Surgical bypass versus endoscopic stenting for malignant gastroduodenal obstruction: a decision analysis

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis

BACKGROUND

Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed.

RESULTS

After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to  - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001).

CONCLUSION

ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

Staged laparoscopic management of locally advanced gastric cancer with outlet obstruction

BACKGROUND

The prognosis of patients with locally advanced gastric cancer with outlet obstruction is poor. Gastrectomy with curative intent is often initially impossible or difficult.

OBJECTIVE

We report our experience of curative distal gastrectomy after laparoscopic gastrojejunostomy and fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy to examine the feasibility and safety of this modified strategy for locally advanced gastric cancer with outlet obstruction, initially deemed unresectable.

METHODS

Between October 2017 and June 2019, 15 patients diagnosed with locally advanced gastric cancer with outlet obstruction sequentially underwent gastrojejunostomy, received four cycles of FLOT chemotherapy, and underwent laparoscopic distal gastrectomy with curative intent (R0 resection + D2 lymphadenectomy). Clinical data were retrospectively collected and analyzed.

RESULTS

R0 resection was possible in 12/15 patients, laparoscopically in 11, and one conversion to laparotomy was necessary. There was no perioperative mortality in the 12 patients. Pathologic evaluation of the resected specimens revealed that complete tumor grade regression 1a (TRG1a), TRG1b, TRG2, and TRG3 occurred in 3, 2, 4, and 3 patients, respectively.

CONCLUSION

This case series showed that curative surgical resection was feasible as a staged approach for patients with locally advanced gastric cancer with outlet obstruction, after initial staged gastrojejunostomy and chemotherapy.

Enteral Stents for Malignant Gastric Outlet Obstruction: Low Reintervention Rates for Obstruction due to Pancreatic Adenocarcinoma Versus Other Etiologies

BACKGROUND AND AIM

Enteral stents (ES) have emerged as first-line therapy for the treatment of malignant gastric outlet obstruction (GOO). Stent occlusion arising from tissue ingrowth may require endoscopic or surgical reintervention. The objective of this study was to compare rates of reintervention following palliative ES for patients with GOO due to pancreatic adenocarcinoma (PDAC) versus other malignant etiologies.

METHODS

Patients who had undergone ES for palliation of malignant GOO between 2009 and 2018 were retrospectively identified and demographic, clinical, and procedural data were collected. Primary outcome was procedural reintervention for recurrent symptomatic GOO following ES placement.

RESULTS

Forty-three patients were included in the study cohort. 62.8% (27/43) of patients had PDAC while 37.2% (16/43) of patients had other malignant etiologies. 11.6% (5/43) of patients were alive at follow-up. Thirty-day and 90-day mortality rates were 22.8% and 70.7% for PDAC and 25% and 56.3% for other malignant etiologies, respectively. Seven patients required reintervention for symptomatic GOO: 14.3% (1/7) had PDAC and 85.7% (6/7) had GOO due to other malignancy (P < .01). Ninety-six percent (26/27) of patients with PDAC required no further intervention for GOO prior to death or end of follow-up. On multivariate analysis, patients with PDAC were significantly less likely to require reintervention than patients with other malignant etiologies (OR 0.064, 95% CI 0.01-0.60).

CONCLUSION

ES offer durable symptom palliation without requirement for reintervention for the overwhelming majority of patients with malignant GOO due to PDAC. Reintervention rates are higher following ES placement for GOO due to other malignant etiologies and future study may be needed to define the optimal palliative intervention for this group of patients.

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Endoscopic ultrasound-guided gastroenterostomy versus open surgical gastrojejunostomy: clinical outcomes and cost effectiveness analysis

BACKGROUND

Early data suggests that endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a safe and efficacious option for gastric outlet obstruction (GOO). However, there is a scarcity of data comparing outcomes with open gastrojejunostomy (OGJ).

METHODS

Single-center retrospective cohort study of adult patients hospitalized with GOO who underwent EUS-GE or OGJ between January 1, 2014 and February 28, 2020. Primary outcomes were technical and clinical success.

RESULTS

Sixty-six patients were included of which 40 (60.0%) underwent EUS-GE and 26 (40.0%) underwent OGJ. Baseline characteristics were similar with respect to age (70.5 vs 69.7, p = 0.81), sex (42.5% vs 42.3% female, p = 0.99), median length of follow-up (98.0 vs 166.5 days, p = 0.8), prior failed intervention for GOO (22.5% vs 26.9%, p = 0.68), and the presence of altered anatomy (12.5% vs 30.8%, p = 0.07) between EUS-GE and OGJ, respectively. Technical success was achieved in 37 (92.5%) of EUS-GE and 26 (100%) of OGJ patients (p = 0.15). EUS-GE was associated with faster resumption of oral intake (1.3 vs 4.7 days, p < 0.001) and shorter length of stay (5 vs 14.5 days, p < 0.001). There were no significant differences in symptom recurrence (17.5% vs 19.2%, HR 1.85, CI 0.52-6.65, p = 0.34), reintervention (20% vs 11.5%, HR 0.82, CI 0.22-3.15, p = 0.78), death within 30 days (12.5% vs 3.8%, HR 0.80, CI 0.09-6.85, p = 0.84), or 30-day readmission (17.5% vs 24.1%, HR 1.69, CI 0.53-5.41, p = 0.37) between EUS-GE and OGJ, respectively. EUS-GE patients initiated chemotherapy sooner (17.7 vs 31.3 days, p = 0.033) and had lower overall costs as compared to OGJ ($49,387 vs $124,192, p < 0.001).

CONCLUSION

There were no significant differences in technical or clinical success, symptom recurrence, reintervention, 30-day readmission, or 30-day mortality between EUS-GE and OGJ. EUS-GE patients experienced shorter delays to resumption of oral intake and chemotherapy, had shorter lengths of stay, and reduced hospital costs. Further prospective comparative studies are warranted to verify our results.

Superiority of Gastrojejunostomy Over Endoscopic Stenting for Palliation of Malignant Gastric Outlet Obstruction

BACKGROUND & AIMS

Gastric outlet obstruction (GOO) in patients with malignancies causes nausea, vomiting, abdominal pain, malnutrition, and dehydration. Endoscopic placement of self-expandable metallic stent (SEMS) and gastrojejunostomy are the 2 main palliative options. We aimed to compare the outcomes of endoscopic SEMS placement with gastrojejunostomy in a propensity score matched study and identified factors associated with clinical success.

METHODS

We performed a retrospective analysis of patients with malignant GOO who underwent endoscopic SEMS placement (n = 183) or gastrojejunostomy (n = 127) from 2011 through 2017 at a tertiary academic medical center. Clinical success was defined as successful resumption of oral intake and relief of obstructive symptoms after either procedure. A propensity score matched analysis was conducted to compare clinical success rate, luminal patency duration, survival length, and adverse outcomes. We performed multivariable analyses to identify factors associated with clinical success.

RESULTS

Proportions of patients with clinical success did not differ significantly between the SMES group (79.4%) and the gastrojejunostomy group (80.1%) (P = .83). The mean patency duration and survival lengths were significantly longer in the gastrojejunostomy group (169.2 and 193.4 days respectively), compared to the endoscopic stenting group (96.5 and 119.9 days respectively). Poor performance status, presence of ascites and low albumin were independent risk factors for failure of enteral stenting and gastrojejunostomy.

CONCLUSIONS

In a retrospective analysis of patients with GOO, due to cancer, who underwent endoscopic SEMS placement or gastrojejunostomy, we found gastrojejunostomy to provide significant increases in patency duration and survival time. Gastrojejunostomy should therefore be considered the primary treatment option for patients with good performance status and reasonable survival expectancy. Nutritional status, the absence of ascites, and pre-procedure performance status are associated with clinical success.

Endoscopic management of gastric outlet obstruction disease

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient's prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Endoscopic management of gastric outlet obstruction disease

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient’s prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Endoscopic Management of Combined Biliary and Duodenal Obstruction

Combined obstruction of the bile duct and duodenum is a common occurrence in periampullary malignancies. The obstruction of gastric outlet or duodenum can follow, occur simultaneously, or precede biliary obstruction. The prognosis in patients with combined obstruction is particularly poor. Therefore, minimally invasive palliation is preferred in these patients to avoid morbidity associated with surgery. Endoscopic palliation is preferred to surgical bypass due to similar efficacy, less morbidity, and shorter hospital stay. The success of endoscopic palliation depends on the type of bilioduodenal stenosis and the presence of previously placed duodenal metal stents. Biliary cannulation is difficult in type II bilioduodenal strictures where the duodenal stenosis is located at the level of the papilla. Consequentially, technical and clinical success is lower in these patients than in those with type I and III bilioduodenal strictures. However, in cases with failure of endoscopic retrograde cholangiopancreatography, with the introduction of endoscopic ultrasound for biliary drainage, the success of endoscopic bilioduodenal bypass is likely to increase further. The safety and efficacy of endoscopic ultrasound-guided drainage has been documented in multiple studies. With the development of dedicated accessories and standardization of drainage techniques, the role of endoscopic ultrasound is likely to expand further in cases with double obstruction.

Closed Loop Duodenal Obstruction Secondary to Pancreatic Carcinoma: A Case Report

BACKGROUND

Patients with pancreatic adenocarcinoma may develop into duodenal obstruction during the course of their disease. The diagnosis of obstruction can be generally achieved by means of imaging technologies.

Case and Outcome

We reported a rare case of pancreatic tumor with duodenal obstruction accompanied by obstructive symptoms, which was finally confirmed by laparotomy. A 68-year-old man was admitted to our department with a 3-day medical history of upper abdominal pain, nausea and vomiting. The diagnosis of duodenal obstruction was established by means of various imagings including computed tomography (CT) scan, gastroscopy and upper gastrointestinal imaging. Upper gastrointestinal imaging and magnetic resonance imaging (MRI) showed extrinsic tumor mass was noted at the second and third portion of the duodenum accompanied by duodenal obstruction and dilatation, respectively. Laparotomy confirmed a tumor mass arising from the head and uncinate process of pancreas, which had invaded the second and third portions of the duodenum and caused closed loop obstruction. A pancreaticoduodenectomy (Whipple procedure) was performed followed by therapeutic trade-off according to intraoperative exploration. Postoperative histopathology revealed pancreatic tumor only infiltrated duodenal wall, while resection margins of pancreas, common bile duct and duodenum were all negative. The patient was cured and discharged home 12 days after surgery.

CONCLUSION

The present case indicated radical operation in our study appeared to be the first choice treatment for patients with malignant duodenal obstruction.

Current role of palliative interventions in advanced pancreatic cancer

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

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.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Palliation of malignant gastroduodenal obstruction: fluoroscopic metallic stent placement with different approaches

PURPOSE

We aimed to evaluate the safety and effectiveness of fluoroscopy-guided gastroduodenal metallic stent placement with different approaches in malignant obstruction.

METHODS

We retrospectively assessed 53 patients (33 men and 20 women; mean age, 58.7±15 years) who underwent stent placement between February 2004 and April 2014. All patients had unresectable tumors. The most common causes of obstruction were gastric (38%) and pancreatic cancers (36%). Uncovered self-expandable metallic stents (SEMS) were placed under fluoroscopic guidance. In addition to transoral approach in 46 patients (86.7%), transgastric and transhepatic approaches were used in six patients (11.3%) and one patient (1.8%), respectively. Gastric outlet obstruction scoring system (GOOSS) was used to evaluate oral intake before and after stenting. Patients were followed until death or the end of the study.

RESULTS

Technical and clinical success rates were 100% and 92%, respectively. The median stent patency was 76 days (range, 4-985 days). Mean preprocedural GOOSS score of 0.1 increased to postprocedural GOOSS score of 2.42 (P < 0.001). Afferent loop decompression was achieved in one symptomatic patient. Neither mortality nor major complications occurred due to stenting. Stent migration occurred in one patient (2%) and stent obstruction occurred in two patients (4%). Combined biliary and duodenal stenting were performed in 21 patients (40%). Post-stenting GOOSS scores were predictive of survival (P = 0.003).

CONCLUSION

Fluoroscopic metallic stent placement for palliation of malignant gastroduodenal obstruction is safe and effective with high technical and clinical success rates and minimal complications. High technical success rates can be achieved using different approaches.

Laparoscopic gastrojejunostomy versus duodenal stenting in unresectable gastric cancer with gastric outlet obstruction

Purpose

To compare the outcome between laparoscopic gastrojejunostomy (LapGJ) and duodenal stenting (DS) in terms of oral intake, nutritional status, patency duration, effect on chemotherapy and survival.

Methods

Medical records of 115 patients, who had LapGJ or duodenal stent placement between July 2005 and September 2015 in Seoul National University Bundang Hospital, have been reviewed retrospectively. Oral intake was measured with Gastric Outlet Obstruction Scoring System. Serum albumin and body weight was measured as indicators of nutritional status. The duration of patency was measured until the date of reintervention. Chemotherapy effect was calculated after the procedures. Survival period and oral intake was analyzed by propensity score matching age, sex, T-stage, comorbidities, and chemotherapy status.

Results

Forty-three LapGJ patients and 58 DS patients were enrolled. Improvement in oral intake was shown in LapGJ group versus DS group (88% vs. 59%, P = 0.011). Serum albumin showed slight but significant increase after LapGJ (+0.75 mg/dL vs. −0.15 mg/dL, P = 0.002); however, there was no difference in their body weight (+5.1 kg vs. −1.0 kg, P = 0.670). Patients tolerated chemotherapy longer without dosage reduction after LapGJ (243 days vs. 74 days, P = 0.006) and maintained the entire chemotherapy regimen after the procedure longer in LapGJ group (247 days vs. 137 days, P = 0.042). LapGJ showed significantly longer survival than DS (220 vs. 114 days, P = 0.004).

Conclusion

DS can provide faster symptom relief but LapGJ can provide improved oral intake, better compliance to chemotherapy, and longer survival. Therefore, LapGJ should be the first choice in gastric outlet obstruction patients for long-term and better quality of life.

Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients

Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.

Treatment of gastric outlet obstruction that results from unresectable gastric cancer: Current evidence

Malignant gastric outlet obstruction (GOO) is a common condition that results from locally advanced malignancies in the upper gastrointestinal tract, such as pancreatic, gastric, and other carcinomas. Two types of procedures for malignant GOO, namely, gastrojejunostomy (GJ) with laparotomy or a laparoscopic approach and endoscopic stenting (ES), are currently available. Although numerous previous reports have clarified the benefits and drawbacks of each procedure, whether GJ or ES should be used in patients with GOO that results from gastric cancer who may have a longer life expectancy than patients with other malignancies has not been determined. In this review, which focuses on gastric cancer-induced GOO, we analyzed the two systematic reviews and a meta-analysis that compared GJ and ES and outlined the current status of GOO treatment. We also provide an updated review that includes laparoscopic GJ. Various data from 13 studies in one review and 6 studies in another review were analyzed. Although the main results of the present review indicated that both GJ and ES were efficacious treatments in patients with GOO that resulted from gastric cancer, current evidence suggests that GJ may be the preferable procedure given its good performance status and improved prognosis in gastric cancer patients.

Fluoroscopic-guided insertion of self-expanding metal stents for malignant gastroduodenal outlet obstruction: immediate results and clinical outcomes

BACKGROUND

Application of self-expanding metal stents (SEMS) to treat patients suffering from malignant gastroduodenal outlet obstruction (GDOO) is today considered a well-recognized palliative treatment. Use of SEMS has emerged as an attractive alternative to surgical treatment of such patients.

PURPOSE

To report the immediate and the mid-term clinical outcomes from a series of consecutive patients treated with exclusively fluoroscopic-guided insertion of SEMS.

MATERIAL AND METHODS

This was a retrospective study including patients suffering from GDOO that were either ineligible for or unwilling to undergo surgery. Patients with potentially curable disease, uncorrectable coagulopathy, gastrointestinal perforation, sepsis, presence of distal small bowel obstruction, and bowel ischemia were excluded. Technical success, clinical success, and major complications were calculated. In addition, stent migration, stent re-obstruction, restenosis, and overall re-interventions due to recurrent symptoms were considered. Kaplan-Meier survival analysis was used for patient survival estimation while both bivariable and multivariable analysis were performed to identify any independent predictors of outcomes.

RESULTS

Fifty-one patients, (mean age, 63.73 ± 15.62 years) met the study's criteria and were included in the final analysis. Technical and clinical success were 90.19% (n = 46/51) and 91.30% (n = 42/46), respectively. Major complications rate was 3.92%. Stent migration was noted in four cases. Restenosis and re-obstruction rates were 19.57% and 10.87%, respectively. No cases of peri-procedural mortality were noted, while Kaplan-Meier estimates for 1- and 2-year survival were 16.8% and 7.2%, respectively. Clinically successful cases and patients with primary GI tumor were related with more favorable survival compared to unsuccessful and patients suffering from GDOO due to extrinsic compression by neoplastic or lymph node disease.

CONCLUSION

Exclusively fluoroscopically inserted SEMS for GDOO is safe and highly effective method for palliative treatment.

Gastrointestinal stenting: Current status and imaging features

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Treatment of pancreatic cancer: A narrative review of cost-effectiveness studies

Cancer of the pancreas is the second most frequent digestive cancer in the US, accounting for about 44,000 new cases per year. In Europe, it is the sixth most frequent cancer, accounting for 2.8% of cancers in men and 3.2% in women. With a five-year survival of less than 10%, it is the fifth leading cause of cancer-related death. The majority of cases are diagnosed above the age of 65 and in about 60% of cases at an advanced stage, explaining that little improvement has been observed in survival over the past 30 years. Radical surgery offers the only curative treatment of pancreatic cancer. Alternative or combined therapeutic options in particular consist of adjuvant or neoadjuvant chemotherapy, with or without radiotherapy. Palliative treatment for locally advanced disease may benefit patient's health status and quality of life. Limitations in healthcare resources, burden of treatment, and uncertainty of the net clinical benefit of adjuvant therapy, underline the need to identify the cost-effectiveness of different therapeutic approaches, as well as a need to establish patient groups who benefit most from these treatments. The present paper reviews cost-effectiveness studies published on pancreatic cancer treatment.

Evidence-based recommendations on upper gastrointestinal tract stenting: a report from the stent study group of the korean society of gastrointestinal endoscopy

Endoscopic stents have evolved dramatically over the past 20 years. With the introduction of uncovered self-expanding metal stents in the early 1990s, they are primarily used to palliate symptoms of malignant obstruction in patients with inoperable gastrointestinal (GI) cancer. At present, stents have emerged as an effective, safe, and less invasive alternative for the treatment of malignant GI obstruction. Clinical decisions about stent placement should be made based on the exact understanding of the patient's condition. These recommendations based on a critical review of the available data and expert consensus are made for the purpose of providing endoscopists with information about stent placement. These can be helpful for management of patients with inoperable cancer or various nonmalignant conditions in the upper GI tract.

Biliary stenting versus surgical bypass for palliation of periampullary malignancy

BACKGROUND

Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear.

METHODS

A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass.

RESULTS

Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n = 39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p = 0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p = 0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival.

CONCLUSION

There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.

Upper gastrointestinal stent

Gastrointestinal (GI) stent has been developed for palliation of obstructive symptoms in various diseases causing obstruction of GI tract. Self-expanding metal stent (SEMS) has replaced old type of plastic stent, and endoscopic insertion of stent has replaced fluoroscopy-guided insertion. Nowadays, newly-designed SEMSs have been developed for prevention of complications such as stent migration and re-obstruction, and indications of stent recently have been widened into benign conditions as well as malignant obstruction. In this review, the types, method of insertion, indications and clinical outcomes of stent in the upper GI tract would be discussed.

Endoscopic stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction

The aim of the present study was to analyze endoscopic stenting versus gastrojejunostomy of malignant gastric outlet obstruction (GOO). A systematic review of the literature was undertaken to analyze clinical trials on GOO. Six studies were eligible for analysis (three randomized control trials and three controlled clinical trials). Technical success (OR [95% CI]: 0.10 [0.02, 0.47]; I(2) = 0%; P = 0.003) and minor complications (OR [95% CI]: 0.28 [0.10, 0.83]; I(2) = 49%; P = 0.02). Time to oral intake and length of survival were also shorter in the endoscopic stenting (ES) group. There was no statistically significant difference in clinical success, length of survival, mortality and major complications. The present review demonstrated potentially improved quality of life in the ES group. ES is a safe and effective, minimally invasive and cost-effective option for palliation of malignant gastric outlet obstruction. The present review provides supportive evidence that ES should be considered as the gold standard treatment for malignant GOO.

Treatment of malignant gastroduodenal obstruction with a nitinol self-expanding metal stent: an international prospective multicentre registry

BACKGROUND

Duodenal stenting has become a broadly accepted first line of treatment for patients with advanced malignant gastroduodenal obstruction as these patients are difficult to treat and are poor surgical candidates.

AIMS

To document duodenal stent performance for palliative management of malignant gastroduodenal obstruction.

METHODS

Multicentre, single arm, prospective registry documenting peroral endoscopic duodenal stenting procedures in 202 patients.

RESULTS

Technical success achieved in 98% (CI, 95%, 99%) of stent placements. Increase of Gastric Outlet Obstruction Score by at least 1 point compared to baseline was achieved in 91% (CI, 86%, 95%) of patients persisting for a median of 184 days (CI, 109, 266). By day 5 (CI, 4, 6) after stent placement, 50% of patients experienced a score increase of at least 1 point. Improvement from 14% of patients at baseline tolerating soft solids or low residue/normal diet to 84% at 15 days, 86% at 30 days, 81% at 90 days, 79% at 180 days, and 70% at 270 days. Complications included stent ingrowth and/or overgrowth (12.4%), transient periprocedural symptoms (3%), bleeding (3%), stent migration (1.5%), and perforation (0.5%).

CONCLUSIONS

Safety and effectiveness of duodenal stenting for palliation of malignant gastroduodenal obstruction was confirmed in the largest international prospective series to date.

Enteral stents

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2010 for articles related to enteral, esophageal, duodenal, and colonic stents. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

Malignant gastroduodenal obstruction: retrospective comparison of endoscopic and surgical palliative therapy

INTRODUCTION

Endoscopic stenting (ES) is a minimally invasive alternative to surgical gastroenterostomy (GE) for palliation of malignant gastroduodenal obstructions. This consecutive, retrospective analysis compares the clinical outcome of all patients undergoing ES or GE in the same period.

METHODS

ES was performed at the Endoscopy Department, University Hospital Mannheim or at the Interdisciplinary Endoscopy Department, University Hospital Hamburg-Eppendorf. GE was performed at the Surgical Department, University Hospital Mannheim. All palliative ES or GE on patients with malignant gastroduodenal obstruction without earlier gastric resections between January 2001 and April 2007 were evaluated. Main outcome measurements were ability of solid food intake (gastric outlet obstruction score), persistence of nausea and vomiting (gut function score), length of hospital stay, morbidity, mortality and re-interventions.

RESULTS

A total of 44 ES and 43 GE were performed. Nausea and vomiting--measured by means of the gut function score--persisted in significantly more patients in the GE group than in those who underwent stent placement (p = 0.0102). The gastric outlet obstruction score at discharge from the hospital revealed no significant difference in the ability of solid food intake between the groups. The hospital stay was significantly longer in the GE group (p = 0.0003). There was no significant difference in mortality and the rates of complications and re-interventions.

CONCLUSION

In this study, ES is a generally equivalent--and in several points superior--alternative to GE for palliation of malignant gastroduodenal obstruction. ES seems to be the less invasive alternative for symptomatic patients. GE has good results in patients with longer survival and can be practiced within abdominal explorations.

Independent predictors of survival in patients with incurable malignant gastric outlet obstruction: a multicenter prospective observational study

OBJECTIVE

Gastric outlet obstruction (GOO) is one of the late complications of a variety of malignancies. Palliation of symptoms of obstruction rather than cure is the primary aim of treatment in affected patients. Thus far prognostic information on life expectancy is lacking in these patients although it can be of importance when deciding upon their optimal treatment. The purpose of this study was to investigate whether baseline data in patients with incurable GOO can independently predict survival.

PATIENTS AND METHODS

In total, 105 consecutive patients with symptomatic GOO treated with duodenal stent placement were enrolled in this multicenter prospective observational study. Patients were followed until death or till 1 November 2008. The Cox proportional hazard regression model was used for both univariate and multivariate analyses of survival.

RESULTS

Baseline data of 101 patients were completed. At the time of analysis, 95% of patients had died; median overall survival was 82 days (75% alive at 36 days, 25% alive at 156 days). The final prediction model revealed the dichotomized WHO performance status (HR: 2.63, 95% CI: 1.68-4.12, p < 0.001), prescription of morphines stronger than tramadol (HR: 2.42, 95% CI: 1.38-4.25, p = 0.002) and pain score of the EORTC QLQ-C30 (HR: 1.01, 95% CI: 1.00-1.01, p = 0.035) as independent significant prognostic factors for short survival.

CONCLUSIONS

This study demonstrates clear predictors of poor outcome for patients presenting with symptomatic malignant GOO. The model may enhance the selection of optimal treatment for individual patients.

Self-expandable metallic stents for malignant gastric outlet obstruction

Duodenal self-expandable metal stents (SEMS) are designed for palliation and prompt relief of malignant gastric outlet obstruction (GOO). This mini-invasive endoscopic treatment is preferable to surgery due to its lower morbidity and mortality, shorter hospitalization, and earlier symptoms relief; furthermore endoscopic enteral stenting can be performed under conscious sedation, reducing the risk of general anesthesia in these already fragile patients. The stent placement technique is well established and should be performed in referral centers with adequate materials and equipment. Duodenal stents can be covered and uncovered. Nitinol stents have almost replaced other materials, being more flexible with a satisfactory axial and radial force. Common duodenal SEMS-related complications are recurrence of GOO symptoms due to stent clogging (tissue ingrowth/overgrowth and food impaction) and stent migration. These complications can be usually managed endoscopically. Perforation and bleeding are the most severe, but rare, complications. After stent placement, malignant GOO patients usually have improvement of the GOO symptoms with good resumption of fluids and solids. Choosing the most appropriate type of stent is arduous and should be done mainly in relation to the morphological aspects of the stricture. Endoscopic duodenal SEMS placement is indicated in symptomatic GOO patients suffering from unresectable malignancy or those inoperable due to advanced age or comorbidities. The absence of peritoneal carcinomatosis and multiple small bowel strictures is a key point for the clinical success of duodenal SEMS. Almost all symptomatic malignant GOO patients are candidates for the duodenal SEMS procedure; resolution of GOO, avoiding the need for a permanent naso-gastric or percutaneous endoscopic gastrostomy tube, significantly improves the patients' quality of life and dignity, even if life expectancy is short. Endoscopic duodenal SEMS insertion, after an adequate training, is a reproducible, simple, safe, and cost-effective procedure.

Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study

BACKGROUND

Palliation of malignant gastric outlet obstruction remains challenging. Although there are 2 established treatment options, ie, surgical gastrojejunostomy and endoscopic duodenal stent insertion, there is an ongoing search for a technique that would combine the safety and rapid effect of duodenal stent placement with the long-term efficacy and low reintervention rate of a surgical gastrojejunostomy.

OBJECTIVE

To investigate the safety and success rate of endoscopic creation of a gastroenteric anastomosis formed by magnetic compression and stent placement.

DESIGN

Prospective, multicenter cohort study.

SETTING

Four referral centers.

PATIENTS

The expected number of patients with symptomatic malignant gastric outlet obstruction to be included at the participating hospitals during a year was 40. Because of a serious adverse device event, the study was terminated after inclusion of 18 patients.

INTERVENTION

Creation of an endoscopic gastroenteric anastomosis by using the Cook Magnetic Anastomosis Device with transanastomotic deployment of a self-expandable stent.

MAIN OUTCOME MEASUREMENTS

Primary endpoints were safety and success rate associated with the creation of an endoscopic gastrojejunostomy by using a magnetic anastomotic device with transanastomotic deployment of a self-expandable stent.

RESULTS

Because of a serious adverse event, the study was terminated prematurely. A success rate of 66.7% (12 of 18 patients) was achieved; 1 serious adverse event (stent perforation) occurred leading to the death of the patient. Three patients (25%) experienced an adverse device effect (stent migration).

LIMITATIONS

Small sample size, lack of a control group.

CONCLUSION

Endoscopic creation of a gastroenteric anastomosis by magnetic compression is feasible and safe; however, the necessity of a stent led to serious morbidity and even mortality in this study. The current system can therefore not be recommended for clinical use.

Stenting of the upper gastrointestinal tract: current status

Minimally invasive image-guided insertion of self-expanding metal stents in the upper gastrointestinal tract is the current treatment of choice for palliation of malignant esophageal or gastroduodenal outlet obstructions. A concise review is presented of contemporary stenting practice of the upper gastrointestinal tract, and the procedures in terms of appropriate patient evaluation, indications, and contraindications for treatment are analyzed, along with available stent designs, procedural steps, clinical outcomes, inadvertent complications, and future technology. Latest developments include biodegradable polymeric stents for benign disease and radioactive or drug-eluting stents for malignant obstructions.

Feasibility of self-expandable metallic stent plus chemotherapy for metastatic gastric cancer with pyloric stenosis

BACKGROUND AND AIM

Self-expandable metallic stent placement is accepted as palliative therapy for advanced gastric cancer with gastric outlet obstruction, but data are lacking for chemotherapy after self-expandable metallic stent insertion. This study retrospectively compared results between surgery plus chemotherapy and stenting plus chemotherapy for metastatic gastric cancer with pyloric stenosis.

METHODS

Subjects comprised 26 patients who received chemotherapy after surgery or endoscopic stenting for metastatic gastric cancer with pyloric stenosis between April 2000 and December 2007 in four Japanese hospitals. Patients were categorized into two groups: 15 patients who received chemotherapy after surgery for pyloric stenosis (Surgery group); and 11 patients who received chemotherapy after self-expandable metallic stent placement for pyloric stenosis (Stent group).

RESULTS

Median survival time and median time to treatment failure were 284 days and 226 days in the Surgery group and 337 days and 247 days in the Stent group, respectively. No significant differences were noted between survival and time to treatment failure. No significant differences were found in median oral intake rate (Surgery, 93.1%; Stent, 93.2%) or median hospital stay rate (Surgery, 24.6%; Stent, 23.7%) during survival. Response rate was 45.5% in the Surgery group and 50% in the Stent group, with no significant difference. Likewise, no significant differences were noted between groups for frequencies of toxicity or complications.

CONCLUSIONS

The present results suggest that chemotherapy after stenting is as effective and safe as chemotherapy after surgery. Stents may replace surgery in combination therapy with chemotherapy for metastatic gastric cancer with gastric outlet obstruction.

Malignant gastric outlet obstruction managed by endoscopic stenting: a prospective single-centre study

OBJECTIVE

Endoscopic stenting for malignant gastric outlet obstruction was chosen as the primary strategy by which to palliate this complication, which is dominated by weight loss and anorexia. Advanced upper gastrointestinal tract cancers present late and life expectancy is limited. Only smaller multicentre studies point to endoscopic stenting as superior to surgery in terms of clinical outcome and cost.

MATERIAL AND METHODS

Forty-five consecutive patients with gastric outlet obstruction as a result of advanced upper GI-tract malignancy were enrolled in accordance with the intention-to-treat principle. All patients were offered endoscopic stenting. Oral intake before and after stenting was assessed using the gastric outlet obstruction score system (GOOSS). Various lengths of duodenal Hanaro self-expanding nitinol stents were delivered through a therapeutic endoscope. Outcome criteria were successful deployment, clinical effect, length of stay in hospital, survival, need for re-intervention and complications.

RESULTS

Forty-one patients (91%) were successfully stented. The mean pre-procedure GOOSS improved significantly from 0.39 (95% CI 0.22-0.56) to 2.29 (95% CI 2.01-2.58) after stenting (p<0.0001). Twenty-six patients (63%) improved GOOSS at least one point, whereas 5 patients (12%) did not change GOOSS at all. Mean length of hospital stay was 13 days (95% CI 9-17 days). Mean survival was 121 days (95% CI 62-181 days). Two patients (4%; numbers 6 and 19) sustained perforation without fatalities. Three patients (7%) had stent migration. Procedure-related mortality was zero.

CONCLUSIONS

Palliative stenting for advanced malignant upper GI-tract tumours at a tertiary Hepato-Pancreato-Biliary Unit is a safe, feasible and effective alternative to surgical bypass with a short hospital stay and prompt improvement of food intake.

A systematic review of methods to palliate malignant gastric outlet obstruction

BACKGROUND

The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome.

METHOD

A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO.

RESULTS

Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ.

CONCLUSION

This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid.

Laparoscopic pancreatic surgery: what now and what next?

In recent years, improved laparoscopic skill sets have expanded surgical management of pancreatic disease to encompass pancreatic resection, tumor enucleation, debridement, and drainage. With the aid of radiologically guided drainage catheters, necrosectomy for acute pancreatitis can be delayed and accomplished laparoscopically in a select patient population. Pancreatic pseudocysts from chronic pancreatitis can now be approached via minimally invasive strategies, including emerging combined laparoscopic procedures and natural orifice transluminal endoscopic surgery. It is clear that laparoscopic pancreaticoduodenectomy is possible in experienced hands; pancreatic neoplasms in the body and tail are more suitable for laparoscopic procedures because distal pancreatic resection requires no reconstruction of the biliary or enteric tract. Laparoscopic staging of pancreatic tumors has decreased as preoperative radiographic imaging becomes more sensitive. Similarly, laparoscopic palliative procedures have decreased because of the emergence of other minimally invasive options for relieving gastric outlet obstruction and biliary obstruction. Nonetheless, major advances in minimally invasive pancreatic surgery will continue as technology and skill sets advance.

Laparoscopic Gastrojejunostomy in Patients with Obstruction of the Gastric Outlet Secondary to Advanced Malignancies

Surgical palliation is an important therapeutic goal in patients with gastric outlet obstruction from cancer. The use of laparoscopic approaches for this condition has not been well studied. Our objective is to compare surgical outcomes of laparoscopic and open gastrojejunostomies in patients with gastric outlet obstruction secondary to advanced malignancies. We did a retrospective review of 20 patients who underwent a palliative gastrojejunostomy as their primary surgical procedure. There were 10 patients in the laparoscopic group and 10 patients in the open one. We identified no significant difference between groups in mean surgery time (116 vs 116 minutes) ( P = 0.99), blood loss (23 vs 142 mL) ( P = 0.19), or length of stay (8 vs 14 days) ( P = 0.14). We also identified no difference in median time to tolerate a regular diet (7 vs 8 days) ( P = 0.49) and median survival (11.2 vs 9.0 months) ( P = 0.83). Delayed gastric emptying was the most common complication occurring in four patients. There is no detectable difference in surgical outcomes between laparoscopic and open gastrojejunostomies in the management of patients with obstruction of the gastric outlet secondary to cancer. Laparoscopic gastrojejunostomy is a safe and feasible operation in this setting

Self-expanding metal stents for duodenal obstruction in advanced pancreatic adenocarcinoma

INTRODUCTION

Gastric outlet obstruction (GOO) is a frequent feature of advanced pancreatic carcinoma. Self-expandable metal stents (SEMS) allow the condition to be managed outside by endoscopy rather than surgical bypass. The aim of this study is to report our experience in a district general hospital with SEMS for palliation of pancreatic carcinoma-related GOO.

PATIENTS AND METHODS

All patients admitted with or developing GOO secondary to pancreatic adenocarcinoma between January 2004 and December 2005 were identified. Notes were retrieved to determine the efficacy of stenting including: complications of the procedure, length of stay, readmissions and long-term patency.

RESULTS

Of 39 new cases of pancreatic cancer, 9 patients presented with (n=6) or developed (n=3) duodenal obstruction. In one patient, previous gastric surgery restricted access. Stenting was attempted in 8 patients (4 M and 4 F) with a mean age of 63 years (range 42-76 years). In one case, the duodenal invasion was too extensive to allow passage of the guide-wire and open bypass was performed. Stenting was successful in the remaining seven patients with no early complications. The median hospital stay post-procedure was 7 days (range 5-11 days). One patient was re-admitted after 11 weeks with recurrent duodenal obstruction and a second stent was placed. The median survival post-stenting was 10 weeks (range 3-28 weeks).

CONCLUSIONS

SEMS allows patients to leave hospital quickly and return to daily activities, albeit for the short term. The procedure requires an experienced interventional endoscopist but can be accomplished safely in the DGH setting.