Introduction
Endoscopic treatment has emerged as a less invasive alternative to surgical gastrojejunostomy
in the palliation of gastric outlet obstruction (GOO) symptoms [1]
[2]. Available endoscopic options include the placement of a self-expandable metal stent
(SEMS; hereinafter referred to as the “stent”) and the more recently introduced endoscopic
ultrasound (EUS)-guided gastrojejunostomy [3]
[4]. As EUS-guided gastrojejunostomy requires expert interventional EUS skills and is
not feasible in all patients, endoscopic stent placement remains the mainstay of palliative
endoscopic treatment of GOO symptoms.
Different stent designs are available for the palliation of GOO symptoms. Previous
studies have shown uncovered duodenal stent placement to be highly successful in the
palliation of GOO symptoms, with a technical success rate of 100 % and a clinical
success rate of 86 % [3]. In the long term, however, a considerable number of patients experience a recurrence
of symptoms requiring additional interventions. Moreover, adverse events (AEs) are
common. Little is known about the parameters that affect GOO symptom recurrence and
AE rates after duodenal stent placement, as only a few studies have investigated the
impact of patient- and disease-specific characteristics on stent-related outcomes
[5]
[6]
[7]
[8]. Furthermore, none of these studies have investigated changes over time in stent-related
outcomes, while ongoing technical developments in stent design and changes in the
management strategies for the underlying malignant disease may have affected clinical
outcomes. Therefore, in this study we evaluated the clinical outcomes of duodenal
stent placement for the palliation of GOO symptoms over a period of 20 years and aimed
to assess trends over time with regard to recurrent GOO symptoms and the number of
AEs.
Methods
A retrospective study was performed of patients who underwent duodenal stent placement
for palliation of GOO symptoms between January 1998 and November 2019 in the Erasmus
MC University Medical Center in the Netherlands, which serves as a tertiary referral
center. Potentially eligible patients were identified using a text search in the statistic
module of ENDOBASE (Olympus, Tokyo, Japan), an endoscopy documentation system, to
find all endoscopy reports in which duodenal stent placement was mentioned.
Before the onset of data collection, the study protocol was approved by the Medical
Research Ethics Committee of the Erasmus MC University Medical Center (MEC-2019–0251).
Patient selection
Patients were eligible if they had GOO symptoms due to a malignant obstruction located
in the distal stomach or duodenum and were scheduled for placement of an uncovered
self-expandable duodenal stent. Patients who had undergone previous treatment for
GOO symptoms (i. e. stent placement or palliative gastrojejunostomy) or had a secondary
more distally located stricture were excluded from this study.
Duodenal stent placement
Duodenal stent placement was performed under fluoroscopic guidance and according to
standard procedures. During stent placement, patients were under conscious sedation,
propofol sedation, or general anesthesia. Selection of the most appropriate stent
design and length was based on the judgement and preference of the endoscopist. Biliary
stent placement was performed before duodenal stent placement depending on biliary
patency and stricture location.
Data collection
Endoscopy reports were used to retrieve data regarding the initial duodenal stent
placement procedure and subsequent endoscopic procedures, when applicable. These data
included the date of procedure, stricture location and length, stent type and measurements,
success of stent placement, prior bile drainage, and whether or not the stent was
covering the papilla. Data on patient characteristics and procedure-related outcomes,
such as age, sex, tumor etiology, prior treatments, the presence of peritoneal deposits
and/or ascites, recurrent GOO symptoms after stent placement, AEs, and the cause and
time of death, were collected from the electronic patient file. The presence of peritoneal
deposits was defined by peritoneal deposits that were described on abdominal imaging
and/or where ascites was present.
All patients with recurrent GOO symptoms underwent thorough evaluations to investigate
stent patency by imaging techniques and/or upper gastrointestinal (GI) endoscopy.
The severity of GOO symptoms were graded according to the Gastric Outlet Obstruction
Symptom Score (GOO Symptom Score) [9]. This widely applied scale ranges from zero to three; with a lower score representing
more severe symptoms. Every increase of the GOO Symptom Score in the period after
stent placement was marked as symptom recurrence. If GOO Symptoms Scores were unavailable,
the mention of “re-dysphagia” in the electronic patient file was used as a surrogate
marker for GOO symptom recurrence. When an AE occurred during the first 30 days after
stent placement, the cause and date of first onset were recorded. The cause and time
of death of all patients were collected. If the time of death was unavailable, the
municipal registry was consulted.
Statistical analysis
The primary outcome of this study was GOO symptom-free survival. Secondary outcomes
included the AE rate and overall survival. Outcomes were reported as percentages,
and means for normally distributed variables or medians for abnormally distributed
variables. To compare outcomes for patients treated in different time periods (1998–2009
vs. 2010–2019), the unpaired t test, Mann–Whitney U test and chi-squared test were used. GOO symptom-free survival and overall survival
were compared using the Kaplan–Meier method with log-rank testing. To explore clinical
parameters affecting treatment outcomes, binary logistic regression and Cox regression
analyses were used. Parameters that were included were selected from previous studies
[5]
[6]
[7]
[8].
All analyses were performed using IBM SPSS statistics, version 25 (IBM Corp., Armonk,
New York, USA) and R (R Foundation for Statistical Computing, Vienna, Austria, https://www.R-project.org/).
Tests were considered statistically significant if P was < 0.05 (two-sided).
Results
Between January 1998 and November 2019, a total of 187 patients underwent duodenal
stent placement at the Erasmus MC University Medical Center. A total of 40 patients
were not included for the following reasons: incomplete follow-up after stent placement
(n = 21), stricture location other than the distal stomach or duodenum (n = 11), use
of a partially covered duodenal stent (n = 4), use of an esophageal stent (n = 1),
a previously performed palliative surgical gastrojejunostomy (n = 1), the presence
of a second stenosis (n = 1), and a missing endoscopy report (n = 1).
Baseline characteristics of the 147 patients included in this study (62 % men; mean
[SD] age 64 [12] years) are shown in [Table 1]. Pancreatic cancer was the most common cancer type (51 %), followed by cholangiocarcinoma
(12 %) and stomach cancer (10 %). A total of 49 patients (33 %) were treated with
chemotherapy and/or radiotherapy prior to stent placement and 18 patients (12 %) with
concomitant chemoradiotherapy. The percentage of patients treated with prior chemotherapy
increased from 25 % in 1998–2009 to 33 % in 2010–2019. Peritoneal deposits were present
in 25 % of patients, ascites in 17 % of patients. The proportion of men was statistically
significantly higher in patients treated in the period 2010–2019 (1998–2009 vs. 2010–2019,
51 % vs. 72 %; P = 0.01). Other baseline characteristics were not statistically significantly different
between the two periods.
Table 1
Baseline characteristics of the 147 patients with gastric outlet obstruction included
in the study.
|
Total
(n = 147)
|
1998–2009 (n = 72)
|
2010–2019 (n = 75)
|
P value[1]
|
|
Age, mean (SD), years
|
64 (12)
|
63 (12)
|
64 (12)
|
0.57
|
|
Sex, male, n (%)
|
91 (62)
|
37 (51)
|
54 (72)
|
0.01
|
|
Tumor etiology, n (%)
|
0.35
|
|
|
75 (51)
|
37 (51)
|
38 (51)
|
|
|
18 (12)
|
6 (8)
|
12 (16)
|
|
|
14 (10)
|
7 (10)
|
7 (9)
|
|
|
6 (4)
|
4 (6)
|
2 (3)
|
|
|
6 (4)
|
4 (6)
|
2 (3)
|
|
|
6 (4)
|
1 (1)
|
5 (7)
|
|
|
22 (15)
|
13 (18)
|
9 (12)
|
|
Prior treatment, n (%)
|
0.51
|
|
|
98 (67)
|
50 (69)
|
48 (64)
|
|
|
|
43 (29)
|
18 (25)
|
25 (33)
|
0.36
|
|
|
1 (1)
|
1 (1)
|
0
|
0.31
|
|
|
5 (3)
|
3 (4)
|
2 (3)
|
0.97
|
|
Concomitant chemotherapy, n (%)
|
18 (12)
|
7 (10)
|
11 (15)
|
0.36
|
|
Peritoneal deposits, n (%)
|
36 (25)
|
15 (21)
|
21 (28)
|
0.31
|
|
Ascites, n (%)
|
25 (17)
|
11 (15)
|
14 (19)
|
0.59
|
1 1998–2009 vs. 2010–2019.
2 Carcinoma of unknown primary (n = 4), sarcoma (n = 3), urothelial carcinoma (n = 3),
breast carcinoma (n = 2), esophageal carcinoma (n = 2), endometrial carcinoma (n = 1),
GIST (n = 1), hepatocellular carcinoma (n = 1), lung carcinoma (n = 1), melanoma (n = 1),
ovarian cancer (n = 1), renal cell carcinoma (n = 1), Merkel cell carcinoma (n = 1).
Duodenal stent placement
The median time between initial diagnosis and duodenal stent placement was 3.5 months
in 1998–2009 and 6 months in 2010–2019 (P = 0.54). Duodenal stent placement was technically successful in 143 of 147 patients
(97 %; 1998–2009 vs. 2010–2019, 94 % vs. 100 %; P = 0.04). Reasons for unsuccessful stent placement were inability to pass the guidewire
(n = 2), unspecified technical issues (n = 1), and a percutaneous transhepatic drain
extending into the duodenum that prevented the stent from deploying (n = 1). Most
patients were treated under conscious sedation (1998–2009 vs. 2010–2019, 100 % vs.
94 %; P = 0.01), but propofol sedation and general anesthesia were also used in the period
2010–2019.
The WallFlex duodenal stent was the most frequently used stent in the period 1998–2009
(72 %), whereas the Evolution duodenal stent was most frequently used in the period
2010–2019 (91 %; P < 0.001) ([Table 2]). A statistically significantly higher rate of duodenal stents overlapping the papilla
was observed in the period 1998–2009 (34 % vs. 17 %; P = 0.01). The percentage of patients who underwent drainage of the bile system prior
to placement of the duodenal stent was comparable (74 % vs. 77 %; P = 0.84).
Table 2
Characteristics of 143 patients in whom the duodenal self-expandable metal stent was
successfully inserted.
|
Total
(n = 143)
|
1998–2009 (n = 68)
|
2010–2019 (n = 75)
|
P value[1]
|
|
Sedation, n (%)
|
< 0.001
|
|
|
138 (96)
|
68 (100)
|
70 (94)
|
|
|
4 (3)
|
0
|
4 (5)
|
|
|
1 (1)
|
0
|
1 (1)
|
|
Stent manufacturer, n (%)
|
< 0.001
|
|
|
68 (48)
|
0
|
68 (91)
|
|
|
10 (7)
|
10 (15)
|
0
|
|
|
1 (1)
|
1 (2)
|
0
|
|
|
1 (1)
|
1 (2)
|
0
|
|
|
55 (39)
|
49 (72)
|
6 (8)
|
|
|
8 (6)
|
7 (10)
|
1 (1)
|
|
Location obstruction, n (%)[2]
|
|
|
|
32 (22)
|
14 (21)
|
18 (24)
|
0.63
|
|
|
67 (47)
|
33 (49)
|
34 (45)
|
0.70
|
|
|
84 (59)
|
41 (60)
|
43 (57)
|
0.72
|
|
|
31 (22)
|
17 (25)
|
14 (19)
|
0.36
|
|
|
4 (3)
|
2 (3)
|
2 (3)
|
0.92
|
|
Extent stricture, n (%)
|
0.21
|
|
|
73 (51)
|
31 (46)
|
42 (56)
|
|
|
70 (49)
|
37 (54)
|
33 (44)
|
|
External compression, n (%)
|
22 (15)
|
17 (25)
|
5 (7)
|
0.002
|
|
Papilla covered, n (%)
|
36 (25)
|
23 (34)
|
13 (17)
|
0.01
|
1 1998–2009 vs. 2010–2019.
2 In some patients, multiple compartments were obstructed.
Recurrent symptoms
During follow-up (median survival time 82 days, range 1–448), a total of 82 patients
(57 %) had recurrent GOO symptoms after successful stent placement (1998–2009 vs.
2010–2019, 38 (56 %) vs. 44 (59 %); P = 0.74) (Table 1 s, see online-only Supplementary material). The median time until recurrent symptoms
was 28 days (1998–2009 vs. 2010–2019, 39 vs. 21 days: P = 0.49). The main reasons for recurrent symptoms were tumor ingrowth (23 %), motility
problems (17 %, i. e. repeated upper GI endoscopy showed a fully patent stent), and
stent migration (8 %) ([Fig. 1a]). An increased rate of stent ingrowth was observed in the period 2010–2019 (18 %
vs. 28 %; P = 0.14). The stent migration rate decreased over time (10 % vs. 5 %; P = 0.27). Other reasons for recurrent GOO symptoms are shown in Table 1 s. Motility problems were not significantly different between patients with and without
peritoneal deposits (25 % vs. 14 %, respectively; P = 0.13).
Fig. 1 Graphs showing the rates, overall and in the two time periods, for: a recurrence of gastric outlet obstruction symptoms, with causes; b adverse events, among the 143 patients who underwent successful duodenal stent placement.
Multivariable binary logistic regression showed no association between recurrent GOO
symptoms and age, sex, prior treatment, chemotherapy, peritoneal deposits and/or ascites,
number of strictures (single vs. multiple stenoses), external compression, or period
of stent placement (Table 2 s).
The GOO symptom-free survival was significantly shorter in patients treated in the
period 2010–2019 (P = 0.009) ([Fig. 2a]). The 1-, 2– and 3-month GOO symptom-free survival rates were 68 %, 49 %, and 38 %,
respectively, between 1998–2009, compared with 52 %, 37 %, and 20 %, respectively,
for patients treated between 2010–2019. Multivariable Cox regression analysis showed
that the period of stent placement was the only independent predictor of a reduced
GOO symptom-free survival (Hazard ratio 1.89; P < 0.001) ([Table 3]).
Fig. 2 Survival curves comparing patients treated between 1998–2009 and 2010–2019 for: a gastric outlet obstruction symptom-free survival; b overall survival.
Table 3
Multivariable Cox regression analysis of predictors for shorter gastric outlet obstruction
symptom-free survival.
|
Hazard ratio
|
Confidence interval
|
P value
|
|
Age
|
0.99
|
0.97–1.00
|
0.06
|
|
Sex
|
0.30
|
|
|
1
|
|
|
|
1.21
|
0.85–1.74
|
|
Prior treatment
|
0.84
|
|
|
1
|
|
|
|
1.04
|
0.71–1.51
|
|
Chemotherapy
|
0.11
|
|
|
1
|
|
|
|
0.65
|
0.38–1.10
|
|
Peritoneal deposits and/or ascites
|
0.07
|
|
|
1
|
|
|
|
0.71
|
0.49–1.03
|
|
Extent of obstruction
|
0.97
|
|
|
1
|
|
|
|
1.00
|
0.71–1.51
|
|
Extrinsic compression
|
0.36
|
|
|
1
|
|
|
|
1.27
|
0.78–2.11
|
|
Time period
|
< 0.001
|
|
|
1
|
|
|
|
1.89
|
1.31–2.75
|
Adverse events
Of the 143 patients who underwent successful stent placement, 49 (34 %) experienced
at least one AE (1998–2009 vs. 2010–2019, 31 % vs. 37 %; P = 0.42), after a median time of 4 days (Table 1 s). The time to occurrence of the first AE did not significantly differ between the
two periods (3 vs. 7 days; P = 0.14).
The rate of stent-related AEs increased over time, from 31 % in 1998–2009 to 37 %
in 2010–2019 ([Fig. 1b]; Table 1 s). Furthermore, when an AE occurred, there was a tendency for multiple AEs to occur
in the same patient, especially for patients treated between 2010–2019. This is reflected
by the notably higher absolute number of AEs in this period (1998–2009 vs. 2010–2019,
26 vs. 40). The number of major AEs increased from 17 (25 %) to 25 (33 %), and minor
AEs from 9 (13 %) to 15 (20 %) in the more recent period.
Major AEs included fever (n = 14), cholangitis (n = 13), hemorrhage (n = 3), pneumonia
(n = 3), deep venous thrombosis (n = 3), perforation (n = 2), pressure necrosis (n = 2),
delirium (n = 1), and pancreatitis (n = 1). All major AEs increased over time, except
pneumonia, which slightly decreased from two events to one. Fistulas were not observed
in this study. One patient died owing to a stent-related perforation 1 day after stent
placement. Cholangitis was more common in patients in whom the duodenal stent overlapped
the papilla (overlap vs. no overlap, n = 5 (14 %) vs. n = 8 (7 %); P = 0.23). Pain was the only reported minor AE (n = 24). An increased rate of stent-related
pain was observed in patients treated in the period 2010–2019 (13 % vs. 20 %; P = 0.28).
Prior treatment with chemotherapy and/or radiotherapy was the only independent risk
factor for AEs (OR 2.53; P = 0.02) ([Table 4]). A total of 23 patients who underwent prior treatment (47 %) developed an AE compared
with 26 patients with no prior treatment (27 %).
Table 4
Multivariable binary logistic regression analysis of risk factors for the occurrence
of adverse events.
|
Odds ratio
|
Confidence interval
|
P value
|
|
Age
|
0.99
|
0.96–1.02
|
0.48
|
|
Sex
|
0.47
|
|
|
1
|
|
|
|
0.75
|
0.35–1.62
|
|
Prior treatment
|
0.02
|
|
|
1
|
|
|
|
2.53
|
1.17–5.47
|
|
Extent of obstruction
|
0.32
|
|
|
1
|
|
|
|
0.69
|
0.33–1.44
|
|
Time period
|
0.69
|
|
|
1
|
|
|
|
1.16
|
0.56–2.44
|
Overall survival
At the time of analysis, 142 of 143 patients (99 %) had died, with 141 patients dying
because of disease progression and one dying owing to a stent-related AE. Overall
survival was lower in patients treated in the more recent period, but this was not
statistically significant (P = 0.13) ([Fig. 2b]). The 1-, 2– and 3-month overall survival rates were 84 %, 68 %, and 54 %, respectively,
in the period 1998–2009, compared with 80 %, 56 %, and 39 % in the period 2010–2019.
Discussion
This is the largest study to date to evaluate the clinical outcome of uncovered duodenal
stent placement for the palliative treatment of malignant GOO symptoms. This study,
including 147 patients over a period of 20 years, provides a valuable insight into
time trends in the efficacy and safety of duodenal stent placement. We showed that
duodenal stent placement remains a successful treatment option for short-term relief
of GOO symptoms. However, the rates of both GOO symptom recurrence and AEs are substantial,
with the GOO symptom-free survival in particular decreasing in the last 10 years.
Furthermore, prior treatment with chemotherapy and/or radiotherapy was found to be
significantly associated with an increased risk of AEs.
Recent changes in treatment strategies have to be taken into account when evaluating
the observed significant decrease in GOO symptom-free survival. Since the publication
of the SUSTENT trial in the early 2010 s, duodenal stent placement has mainly been
recommended for patients with an expected survival of less than 2 months, whereas
surgical gastrojejunostomy has been recommended for patients with a life expectancy
longer than 2 months [1]. As a result, patients treated with a duodenal stent were likely to have a lower
life expectancy in the last 10 years, introducing a considerable inclusion bias for
this study. In our study, a lower overall survival in 2010–2019 (although not reaching
statistical significance) supports this assumption. This shift in patient selection
might explain the decrease in GOO symptom-free survival in the last 10 years. Not
only because overall survival has a direct impact on GOO symptom-free survival, but
also because it is known that patients with a poor overall clinical condition may
have GOO symptoms such as nausea, vomiting and early satiety due to factors other
than duodenal stent dysfunction, which can negatively affect a patient’s condition.
In the present study, more than half of the patients (59 %) experienced recurrent
GOO symptoms, after a median time of 28 days. This recurrence rate is much higher
than has been previously reported for uncovered stents, with prospective studies showing
rates ranging from 16 % up to 30 % [7]. In the present study, tumor in- or overgrowth influenced GOO symptom-free survival
the most, accounting for 23 % of GOO recurrence. This percentage is comparable to
other studies with uncovered duodenal stents, which are prone to tumor ingrowth but
are less likely to migrate than covered stents. Although stent occlusion is not a
desired outcome, it can be managed with additional stent therapy. Our higher recurrence
rate may largely be explained by the fact that also nonstent-related causes of GOO
symptoms were included, with motility problems (defined as repeated upper GI endoscopy
revealing a patent stent) causing 17 % of our recurrence rate. Other studies did not
include this outcome, but we believe it provides clinically relevant information.
The follow-up time did not affect the GOO recurrence rates, as our median survival
time of 82 days is comparable with other studies.
The presence of peritoneal deposits, Karnofsky performance status, and use of chemotherapy
have previously been reported to be related to the clinical success of duodenal stent
placement [5]
[6]
[7]
[10]. In our study, additional regression analysis did not identify any clinical parameters
related to the recurrence of symptoms. A potential explanation for this difference
might be an underestimation of the number of patients with peritoneal deposits in
our study, which was considerably lower at 25 % compared with 44 %–56 % in other studies
[7]
[11]
[12]. Data on Karnofsky performance status was not available owing to the retrospective
design of this study.
Not only GOO symptom recurrence but also stent-related AEs have a negative impact
on quality of life in patients with incurable disease. In previous studies, the rate
of AEs after duodenal stent placement has varied widely, ranging from 5 % up to 42 %
[3]
[5]
[7]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]. In this study, more than one-third of patients experienced at least one AE in the
first 30 days after duodenal stent placement. Major iatrogenic complications, such
as perforation, bleeding, and pressure ulcers, were rare in both time periods. Perforation
rates remained stable over time but there was a slight increase in bleeding and pressure
ulcers in more recent years. Furthermore, fever and cholangitis rates were highest
in 2010–2019. The increase in cholangitis is remarkable considering the lower rate
of duodenal stents overlapping the papilla in this period, which would have been expected
to reduce cholangitis rates. A possible explanation for this observation might be
found in the etiology of the underlying malignant stricture, with relatively more
patients with gallbladder or bile duct cancer in recent years, possibly increasing
the risk of cholangitis.
The reason why the number of duodenal stents that covered the papilla was lower in
more recent years is not known. Possibly the underlying malignancies, with more biliary
malignancies in recent years, may play a role. First, hilar biliary tract malignancies
have a tendency to grow more proximally than for example pancreatic tumors, which
could result in a more proximal stent placement (i. e. not covering the papilla) in
more recent years. Second, most endoscopists will preferably not cover the papilla
if gallbladder or bile duct cancer is present, to enable potential endoscopic (re)interventions
of the bile duct.
Furthermore, a notable increase of stent-related pain was observed in the last 10
years. More patients were treated with prior chemotherapy and/or radiotherapy in 2010–2019
compared with 1998–2009, which can be proposed as an explanation for the overall increase
in both major and minor AEs. Multivariable regression analysis revealed that prior
chemotherapy and/or radiotherapy was significantly associated with the risk of AEs:
almost half of these patients developed at least one stent-related AE, compared with
27 % of patients with no prior therapy. The association between stent-related AEs
and prior treatment has been described in patients undergoing esophageal stent placement
[21], but no studies have explored this association for duodenal stent placement.
Remarkably, pneumonia was the only AE that decreased over time. Unfortunately, pneumonia
rates were too low to analyze the relation between the risk of getting pneumonia and
altered sedation strategies or the placement of a nasogastric tube prior to duodenal
stent placement. In addition, all AE numbers were relatively low in this study; therefore,
it is challenging to prove any causal relationship between a parameter and an AE.
In order to improve future outcomes, more studies are needed to investigate the impact
of different clinical parameters on the risk of stent-related AEs.
Several limitations of this study should be acknowledged, including its retrospective
nature and the heterogeneity of the study population, which is inherent to the duodenal
stenting population. Because of the retrospective study design, we were unable to
re-collect clinical success rates of duodenal stent placement. Unfortunately, owing
to the lack of a structured follow-up scheme to evaluate GOO symptoms, the clinical
success directly after stent placement was often not reported in the electronic patient
file. Given the limited overall survival in this population, the true success of palliation
is best measured by the improvement of GOO symptoms and quality of life, rather than
by technical success rates.
Furthermore, the study population was too small to perform stratified analyses for
different tumor etiologies, or to analyze potential explanatory parameters for separate
AEs. In addition, during the study period, different types of duodenal stent were
used. To date, however, no comparative study has shown the superiority of one stent
manufacturer over another. Finally, we have used two defined time periods as a variable
within regression analyses to explore trends over a 20-year period, which prohibits
the assessment of fluctuations in smaller time periods.
In conclusion, our study demonstrates that improvement in the outcome of duodenal
stent therapy for malignant GOO symptoms is challenging, despite ongoing technical
developments. Although successful for short-term palliation of malignant GOO, duodenal
stent placement was related to a considerable risk of GOO symptom recurrence and AEs.
Recent changes in management strategies, particularly the increased number of patients
being pretreated with chemotherapy and/or radiotherapy, are associated with an increase
in AEs. More studies are needed to elucidate the influence of different clinical parameters
on stent-related outcomes.
Given the decrease of GOO symptom-free survival and the increase in AEs in the last
decade, attention should be paid to informing patients about the benefits and potential
risks of duodenal stent placement, especially in patients who have received prior
chemo- and/or radiotherapy. Nevertheless, considering the lack of generally applicable
alternatives, we believe that duodenal stent placement remains the preferred option
for the management of GOO symptoms in patients with an expected short-term survival.
