxib 50 mg/day or naproxen 500 mg bd. The primary endpoint was a confirmed clinical upper gastrointestinal event (gastroduodenal perforation or obstruction, upper gastrointestinal bleeding, and symptomatic gastroduodenal ulcer). 

Insertion of self-expanding metallic stents is now a well-established method to treat obstructions of the biliary tract (Rossi et al. 1994) and the oesophagus (Song et al. 1994 Adam et al. 1997). Recently their use has been extended to gastroduodenal outlet obstruction and treatment of acute ileus in colorectal obstruction. Patients with malignant gastroduodenal as well as colorectal obstruction are often elderly,... 

Unlike treatment in the oesophagus and biliary tree, the treatment of gastroduodenal and colonic obstruction is not yet as well established. This is probably most likely due to the limited familiarity with the indications and available devices. 

In this chapter we describe the indications, results and problems with stenting of gastroduodenal and colorectal obstruction. 

In some recent publications from Korea custom made flexible covered metallic stents were advocated for gastroduodenal as well as colonic obstruction. Modified Z-stents were covered with a polyurethane membrane and stent shapes were further changed to improve flexibility and fixation (Choo et al. 1998 Jung et al. 2000 Park et al. 1999, 2001 Lee et al. 2001). 

If there is known or impending biliary obstruction in the presence of duodenal obstruction which needs possible stenting across the papilla an expandable metal biliary stent should be placed before the duodenal stent. The presence of a transpapillary duodenal stent may make transhepatic placement of a bihary stent more difficult and an endoscopic approach impossible. Therefore it would seem prudent to evaluate also the biliary tree in patients who are to undergo gastroduodenal stenting. 

Mauro AM, Koehler RE, Baron TH (2000) Advances in gastrointestinal intervention the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology 215 659-669... 

The pathologic specimens of the stomach and tumor (resected in 1881 by Billroth) of Theresa Heller, on display at the Josephinum in Vienna. The left bottle is the resection specimen, containing the obstructed pyloric antrum that was successfully resected. The right specimen is of the stomach, recovered at autopsy SVi months later, when the patient died of hepatic metastases. The patent gastroduodenal anastomosis is evident. It is worthy of note that more than a century later, the survival of patients with gastric cancer has not improved appreciably since the first intervention by Billroth. 

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