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Endoscopy
Original research
Endoscopic placement of covered versus uncovered self-expandable metal stents for palliation of malignant gastric outlet obstruction
  1. Kentaro Yamao1,
  2. Masayuki Kitano1,2,
  3. Yasutaka Chiba3,
  4. Takeshi Ogura4,
  5. Takaaki Eguchi5,
  6. Ichiro Moriyama6,
  7. Yukitaka Yamashita7,
  8. Hironari Kato8,
  9. Takahisa Kayahara9,
  10. Noriyuki Hoki10,
  11. Yoshinobu Okabe11,
  12. Hideyuki Shiomi12,
  13. Yoshitaka Nakai13,
  14. Yoshinori Kushiyama14,
  15. Yoshifumi Fujimoto15,
  16. Shiro Hayashi16,
  17. Shigeki Bamba17,
  18. Yasushi Kudo18,
  19. Nobuaki Azemoto19,
  20. Toshiharu Ueki20,
  21. Norimitsu Uza21,
  22. Masanori Asada22,
  23. Kazuya Matsumoto23,
  24. Hiroko Nebiki24,
  25. Hiroshi Takihara25,
  26. Chisio Noguchi26,
  27. Hideki Kamada27,
  28. Kojiro Nakase28,
  29. Daisuke Goto29,30,
  30. Tsuyoshi Sanuki31,
  31. Tetsuya Koga32,
  32. Shinichi Hashimoto33,
  33. Hidefumi Nishikiori34,
  34. Masahiro Serikawa35,
  35. Keiji Hanada36,
  36. Ken Hirao37,
  37. Masaya Ohana38,
  38. Imakiire Kazuyuki39,
  39. Takao Kato40,
  40. Motoyuki Yoshida41,
  41. Hirofumi Kawamoto42
  1. 1Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine Hospital, Osakasayama, Osaka, Japan
  2. 2Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Wakayama, Japan
  3. 3Clinical Research Center, Kindai University Hospital, Osaka-sayama, Japan
  4. 4Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
  5. 5Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
  6. 6Innovative Cancer Center, Shimane University Hospital, Matsue, Shimane, Japan
  7. 7Department of Gastroenterology and Hepatology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
  8. 8Department of Gastroenterology and Hepatology, Okayama University, Okayama, Japan
  9. 9Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Kurashiki, Japan
  10. 10Gastroenterology, Bell Land General Hospital, Sakai, Japan
  11. 11Division of Gastroenterology, Department of Medicine, Kurume University, Kurume, Japan
  12. 12Division of Gastroenterology, Department of Internal Medicine, Kobe University, Kobe, Hyogo, Japan
  13. 13Digestive Disease Center, Department of Gastroenterology and Hepatology, Kyoto Katsura Hospital, Kyoto, Japan
  14. 14Department of Gastroenterology, Matsue Red Cross Hospital, Matsue, Japan
  15. 15Department of Gastroenterology and Hepatology, JA Hiroshima Koseiren Hiroshima General Hospital, Hatsukaichi, Hiroshima, Japan
  16. 16Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
  17. 17Division of Clinical Nutrition, Shiga University of Medical Science, Otsu, Japan
  18. 18Digestive Disease Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
  19. 19Department of Gastroenterology, Shikoku Cancer Center, Matuyama, Japan
  20. 20Department of Gastroenterology, Fukuoka University Chikushi Hospital, Chikushino, Japan
  21. 21Department of Gastroenterology and Hepatology, Kyoto University, Kyoto, Japan
  22. 22Department of Gastroenterology and Hepatology, Japanese Red Cross Society Osaka Hospital, Osaka, Osaka, Japan
  23. 23Division of Medicine and Clinical Science, Tottori University, Yonago, Japan
  24. 24Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
  25. 25Department of Gastroenterology and Hepatology, Kishiwada Tokushukai Hospital, Kishiwada, Japan
  26. 26Department of Gastroenterology, Shinbeppu Hospital, Beppu, Japan
  27. 27Gastroenterology and Neurology, Kagawa University, Kagawa, Japan
  28. 28Department of Gastroenterology, Japanese Red Cross Kyoto Daini Hospital, Kyoto, Japan
  29. 29Department of Gastroenterology and Hepatology, Tottori Municipal Hospital, Tottori, Japan
  30. 30Department of Gastroenterology and Hepatology, Tottori Red Cross Hospital, Tottori, Japan
  31. 31Department of Gastroenterology, Kitaharima Medical Center, Ono, Japan
  32. 32Department of Gastroenterology, Social Media Corporation Tenyoukai Central Hospital, Kagoshima, Japan
  33. 33Digestive and Life-style Diseases, Kagoshima University Graduate School of Medicine and Dental Sciences, Kagoshima, Kagoshima, Japan
  34. 34Department of Gastroenterology, Oita Sanai Medical Center, Oita, Japan
  35. 35Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
  36. 36Department of Gastroenterology, Onomichi General Hospital, Onomichi, Hiroshima, Japan
  37. 37Department of Internal Medicine, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Hiroshima, Japan
  38. 38Department of Gastroenterology, Tenri Hospital, Tenri, Nara, Japan
  39. 39Department of Gastroenterology, Imakiire General Hospital, Kagoshima, Japan
  40. 40Department of Gastroenterology, Hyogo Prefectural Awaji Medical Center, Sumoto, Japan
  41. 41Third department of Internal Medicine, Nara Medical University, Kashihara, Nara, Japan
  42. 42General Medicine 2, Kawasaki Medical School, Okayama, Japan
  1. Correspondence to Professor Masayuki Kitano, Second Department of Internal Medicine, Wakayama Medical University, Wakayama, Wakayama 641-0012, Japan; kitano{at}wakayama-med.ac.jp

Abstract

Objective Stenting is an established endoscopic therapy for malignant gastric outlet obstruction (mGOO). The choice of stent (covered vs uncovered) has been examined in prior randomised studies without clear results.

Design In a multicentre randomised prospective study, we compared covered (CSEMS) with uncovered self-expandable metal stents (UCSEMS) in patients with mGOO; main outcomes were stent dysfunction and patient survival, with subgroup analyses of patients with extrinsic and intrinsic tumours.

Results Overall survival was poor with no difference between groups (probability at 3 months 49.7% for covered vs 48.4% for uncovered stents; log-rank for overall survival p=0.26). Within that setting of short survival, the proportion of stent dysfunction was significantly higher for uncovered stents (35.2% vs 23.4%, p=0.01) with significantly shorter time to stent dysfunction. This was mainly relevant for patients with extrinsic tumours (stent dysfunction rates for uncovered stents 35.6% vs 17.5%, p<0.01). Subgrouping was also relevant with respect to tumour ingrowth (lower with covered stents for intrinsic tumours; 1.6% vs 27.7%, p<0.01) and stent migration (higher with covered stents for extrinsic tumours: 15.3% vs 2.5%, p<0.01).

Conclusions Due to poor patient survival, minor differences between covered and uncovered stents may be less relevant even if statistically significant; however, subgroup analysis would suggest to use covered stents for intrinsic and uncovered stents for extrinsic malignancies.

  • stents
  • gastrointesinal endoscopy

https://doi.org/10.1136/gutjnl-2020-320775

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    Footnotes

    • Contributors KY：contributed to the study design, recruited patients to the study, treated patients, contributed to the running of the study, analysed the results and wrote the manuscript draft. MK：designated the study, recruited patients to the study, treated patients, contributed to the running of the study, reviewed the analysis, and reviewed and contributed to the writing of the manuscript. YC：contributed to the study design, analysed the results, and reviewed and contributed to the writing of the manuscript. SB：contributed to the study design, recruited patients to the study, treated patients, contributed to the running of the study, reviewed the analysis, and reviewed and contributed to the writing of the manuscript. SH：contributed to the study design, recruited patients to the study, treated patients, contributed to the running of the study and reviewed the analysis. All other authors contributed to the study design, recruited patients to the study, treated patients and contributed to the running of the study.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The study was approved by the ethical committees at 41 tertiary centres in Japan.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon reasonable request. We are ready to respond to any inquiries about the detailed data in this study.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.