Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction

BACKGROUND

Malignant gastric outlet obstruction is the clinical and pathological consequence of cancerous disease causing a mechanical obstruction to gastric emptying. It usually occurs when malignancy is at an advanced stage; therefore, people have a limited life expectancy. It is of paramount importance to restore oral intake to improve quality of life for the person in a manner that has a minimal risk of complications and a short recovery period.

OBJECTIVES

To assess the benefits and harms of endoscopic stent placement versus surgical palliation for people with symptomatic malignant gastric outlet obstruction.

SEARCH METHODS

In May 2018 we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and Ovid CINAHL. We screened reference lists from included studies and review articles.

SELECTION CRITERIA

We included randomised controlled trials comparing stent placement with surgical palliation for people with gastric outlet obstruction secondary to malignant disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes, mean difference (MD) or standardised mean difference (SMD) with 95% CI for continuous outcomes and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where meaningful. We assessed the quality of evidence using GRADE criteria.

MAIN RESULTS

We identified three randomised controlled trials with 84 participants. Forty-one participants underwent surgical palliation and 43 participants underwent duodenal stent placement. There may have been little or no difference in the technical success of the procedure (RR 0.98, 95% CI 0.88 to 1.09; low-quality evidence), or whether the time to resumption of oral intake was quicker for participants who had undergone duodenal stent placement (MD -3.07 days, 95% CI -4.76 to -1.39; low-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved all-cause mortality and median survival postintervention.The time to recurrence of obstructive symptoms may have increased slightly following duodenal stenting (RR 5.08, 95% CI 0.96 to 26.74; moderate-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved serious and minor adverse events. The heterogeneity for adverse events was moderately high (serious adverse events: Chi² = 1.71; minor adverse events: Chi² = 3.08), reflecting the differences in definitions used and therefore, may have impacted the outcomes. The need for reintervention may have increased following duodenal stenting (RR 4.71, 95% CI 1.36 to 16.30; very low-quality evidence).The length of hospital stay may have been shorter (by approximately 4 to 10 days) following stenting (MD -6.70 days, 95% CI -9.41 to -3.98; moderate-quality evidence).

AUTHORS' CONCLUSIONS

The use of duodenal stent placement in malignant gastric outlet obstruction has the benefits of a quicker resumption of oral intake and a reduced inpatient hospital stay; however, this is balanced by an increase in the recurrence of symptoms and the need for further intervention.It is impossible to draw further conclusions on these and the other measured outcomes, primarily due to the low number of eligible studies and small number of participants which resulted in low-quality evidence. It was not possible to analyse the impact on quality of life each intervention had for these participants.

Palliative gastrojejunostomy versus endoscopic stent placement for gastric outlet obstruction in patients with unresectable gastric cancer: a propensity score-matched analysis

BACKGROUND

It remains unclear whether selection of treatment modality affects the survival of patients with malignant gastric outlet obstruction (GOO). We compared the effect of gastrojejunostomy (GJ) and endoscopic self-expandable metallic stent (SEMS) placement on the long-term outcomes of patients with malignant GOO caused by unresectable gastric cancer.

METHOD

We conducted a retrospective study of gastric cancer patients undergoing GJ or endoscopic SEMS placement for the palliation of malignant GOO. To reduce the effect of selection bias, we performed a propensity score-matching analysis between two groups.

RESULTS

In a propensity-matched analysis (45 and 99 in GJ and SEMS groups, respectively), clinical success rates were comparable between the GJ and SEMS groups (95.6 and 96.0%), while the SEMS group showed significantly shorter hospital stays than the GJ group. The GJ group showed a significantly longer reintervention period and overall survival (393 and 129 days) compared to the SEMS group. In multivariate Cox regression analysis, GJ, low ECOG scale (good performance status), and additional chemo- or radiation therapy were identified as independent favorable predictors of overall survival. GJ was also identified as an independent protective predictor against reintervention.

CONCLUSION

We found that palliative GJ was significantly associated with longer overall survival and lower risk of reintervention than SEMS placement in patients with malignant GOO caused by unresectable gastric cancer. Given very limited expected survival in selected patients with unresectable gastric cancer and more favorable short-term outcomes in cases of SEMS placement, individualized approach might be required in treatment decision between palliative GJ and SEMS placement.

Self-expanding metal stents for the palliation of malignant gastric outlet obstruction in patients with peritoneal carcinomatosis

AIM

To evaluate the efficacy of self-expanding metal stents (SEMS) for the palliation of malignant gastric outlet obstruction in patients with and without peritoneal carcinomatosis (PC).

METHODS

We performed a retrospective analysis of 62 patients who underwent SEMS placement for treatment of malignant gastroduodenal obstruction at our hospital over a six-year period. Stents were deployed through the scope under combined fluoroscopic and endoscopic guidance. Technical success was defined as successful stent placement and expansion. Clinical success was defined as an improvement in the obstructive symptoms and discharge from hospital without additional parenteral nutrition. According to carcinomatosis status, patients were assigned into groups with or without evidence of peritoneal disease.

RESULTS

In most cases, obstruction was caused by pancreatic (47%) or gastric cancer (23%). Technical success was achieved in 96.8% (60/62), clinical success in 79% (49/62) of all patients. Signs of carcinomatosis were identified in 27 patients (43.5%). The diagnosis was confirmed by pathology or previous operation in 7 patients (11.2%) and suspected by CT, MRI or ultrasound in 20 patients (32.2%). Presence of carcinomatosis was associated with a significantly lower clinical success rate compared to patients with no evidence of peritoneal disease (66.7% vs 88.6%, P = 0.036). There was no significant difference in overall survival between patients with or without PC (median 48 d vs 70 d, P = 0.21), but patients showed significantly longer survival after clinical success of SEMS placement compared to those experiencing clinical failure (median 14.5 d vs 75 d, P = 0.0003).

CONCLUSION

Given the limited therapeutic options and a clinical success rate of at least 66.7%, we believe that SEMS are a reasonable treatment option in patients with malignant gastric outlet obstruction with peritoneal carcinomatosis.

Impact of Carcinomatosis on Clinical Outcomes after Self-Expandable Metallic Stent Placement for Malignant Gastric Outlet Obstruction

BACKGROUND

It is still unclear whether the peritoneal carcinomatosis had a negative effect on the clinical outcomes of patients who underwent self-expandable metallic stent (SEMS) placement for malignant gastric outlet obstruction (GOO). Although carcinomatosis may be associated with the development of multifocal gastrointestinal (GI) tract obstruction or decreased bowel movement, previous studies investigated the occurrence of stent failure only and thus had limitation in evaluating clinical outcomes of patients with carcinomatosis.

METHODS

Between 2009 and 2013, 155 patients (88 patients without carcinomatosis and 67 patients with carcinomatosis) underwent endoscopic SEMS placement for malignant GOO. Factors affecting clinical success and obstructive symptom-free survival (time period between SEMS placement and the recurrence of obstructive symptoms due to multifocal GI tract obstruction or decreased bowel movement as well as stent failure) were assessed.

RESULTS

Patients with carcinomatosis showed higher Eastern Cooperative Oncology Group (ECOG) scale than those without carcinomatosis. Clinical success rates were 88.1% in patients with carcinomatosis and 97.7% in patients without carcinomatosis. In multivariate analysis, only ECOG scale was identified as an independent predictor of clinical success. During follow-up period, patients with carcinomatosis showed significantly shorter obstructive symptom-free survival than those without carcinomatosis. In multivariate analysis, the presence of carcinomatosis, chemotherapy or radiation therapy after SEMS placement, and obstruction site were identified as independent predictors of obstructive symptom-free survival. For patient without carcinomatosis, stent failure accounted for the recurrence of obstructive symptoms in 84.6% of cases. For patients with carcinomatosis, multifocal GI tract obstruction or decreased bowel movement accounted for 37.9% of cases with obstructive symptom recurrence and stent failure accounted for 44.8% of cases.

CONCLUSIONS

Carcinomatosis predicts unfavorable long-term clinical outcomes in patients undergoing SEMS placement for malignant GOO. This is mainly due to the development of multifocal GI tract obstructions or decreased bowel movement as well as stent failure.

[STENTING VERSUS PALLIATIVE SURGERY IN PATIENTS WITH MALIGNANT GASTROINTESTINAL STENOSIS]

AIM

Retrospective analysis of the results of stenting versus surgical palliation in patients with malignant gastrointestinal stenosis.

MATERIAL AND METHODS

85 patients underwent endoscopic stenting (41) or surgical intervention (44). Level of stenosis: gastric outlet (23/38), multi-level gastric obstruction (2/3), duodenum or jejunum (12/3), gastrojejunoanastomosis (3/0) and gastroduodenoanastomosis (1/0). 49 self-expanding metal stents were implanted in 41 patients. 41 gastroenteroanastomoses and 3 jejunostomas were performed in surgical group.

RESULTS

Stents were successfully inserted in all patients. Early complications were observed in 3 (7.3%) patients after stenting and in 9 (20.5%) after surgical palliation, p = 0.0755. Postoperative lethality was 2,4% (1 patient) after stenting and 31.8% (14 patients) after surgery, p = 0.0003. Mean hospital stay was 15 days in stenting group and 23 days in surgical group, p < 0.001. There was no statistically significant difference in long-term results, neither in late complications (p = 0.3691), nor in survival (p =0.3697).

CONCLUSION

Endoscopic placement of self-expanding stents is an effective method of restoration of oral intake in patients with malignant gastrointestinal obstruction. Stenting is associated with equal rates of early and late complications, lower mortality and decreased in-hospital stay as compared with surgery, and therefore may be recommended as a final palliation in inoperable patients.

Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases

BACKGROUND

Gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. There is a paucity of published data on this subject in our setting. This study was undertaken to highlight the etiological spectrum and treatment outcome of gastric outlet obstruction in our setting and to identify prognostic factors for morbidity and mortality.

METHODS

This was a descriptive prospective study which was conducted at Bugando Medical Centre between March 2009 and February 2013. All patients with a clinical diagnosis of gastric outlet obstruction were, after informed consent for the study, consecutively enrolled into the study. Statistical data analysis was done using SPSS computer software version 17.0.

RESULTS

A total of 184 patients were studied. More than two-third of patients were males. Patients with malignant gastric outlet obstruction were older than those of benign type. This difference was statistically significant (p < 0.001). Gastric cancer was the commonest malignant cause of gastric outlet obstruction where as peptic ulcer disease was the commonest benign cause. In children, the commonest cause of gastric outlet obstruction was congenital pyloric stenosis (13.0%). Non-bilious vomiting (100%) and weight loss (93.5%) were the most frequent symptoms. Eighteen (9.8%) patients were HIV positive with the median CD 4+ count of 282 cells/μl. A total of 168 (91.3%) patients underwent surgery. Of these, gastro-jejunostomy (61.9%) was the most common surgical procedure performed. The complication rate was 32.1 % mainly surgical site infections (38.2%). The median hospital stay and mortality rate were 14 days and 18.5% respectively. The presence of postoperative complication was the main predictor of hospital stay (p = 0.002), whereas the age > 60 years, co-existing medical illness, malignant cause, HIV positivity, low CD 4 count (<200 cells/μl), high ASA class and presence of surgical site infection significantly predicted mortality ( p< 0.001). The follow up of patients was generally poor as more than 60% of patients were lost to follow up.

CONCLUSION

Gastric outlet obstruction in our setting is more prevalent in males and the cause is mostly malignant. The majority of patients present late with poor general condition. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with gastric outlet obstruction are to be avoided.

Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery

BACKGROUND

In patients with gastric outlet obstruction (GOO) caused by gastric cancer, choosing between self-expandable metal stent (SEMS) placement and gastrojejunostomy (GJJ) is of concern, especially in those with good performance status.

OBJECTIVE

To compare SEMS placement and GJJ.

DESIGN

Retrospective study.

SETTING

Single tertiary referral center.

PATIENTS

Patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 who had GOO caused by unresectable gastric cancer.

INTERVENTIONS

SEMS placement and GJJ.

MAIN OUTCOME MEASUREMENTS

Success rate, adverse events, patency, and survival duration.

RESULTS

Of the 113 patients in this study, 72 underwent SEMS placement and 41 underwent GJJ. The 2 groups did not differ in the technical and clinical success and incidence of early adverse events. However, the rate of late adverse events was significantly higher in the SEMS group (44.4% vs 12.2%; P < .001). The median patency duration was shorter after SEMS placement than after GJJ (125 days vs 282 days; P = .001), even after additional SEMS placement (210 days vs 282 days; P = .044). The median survival was also significantly shorter after SEMS placement than after GJJ (189 days vs 293 days; P = .003). Survival differed between treatments in patients with ECOG 0-1 (P = .006) but not in those with an ECOG performance status of 2 (P = .208).

LIMITATIONS

Retrospective and single-center study.

CONCLUSIONS

GJJ is preferable to SEMS placement for the palliation of GOO caused by unresectable or metastatic gastric cancer in patients with a good performance status, especially ECOG 0-1.

Optimal indications of surgical palliation for incurable advanced gastric cancer presenting with malignant gastrointestinal obstruction

BACKGROUND

Decision-making for surgical palliation remains one of the most challenging clinical scenarios. We investigated the optimal indications for surgical palliation in advanced gastric cancer (AGC) patients presenting with gastrointestinal (GI) obstruction.

METHODS

A retrospective analysis was performed on 53 consecutive patients who underwent surgical palliation for GI obstruction caused by AGC between 2000 and 2007 at Osaka National Hospital. The clinical course of each patient was followed until death. Postoperative improvement of oral intake, achievement of hospital discharge, and implementation of chemotherapy in each patient were documented and used as a triad to assess the quality of life (QOL). Prognostic factors for overall survival were investigated by univariate and multivariate analyses. In addition, postoperative morbidity and mortality rates were recorded.

RESULTS

Of the entire patient cohort, 64% demonstrated a QOL improvement by having achieved the triad. Performance status (PS) of 1 or less was the only significant predictive factor for QOL improvement. The median survival time (MST) of the whole patient cohort following surgical palliation was 161 days, while the MSTs of patients fulfilling the triad and of those failing to achieve the triad were 253 and 60 days, respectively, with a significant difference between them (P < 0.0001). PS of 1 or less (hazard ratio 0.265, P = 0.0008) and recurrent disease (hazard ratio 0.394, P = 0.043) were identified as significant independent prognostic factors for longer survival on multivariate analysis. Overall morbidity and 30-day postoperative mortality rates were 24.5% (13 patients) and 7.5% (4 patients) respectively.

CONCLUSIONS

In AGC patients presenting with GI obstruction, surgical palliation was beneficial in patients with PS of 0-1 and those with recurrent disease, in terms of improved QOL and prolonged survival, with acceptable operative morbidity and mortality rates.

Fatal gastrointestinal obstruction and hypertension in mice lacking nitric oxide-sensitive guanylyl cyclase

The signaling molecule nitric oxide (NO), first described as endothelium-derived relaxing factor (EDRF), acts as physiological activator of NO-sensitive guanylyl cyclase (NO-GC) in the cardiovascular, gastrointestinal, and nervous systems. Besides NO-GC, other NO targets have been proposed; however, their particular contribution still remains unclear. Here, we generated mice deficient for the beta1 subunit of NO-GC, which resulted in complete loss of the enzyme. GC-KO mice have a life span of 3-4 weeks but then die because of intestinal dysmotility; however, they can be rescued by feeding them a fiber-free diet. Apparently, NO-GC is absolutely vital for the maintenance of normal peristalsis of the gut. GC-KO mice show a pronounced increase in blood pressure, underlining the importance of NO in the regulation of smooth muscle tone in vivo. The lack of an NO effect on aortic relaxation and platelet aggregation confirms NO-GC as the only NO target regulating these two functions, excluding cGMP-independent mechanisms. Our knockout model completely disrupts the NO/cGMP signaling cascade and provides evidence for the unique role of NO-GC as NO receptor.

Palliative treatment of upper gastrointestinal obstruction using self-expansible metal stents

Gastric outlet obstruction is either a late event in the natural history of bilio-pancreatic tumors or the result of recurrent gastric or pancreatic tumors. Self-expansible metal stents, inserted under endoscopic and fluoroscopic control, can be used for palliative treatment. The present study was aimed at evaluating both the feasibility and the results of stenting in patients with malignant gastric outlet obstruction; in addition, some technical suggestions are presented. A total of 33 patients, who had a metal stent positioned, were retrospectively evaluated; 20 of them were women and 13 were men, aged from 45 to 94 years, with a mean age of 75 years. Twenty-seven patients had a pancreatic adenocarcinoma, 4 had a stricture of a gastrojejunal anastomosis due to recurrent pancreatic tumor, 2 had a stricture of a gastrojejunal anastomosis secondary to gastric cancer surgery. No postoperatory complications were observed. Improvement in the quality of life was obtained in all patients. Following the stenting procedure, the median duration of hospitalization was 8 days (range: 6-20 days), and the mean survival rate was 12 weeks (range: 2-66 weeks). Endoscopic stenting for the palliation of malignant gastric outlet obstruction is feasible and is well tolerated by most patients. In some cases a period of enteral nutrition had to be necessarily carried out; nonetheless, the insertion of the stent improved the quality of life.

Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series

BACKGROUND

Self-expandable metal stents (SEMS) are being increasingly used to palliate malignant stenoses of the gastric outlet and proximal small bowel. Accordingly, we reviewed our experience in this setting.

METHODS

Patients with gastric outlet or proximal small bowel stents were identified by reviewing hospital charts. Outcome criteria included survival data, need for reintervention, and clinical improvement.

RESULTS

A total of 52 SEMS were placed in 36 patients with nonesophageal upper GI stenosis. Initial stent placement was successful in 92% and clinical improvement documented in 75%. Mean survival of patients who eventually died was 3.5 months. Seven patients are alive (mean follow-up, 5.0 months). Stent dysfunction occurred in 36% and required subsequent interventions. Biliary obstruction was documented in 50% of patients, 12 of whom had previously undergone biliary stenting and 5 who needed subsequent biliary decompression.

CONCLUSIONS

Enteral stent placement has been reported to be an effective alternative for palliation of high-risk surgical patients with malignant gastric outlet and small bowel obstruction. Considering the short life expectancy of these patients and significant complications including stent migration, perforation, biliary obstruction, and need for subsequent endoscopic, radiologic and surgical interventions, the authors suggest that this procedure be performed in experienced centers on selected patients only and that biliary decompression be ensured early.

Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study

BACKGROUND

Endoscopic placement of self-expandable metallic stents for palliation of patients with malignant gastric outlet obstruction is safe and feasible.

METHODS

Patients with malignant gastric outlet obstruction undergoing enteral stent insertion were identified from endoscopy databases. Duration of oral intake after stent insertion was calculated by using the log-rank test. Factors associated with duration of oral intake were assessed by using Cox multivariable regression analysis.

RESULTS

A total of 176 patients (mean age 65 [14] years) treated at 4 centers from 1996 to 2003 were identified. Obstruction was caused by cancer of the pancreas in 84, the stomach in 20, the bile duct in 15, the major duodenal papilla in 8, another primary site in 16, and metastases in 33. The site of obstruction was the duodenum in 125, the distal stomach in 17, the stomach and the duodenum in 18, and surgical anastomosis in 16 patients. Stent deployment was technically successful in 173. Complications occurred in 14 patients. Seventeen patients were lost to follow-up. Of the remaining 159 patients, 133 resumed oral intake for a median time of 146 days: 95% CI [65, 202]. On regression analysis, chemotherapy after stent placement was associated with prolonged duration of oral intake (hazard ratio 0.41: 95% CI [0.23, 0.72]).

CONCLUSIONS

After enteral stent insertion for malignant gastric outlet obstruction, 84% of patients resumed oral intake for a median time of 146 days. Chemotherapy after enteral stent insertion was independently associated with prolongation of oral intake.

Which types of stent, uncovered or covered, should be used in gastric outlet obstructions?

BACKGROUND

Self-expandable metallic stents (SEMS) have been widely used in inoperable malignant gastric outlet obstructions, but stent obstructions caused by tumor ingrowth and migration are a major problem of SEMS. The aims of this study were to assess the rate of stent restenosis, to identify lesion characteristics related to early restenosis by tumor ingrowth, and, in particular, to find suitable patient groups for uncovered or covered stents at first implantation.

METHODS

Forty-nine patients were reviewed: stomach cancer in 34 patients, primary duodenal cancer in 3 patients, pancreatic cancer in 5 patients, and common bile duct cancer in 7 patients. In principle, uncovered stents were initially placed at the time when obstruction symptoms occurred and the endoscope would not pass through. Stent obstruction due to tumor ingrowth within 4 weeks after the first stent implantation was regarded as early stent restenosis.

RESULTS

Technical success was seen in 49/49 patients (100%). Migration did not occur. Stent obstructions caused by tumor overgrowth were found in 2/49 patients (4.1%) after 1 month. Stent obstructions caused by tumor ingrowth occurred in 14/49 patients (28.5%), and 7 of them (14.3%) were found to have early restenosis. The only statistically significant factor for early restenosis was stenosis site, and early restenosis was more frequent in the postoperative anastomosis site in the current study; a) 2/18 antropyloric obstructions (11.1%), b) 1/15 pyloric and duodenal bulb obstructions (6.7%), c) 0/10 duodenal second portion obstructions (0%), and d) 4/6 postoperative anastomosis site obstructions (66.7) (P < 0.05, 95% CI 0.003-0.005).

CONCLUSIONS

Uncovered stents are technically feasible and effective for most malignant gastric outlet obstructions. However, because of frequent early restenosis among patients with postoperative anastomosis site obstructions, the placement of covered or simultaneous dual stents to prevent early restenosis should be considered when stenting postoperative anastomosis site obstructions.

Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation

Gastroduodenal outlet obstruction is a complication of advanced gastrointestinal malignant disease. In the past it was usually treated by an open surgical bypass procedure. During the last decade, endoscopic self-expandable stents (SEMS) have been used. The aim of this study was to compare these two palliative strategies concerning clinical outcome and health economy. A series of 36 patients with incurable malignant disease and gastroduodenal outlet obstruction syndrome were treated in a prospective study. According to the attending hospital and endoscopist on duty, 21 of the 36 patients were endoscopically treated with SEMS and 15 underwent an open surgical gastroenteroanastomosis. Health economic evaluation was based on the monetary charges for each patient associated with the procedure, postoperative care, and hospital stay. The hospital stay was 7.3 days for the stented group compared with 14.7 days for the open surgery group ( p > 0.05). The survivals were 76 and 99 days, respectively (NS). In the stented group all 15 patients (100%) alive after 1 month were able to eat or drink, and 11 (73%) of them tolerated solid food. In the surgical bypass group,9 out of 11 (81%) patients alive after 1 month could eat or drink, and 5 of them (45%) could eat solid food. The mean charges (U.S. dollars) during the hospital stay were $7215 for the stented group and $10,190 for the open surgery group ( p < 0.05). Palliation of the gastroduodenal obstruction in patients with malignant disease were at least as good, and the charges were lower for the endoscopic stenting procedure than for an open surgical bypass.

Malignant esophagogastric junction obstruction: efficacy of balloon dilation combined with chemotherapy and/or radiation therapy

PURPOSE

To assess the efficacy of balloon dilation combined with chemotherapy and/or radiation therapy for palliation of dysphagia due to malignant esophagogastric junction strictures.

METHODS

Fluoroscopically guided balloon dilation was attempted in 20 patients. The causes of strictures were gastric adenocarcinoma (n = 10) and esophageal squamous cell carcinoma (n = 10). Scheduled chemotherapy and/or radiation therapy followed balloon dilation in all patients.

RESULTS

There were no technical failures or major complications. After balloon dilation, 15 (75%) patients showed improvement of dysphagia. No patient complained of reflux esophagitis during the follow-up period. Among the 15 patients, seven needed no further treatment for palliation of dysphagia until their deaths. The remaining eight patients underwent repeat balloon dilation (n = 4) or stent placement (n = 4) 3-43 weeks (mean 15 weeks) after the initial balloon dilation because of recurrent dysphagia.

CONCLUSION

Balloon dilation combined with chemotherapy and/or radiation therapy seems to be an easy and reasonably effective palliative treatment for malignant esophagogastric strictures.

[Surgical palliation for pancreatic cancer. The 25-year experience of a single reference centre]

BACKGROUND

In spite of dynamic development of modern diagnostic and therapeutic methods, the long-term results of surgical therapy in pancreatic cancer are still unsatisfying. The aim of this study was to analyse long-term results of surgical palliation for pancreatic cancer in a pancreatic surgery centre.

METHODS

We performed a retrospective analysis of 418 patients who underwent non-resective, palliative procedures for pancreatic cancer between 1975 and 1999. In order to compare two consecutive periods of time, the patients were divided in 2 groups; group I treated from 1975 to 1990 (n = 204), and group II from 1991 to 1999 (n = 214).

RESULTS

Of all patients qualified for surgery, 281 (67.2 %) underwent surgical bypass, 107 (25.6 %) laparotomy, and in 30 cases surgical intervention was limited to implantation of endoprosthesis. A significant tendency towards double (i. e. biliary and gastric) anastomosis was observed (32.3 % vs. 74.8 %; p < 0.01) in patients who underwent bypass procedures. The postoperative morbidity was 16.3 %. The postoperative mortality rate was 5.7 % and significantly (p < 0.01) decreased from 10.3 % (group I) to 1.4 % (group II). No differences neither in mortality nor morbidity related to the type of performed surgery were found. The mean time of hospital stay was 15.5 +/- 6.9 days and showed no differences related to the type of intervention. Jaundice or symptoms of gastric outlet obstruction were observed in 16 % of patients in the follow-up period and concomitantly performed biliary and gastric bypasses were associated with the lowest rate of the late gastrointestinal obstruction (4 %). The median survival time was 169 days and only 4 % of patients survived 12 months. The univariate analysis of prognostic factors showed that location and stage of the tumour, the type of surgical intervention and bypass procedure influenced 1-year survival. The multivariate analysis using Cox proportional hazard model proved that only stage and location of the tumour had independent prognostic value.

CONCLUSION

Surgical palliation for pancreatic cancer can be performed with acceptable morbidity and mortality rates. For tumours located in the head and body of the pancreas combined biliary and gastric bypass should be preferred. For cancers located in the tail of the pancreas gastric bypass should be performed routinely. Because surgical palliation can prevent gastric outlet obstruction by gastroenterostomy, endoscopic biliary stenting should be only performed in patients with pancreatic head cancers and simultaneous evidence of distal metastases as well as in older patients with high comorbidity.

Technical modifications and strategies for stenting gastric outlet strictures using esophageal endoprostheses

BACKGROUND AND STUDY AIMS

The outcome of stenting gastric outlet stricture is favorable compared with a bypass operation which has significant morbidity and mortality. In Japan, this procedure is particularly complicated by a lack of enteral stents. We report some technical stratagems for stent placement for gastric outlet strictures.

PATIENTS AND METHODS

Between February 1993 and July 2001, 23 patients with gastric outlet strictures (14 men, nine women; mean age 72 years) underwent stent placement using an esophageal stent system. The Ultraflex or Z-stents were used in 18 or five patients, respectively. With the Ultraflex, we increased the length of the delivery system. Some patients underwent stent placement with the help of endoscopic assistance with a grasping forceps or a home-made sheath.

RESULTS

The metal stent was successfully inserted in all patients. There were no complications during the procedure. Migration occurred in two out of five patients treated with the Z-stent, whereas there was no migration in patients treated with the Ultraflex stent. In two patients, curable pancreatitis was caused by pressure on the duodenal papilla. One of these patients also experienced bile stasis which required biliary decompression. There were three cases of obstruction, caused by tumor ingrowth (1), hyperplasia (1) and stent fracture (1); recanalization by an additional stent placement and/or cutting stent filaments was successful. All the patients died, with a median survival period of 52 days. There was no procedure-related mortality.

CONCLUSIONS

With some technical modification, stent placement for gastric outlet stricture, even using an esophageal stent, is feasible. This procedure offers good palliation with no major complications.

Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation

BACKGROUND

Gastric outlet obstruction in patients with pancreatic cancer has a grim prognosis. Open surgical bypass is associated with high morbidity, whereas endoscopic duodenal stenting appears to provide better palliation.

METHODS

We reviewed the medical records of patients with gastric outlet obstruction secondary to pancreatic carcinoma who were admitted to our clinic between 1 October 1988, and 30 September 1998. The data included stage of disease, American Society of Anesthesiologists (ASA) class, surgical interventions, complications, and survival.

RESULTS

A total of 250 patients with pancreatic cancer were identified. Twenty-five of them (10%) had gastric outlet obstruction. Of these 25, 17 were treated with gastrojejunostomy, six had duodenal stenting (Wallstent), and two were resectable. There was no significant difference between the gastrojejunostomy group and the duodenal stenting group in ASA class or stage of disease. For the gastrojejunostomy group, median survival was 64 days (range, 15-167) and postoperative stay in hospital was 15 days (range, 8-39). For the duodenal stenting group, median survival was 110.5 days (range, 42-212) and postoperative stay was 4 days (range, 2-6). Ten patients (58.8%) in the gastrojejunostomy group had delayed gastric emptying. All of the patients in the duodenal stenting group were able to tolerate a soft diet the day after stent placement. Thirty-day mortality in the gastrojejunostomy group was 17.64%; in the duodenal stenting group, it was 0.

CONCLUSION

In pancreatic carcinoma patients with gastric outlet obstruction, duodenal stenting results in an earlier discharge from hospital and possibly improved survival.

Palliative treatment of malignant obstruction of gastric outlet using an endoscopically placed enteral Wallstent

Surgical gastrojejunostomy is the standard treatment for malignant gastric outlet obstruction, although it is associated with significant morbidity and mortality. The aim of this study was to evaluate the efficacy and feasibility of a newly designed expandable metal stent (Wallstent Enteral) to treat malignant gastric outlet obstruction. Six patients (five women, one man; mean age 76 years) underwent stenting. Stents 20-22 mm in diameter and 60-90 mm in length were deployed through a duodenoscope channel under endoscopic and fluoroscopic control, without previous stricture dilation. In all six cases the stent was adequately positioned and food intake was possible in the next 24 h. The mean time for hospital discharge was 2.5 days (1-5 days), without complications related to the procedure. Five patients died in the follow-up from progression of their cancer and one remains alive; none had recurrent obstruction. The median survival time was 9 weeks (95% CI: 3-15 weeks). In conclusion, endoscopic self-expandable stent (Wallstent Enteral) placement is safe and effective palliation for malignant gastric outlet obstruction and appears to be a therapeutic alternative to surgical gastrojejunostomy.

Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction

BACKGROUND

The endoscopically placed enteral stent has emerged as a reasonable alternative to palliative surgery for malignant intestinal obstruction. This is a report of our experience with the use of enteral stents for nonesophageal malignant upper GI obstruction.

METHODS

Data on all patients who had undergone enteral stent placement were reviewed. Those with a diagnosis of pancreatic cancer were compared with another similar cohort of patients who underwent palliative gastrojejunostomy.

RESULTS

Thirty-one procedures were performed on 29 patients (mean age 67.7 years). Thirteen (45%) were men and 16 (55%) women. The diagnoses were gastric (13.8%), duodenal (10.3%), pancreatic (41.4%), metastatic (27.6%), and other malignancies (6.9%). Malignant obstruction occurred at the pylorus (20.7%), first part of duodenum (37.9%), second part of duodenum (27.6%), third part of duodenum (3.5%), and anastomotic sites (10.3%). Twenty-nine (93.5%) procedures were successful and good clinical outcome was achieved in 25 (80.6%). Re-obstruction by tumor ingrowth occurred in 2 patients after a mean of 183 days. The median survival time for patients with pancreatic cancer who underwent enteral stent placement compared with those who underwent surgical gastrojejunostomy was 94 and 92 days, charges were $9921 and $28,173, and duration of hospitalization was 4 and 14 days, respectively (latter 2 differences with p value < 0.005).

CONCLUSION

Endoscopic enteral stent placement of nonesophageal malignant upper GI obstruction is a safe, efficacious, and cost-effective procedure with good clinical outcome, lower charges, and shorter hospitalization period than the surgical alternative.

Self-expandable metallic stents in malignant gastric outlet obstructions--an alternative approach using modified techniques

Malignant gastric outlet obstructions are commonly present in an advanced tumor stage. Surgery and other therapy options are often accompanied with substantial problems and reduced quality of life. We therefore investigated the endoscopic palliation with self-expandable metallic stents. This report documents the clinical benefit of new stent systems. During a period of eleven months we implanted eleven self-expandable metallic stents (one Ultraflex Esophageal Stent/five Ultraflex Duodenal Diamond Stents/five Enteral Wallstents) in eight patients with malignant gastric outlet stenoses (five female/three male, average age 66 years, range 42-85 years). The procedure was performed under analgosedation and in seven cases on an outpatient bases. The stenosis could be dilated in all cases without complications, allowing semi-liquid oral feeding at the procedure day. Three patients needed a second stent in the follow-up. Stent dislocation appeared in one case after one month--the stent protruded per vias naturales. The stent struts broke in two patients after one and four months post stent implantation. A new stent could be inserted without complications in both cases. The used products enabled a fast and precise positioning of the metallic stent in malignant gastric outlet stenosis. We experienced some problems with the Ultraflex Duodenal Diamond Stent. This didn't occur with the Enteral Wallstent. Additionally with the Enteral Wallstent we could solve the diamond stent complications. Due to the small diameter (10 French) the Enteral Wallstent system can be positioned wire guided in the stenosis through the working channel of the endoscope. Stent release is performed fluoroscopically and with the use of endoscopic guidance retaining the instrument in the stomach. In our point of view, this metallic stent is an optimal device for the palliative treatment of malignant gastric outlet obstructions.

[Laparoscopic palliative gastrointestinal operation in inoperable upper abdominal tumors with gastric outlet obstruction]

In the period from June 1994 to February 1997, a laparoscopic gastroenterostomy was carried out without intraoperative complications or mortality. In 12 out of 13 patients with gastric outlet obstruction due to inoperable tumor of the upper GI tract (gastric, gallbladder or pancreas carcinoma). From the above, a total of 4 patients had postoperative complications (30.7%), three of which could be treated without further operation. The average duration of the operation was 130 min (range 70-285 mins) followed by an approximal postoperative hospital stay of 17 days (8-41 days).

A minimally invasive palliative approach to advanced pancreatic and papillary cancer causing both biliary and duodenal obstruction

BACKGROUND

In patients with both duodenal and biliary obstruction in whom endoscopic drainage is not feasible, the standard approach has been gastroenterostomy plus biliodigestive anastomosis. We present our results of percutaneous biliary drainage in combination with gastroenterostomy.

PATIENTS AND METHODS

Twenty-one patients, who received permanent percutaneous transhepatic biliary drainage (PTBD) and gastroenterostomy in case of symptomatic gastric outlet obstruction were retrospectively evaluated.

RESULTS

PTBD insertion succeeded in all patients; minor complications were encountered in 47.6% of cases. Bilirubin fell from 9.2 mg/dl (SD 7.6) to 4.9 mg/dl (SD 3.6). Gastroenterostomy, either open (n = 10) or laparoscopic (n = 6), had to be performed in 16 patients before, during or after PTBD. Thirty day mortality was 23.8%, not related to the procedure, but due to advanced neoplastic disease. Mean survival and hospital stay were 4.9 months (SD 3.6) and 21.5 days (SD 7.3) respectively.

CONCLUSIONS

The combination of PTBD and gastroenterostomy offers a promising alternative to surgery. However efforts to reduce complications as well as the duration of hospital stay are necessary.