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Hai NV, Thong DQ, Dat TQ, Nguyen DT, Quoc HLM, Minh TA, Anh NVT, Vuong NL, Trung TT, Bac NH, Long VD. Stomach-partitioning versus conventional gastrojejunostomy for unresectable gastric cancer with gastric outlet obstruction: A propensity score matched cohort study. Am J Surg 2024; 228:206-212. [PMID: 37827868 DOI: 10.1016/j.amjsurg.2023.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Stomach partitioning gastrojejunostomy (SPGJ) was introduced to deal with delayed gastric emptying (DGE). This study aimed to compare the short- and long-term outcomes of SPGJ versus conventional gastrojejunostomy (CGJ). METHOD This cohort study analyzed 108 patients who underwent gastrojejunostomy for unresectable gastric cancer: 70 patients underwent SPGJ, and 38 patients underwent CGJ between 2018 and 2022. Propensity score-matched (PSM) analysis was used to balance the baseline characteristics. RESULTS After PSM, there were 26 patients in each group. SPGJ group had significantly lower incidence of DGE (3.8% vs. 34.6%), vomiting (3.8% vs. 42.3%), and prokinetics requirement (11.5% vs. 46.2%). SPGJ group had significantly shorter time to solid diet tolerance (4.1 days vs. 5.7 days) and postoperative hospital stay (7.7 days vs. 9.3 days). There was no significant difference in relapse reinterventions, gastric outlet obstruction (GOO) recurrence, conversion surgery, and survival outcomes. CONCLUSIONS SGPJ was associated with lower rate of DGE, prokinetics requirement, and shorter time of solid diet tolerance compared to CGJ in the treatment of unresectable gastric cancer patients with GOO.
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Affiliation(s)
- Nguyen Viet Hai
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam
| | - Dang Quang Thong
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam
| | - Tran Quang Dat
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam
| | - Doan Thuy Nguyen
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam
| | - Ho Le Minh Quoc
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam
| | - Tran Anh Minh
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam; Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Nguyen Vu Tuan Anh
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Nguyen Lam Vuong
- Department of Medical Statistics and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Tran Thien Trung
- Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Nguyen Hoang Bac
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam; Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam
| | - Vo Duy Long
- Department of Gastro-Intestinal Surgery, University of Medical Center at Ho Chi Minh City at Ho Chi Minh City, Viet Nam; Department of General Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet Nam.
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2
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Canakis A, Irani SS. Endoscopic Treatment of Gastric Outlet Obstruction. Gastrointest Endosc Clin N Am 2024; 34:111-125. [PMID: 37973223 DOI: 10.1016/j.giec.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Endoscopic management of gastric outlet obstruction includes balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to relieve mechanical blockage and reestablish per oral intake. Based on the degree of obstruction, patients may experience debilitating symptoms that can quickly lead to malnutrition and delays in chemotherapy. Compared with surgery, minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations. EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates. This article aims to describe endoscopic treatment options and future considerations.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Mailstop: C3-GAS, Seattle, WA 98101, USA.
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Magahis PT, Salgado S, Westerveld D, Dawod E, Carr-Locke DL, Sampath K, Sharaiha RZ, Mahadev S. Preferred techniques for endoscopic ultrasound-guided gastroenterostomy: a survey of expert endosonographers. Endosc Int Open 2023; 11:E1035-E1045. [PMID: 37954107 PMCID: PMC10635781 DOI: 10.1055/a-2185-6426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/15/2023] [Indexed: 11/14/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an emerging procedure that lacks technical standardization with limited adoption beyond expert centers. We surveyed high-volume endosonographers about the technical aspects of EUS-GE to describe how the procedure is currently performed at expert centers and identify targets for standardization. Methods Invitations to complete an electronic survey were distributed to 21 expert EUS practitioners at 19 U.S. centers. Respondents were surveyed about technical aspects of EUS-GE, indications, efficacy, safety, and attitudes toward the procedure. Results All 21 (100%) invited expert endoscopists completed the survey. Nine (42.9%) reported performing >10 EUS-GEs in the last 12 months. About half (47.6%, 10/21) puncture the target loop prior to lumen-apposing metal stent (LAMS) introduction, most often to confirm the loop is jejunum. No respondents reported guidewire placement prior to LAMS introduction. Most (71.4%, 15/21) do not use a guidewire at any time, while 28.6% (6/21) reported wire placement after distal flange deployment to secure the tract during apposition. Eight (38.1%, 8/21) reported at least one major adverse event, most commonly intraperitoneal LAMS deployment (87.5%, 7/8). Factors most often reported as advantageous for EUS-GE over enteral stenting included lack of papilla interference (33.3%, 7/21) and decreased occlusion risk (23.8%, 5/21). Conclusions Significant variation in performance technique for EUS-GE exists among expert US endoscopists, which may hinder widespread adoption and contribute to inconsistencies in reported patient outcomes. The granularity provided by these survey results may identify areas to focus standardization efforts and guide future studies on developing an ideal EUS-GE protocol.
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Affiliation(s)
| | - Sanjay Salgado
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Weill Cornell Medical Center, New York, United States
| | - Donevan Westerveld
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Weill Cornell Medical Center, New York, United States
| | - Enad Dawod
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Weill Cornell Medical Center, New York, United States
| | - David L. Carr-Locke
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Weill Cornell Medical Center, New York, United States
| | - Kartik Sampath
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Weill Cornell Medical Center, New York, United States
| | - Reem Z. Sharaiha
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, United States
| | - Srihari Mahadev
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Weill Cornell Medical Center, New York, United States
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4
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Wang C, Zhang X, Liu Y, Lin S, Yang C, Chen B, Li W. Efficacy and long-term prognosis of gastrojejunostomy for malignant gastric outlet obstruction: A systematic review and Bayesian network meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:106967. [PMID: 37385941 DOI: 10.1016/j.ejso.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/18/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND Gastrojejunostomy (GJ) is becoming a standard surgical treatment for ameliorating malignant gastric outlet obstruction (MGOO). However, data on the long-term outcomes of MGOO treatment are lacking. This network meta-analysis aimed to compare overall survival (OS) rates and subsequent anticancer treatment outcomes of GJwith other therapies in MGOO. METHODS We searched four electronic databases, including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, from inception to August 1, 2022. Studies reporting OS associated with GJ versus other treatments for MGOO were selected. The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome assessed was OS, whereas the secondary outcome was subsequent anticancer treatment. We performed a Bayesian network meta-analysis to produce hazard ratios (HR) and odds ratios (OR) with 95% credible intervals (CrIs). RESULTS We identified 24 retrospective studies that included 2473 patients. The studies assessed the outcomes of six treatments to alleviate MGOO. Results showed that GJ (hazard ratio: 0.83, 95% CrI: 0.78-0.88) was the most effective treatment for patients with MGOO, with the greatest surface under the cumulative ranking curve (SUCRA) values (79.9%) versus non-resection, palliative chemotherapy (13.9%) in terms of OS. Similarly, GJ (SUCRA: 46.5%) improved subsequent anticancer treatment requirements, ranking second only to jejunostomy/gastrostomy (JT/GT) (SUCRA: 95.9%). CONCLUSIONS Our study demonstrates that GJ improves OS and follow-up treatments versus other non-resection treatments in patients with MGOO. These findings may serve for selecting appropriate therapy for MGOO.
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Affiliation(s)
- Chuandong Wang
- Department of Thyroid and Breast Surgery, Xiamen Humanity Hospital Fujian Medical University, Xiamen, 361006, China; Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China
| | - Xiaojuan Zhang
- Department of Radiology, Xiamen Humanity Hospital Fujian Medical University, Xiamen, 361006, China
| | - Yi Liu
- Endoscopic Center, The First Affiliated Hospital of Xiamen University, Xiamen, 361003, China; Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, 100021, China
| | - Shengtao Lin
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China; Department of Surgical Oncology, Fujian Provincial Hospital, Fuzhou, 350001, China
| | - Changshun Yang
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China; Department of Surgical Oncology, Fujian Provincial Hospital, Fuzhou, 350001, China
| | - Bing Chen
- Department of Thyroid and Breast Surgery, Xiamen Humanity Hospital Fujian Medical University, Xiamen, 361006, China.
| | - Weihua Li
- Shengli Clinical Medical College of Fujian Medical University, Fuzhou, 350001, China; Department of Surgical Oncology, Fujian Provincial Hospital, Fuzhou, 350001, China.
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Lai H, Wu K, Liu Y, Li D, Peng T, Zhang B. Efficacy and safety of self-expandable metal stent placement for treatment of primary and metastatic gastric outlet obstruction. Ir J Med Sci 2023; 192:2077-2084. [PMID: 36441448 DOI: 10.1007/s11845-022-03195-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/15/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND GOALS: Gastric outlet obstruction (GOO) usually occurs at the pylorus or the duodenum through primary gastric, duodenal, or pancreatic tumors. However, metastatic GOO is relatively rare. Although self-expandable metal stent (SEMS) placement is often performed as an alternative and practical palliative approach for primary GOO, there are few reports of metastatic GOO treatment with SEMS. This study aimed to investigate the efficacy, safety, stent patency, and complications of SEMS for treating primary and metastatic GOO. METHODS The data of 42 patients with GOO who received SEMS from November 2016 to April 2022 were reviewed retrospectively. Patients were divided into primary group (n = 25) and metastatic group (n = 17) according to the cause of GOO. The rates of technical and clinical success, stent patency, and complications were compared between the two groups. RESULTS The overall technical and clinical success rates were 97.9% and 93.5%, respectively. The total SEMS implantation time was 48.2 ± 33.5 (10.0-140.0) minutes. The primary technical success rate was 100.0% in both primary and metastatic groups, and the primary clinical success rate was 96.0% (24/25) in the primary group vs 88.2% (15/17) in the metastatic group (P = 0.350). After reintervention, the secondary technical success rate was 100.0% (27/27) in the primary group vs 95.0% (19/20) in the metastatic group (P = 0.330); and the secondary clinical success rate was 96.3% (26/27) in the primary group vs 89.5% (17/19) in the metastatic group (P = 0.367). No serious complications, such as gastrointestinal perforation, stent migration, bleeding, or aspiration pneumonia, were observed in these patients. CONCLUSIONS SEMS under fluoroscopic guidance is an effective and safe treatment for primary and metastatic GOO. The etiology of obstruction did not influence stent patency or complications. Therefore, stent implantation is recommended for patients with metastatic GOO caused by multiple peritoneal metastases to improve their quality of life.
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Affiliation(s)
- Haiyang Lai
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Ketong Wu
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Yang Liu
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Dan Li
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Tao Peng
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China
| | - Bo Zhang
- Department of Interventional Center, Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-Sen University, No. 26, Yuancun Erheng Road, 510655, Guangzhou, China.
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Cohen JT, Beard RE, Cioffi WG, Miner TJ. Was It Worth It? Critical Evaluation of a Novel Outcomes Measure in Oncologic Palliative Surgery. J Am Coll Surg 2023; 236:1156-1162. [PMID: 36786475 DOI: 10.1097/xcs.0000000000000649] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Patient selection for palliative surgery is complex, and appropriate outcomes measures are incompletely defined. We explored the usefulness of a specific outcomes measure "was it worth it" in patients after palliative-intent operations for advanced malignancy. STUDY DESIGN A retrospective review of a comprehensive longitudinal palliative surgery database was performed at an academic tertiary care center. All patients who underwent palliative-intent operation for advanced cancer from 2003 to 2022 were included. Patient satisfaction ("was it worth it") was reported within 30 days of operation after palliative-intent surgery. RESULTS A total of 180 patients were identified, and 81.7% self-reported that their palliative surgery was "worth it." Patients who reported that their surgery was "not worth it" were significantly older and were more likely to have recurrent symptoms and to need reoperation. There was no significant difference in overall, recurrence-free, and reoperation-free survival for patients when comparing "worth it" with "not worth it." Initial symptom improvement was not significantly different between groups. Age older than 65 years (hazard ratio 0.25, 95% CI 0.07 to 0.80, p = 0.03), family engagement (hazard ratio 6.71, 95% CI 1.49 to 31.8, p = 0.01), and need for reoperation (hazard ratio 0.042, 95% CI 0.01 to 0.16, p < 0.0001) were all independently associated with patients reporting that their operation was "worth it." CONCLUSIONS Here we demonstrate that simply asking a patient "was it worth it" after a palliative-intent operation identifies a distinct cohort of patients that traditional outcomes measures fail to distinguish. Family engagement and durability of an intervention are critical factors in determining patient satisfaction after palliative intervention. These data highlight the need for highly individualized care with special attention paid to patients self-reporting that their operation was "not worth it."
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Affiliation(s)
- Joshua T Cohen
- From the Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
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Vedantam S, Shah R, Bhalla S, Kumar S, Amin S. No difference in outcomes with 15 mm vs. 20 mm lumen-apposing metal stents for endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a meta-analysis. Clin Endosc 2023; 56:298-307. [PMID: 37259242 DOI: 10.5946/ce.2022.299] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 03/10/2023] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND/AIMS We compared outcomes between use of 15 vs. 20 mm lumen-apposing metal stents (LAMSs) in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction. METHODS Databases were queried for studies that used LAMS for EUS-GE to relieve gastric outlet obstruction, and a proportional meta-analysis was performed. RESULTS Thirteen studies were included. The 15 mm and 20 mm LAMS had pooled technical success rates of 93.2% (95% confidence interval [CI], 90.5%-95.2%) and 92.1% (95% CI, 68.4%-98.4%), clinical success rates of 88.6% (95% CI, 85.4%-91.1%) and 89.6% (95% CI, 79.0%-95.1%), adverse event rates of 11.4% (95% CI, 8.1%-15.9%) and 14.7% (95% CI, 4.4%-39.1%), and reintervention rates of 10.3% (95% CI, 6.7%-15.4%) and 3.5% (95% CI, 1.6%-7.6%), respectively. Subgroup analysis revealed no significant differences in technical success, clinical success, or adverse event rates. An increased need for reintervention was noted in the 15 mm stent group (pooled odds ratio, 3.59; 95% CI, 1.40-9.18; p=0.008). CONCLUSION No differences were observed in the technical, clinical, or adverse event rates between 15 and 20 mm LAMS use in EUS-GE. An increased need for reintervention is possible when using a 15 mm stent compared to when using a 20 mm stent.
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Affiliation(s)
- Shyam Vedantam
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Rahil Shah
- Department of Medicine, University of Miami, Miami, FL, USA
| | - Sean Bhalla
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA
| | - Shria Kumar
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miami, FL, USA
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Narita Y, Muro K. Updated Immunotherapy for Gastric Cancer. J Clin Med 2023; 12:jcm12072636. [PMID: 37048719 PMCID: PMC10094960 DOI: 10.3390/jcm12072636] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Gastric cancer treatments are evolving rapidly. For example, immune checkpoint inhibitors, especially those that target PD-1 or PD-L1, have long-term efficacy in a subset of gastric cancer patients, and are currently the first-line therapy. Immunotherapies approved for use in untreated gastric cancer patients include monotherapy and chemotherapy-immunotherapy combinations. Major clinical trials have reported efficacy and safety data suggesting that PD-L1 expression is important for regimen selection, although other biomarkers, clinicopathologic factors, and patient preference might also be relevant in other situations. Currently, several novel biomarkers and therapeutic strategies are being assessed, which might refine the current treatment paradigm. In this review, we describe the current treatment regimens for patients with gastric cancer and detail the approach we use for the selection of first-line immunotherapy regimens.
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Affiliation(s)
- Yukiya Narita
- Department of Clinical Oncology, Aichi Cancer Center Hospital, Nagoya 464-8681, Japan
| | - Kei Muro
- Department of Clinical Oncology, Aichi Cancer Center Hospital, Nagoya 464-8681, Japan
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Del Nero L, Sheijani AD, De Ceglie A, Bruzzone M, Ceppi M, Filiberti RA, Siersema P, Conio M. A Meta-Analysis of Endoscopic Stenting Versus Surgical Treatment for Malignant Gastric Outlet Obstruction. World J Surg 2023; 47:1519-1529. [PMID: 36869171 DOI: 10.1007/s00268-023-06944-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND AND AIM Surgical gastrojejunostomy (GJJ) and endoscopic stenting (ES) are the two most available treatments for palliation of malignant gastric obstruction (MGOO). The aim of this study is to compare these two techniques regarding efficacy, safety, time of hospitalization and survival. METHODS We performed a literature search from January 2010 to September 2020 to identify available randomized controlled studies and observational studies that compared ES and GJJ for the treatment of MGOO. RESULTS A total of 17 studies were found. ES and GJJ showed similar technical and clinical success rate. ES was superior to obtain early oral re-feeding, shorter length of hospitalization and a lower incidence of complications than GJJ. Surgical palliation had a lower recurrence rate of obstructive symptoms and longer overall survival than ES. CONCLUSIONS Both procedures have advantages and disadvantages. Probably we should not find the best palliation but the best approach based on the patient characteristics and tumor type.
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Affiliation(s)
- Lorenzo Del Nero
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy.
| | - Afscin Djahandideh Sheijani
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy
| | - Antonella De Ceglie
- Gastroenterology Department, Sanremo General Hospital, ASL1 Imperiese, Sanremo, IM, Italy
| | - Marco Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marcello Ceppi
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Peter Siersema
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy.,Gastroenterology Department, Sanremo General Hospital, ASL1 Imperiese, Sanremo, IM, Italy.,Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Massimo Conio
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy
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10
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Kim TH, Kim IH, Kang SJ, Choi M, Kim BH, Eom BW, Kim BJ, Min BH, Choi CI, Shin CM, Tae CH, Gong CS, Kim DJ, Cho AEH, Gong EJ, Song GJ, Im HS, Ahn HS, Lim H, Kim HD, Kim JJ, Yu JI, Lee JW, Park JY, Kim JH, Song KD, Jung M, Jung MR, Son SY, Park SH, Kim SJ, Lee SH, Kim TY, Bae WK, Koom WS, Jee Y, Kim YM, Kwak Y, Park YS, Han HS, Nam SY, Kong SH. Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach. J Gastric Cancer 2023; 23:3-106. [PMID: 36750993 PMCID: PMC9911619 DOI: 10.5230/jgc.2023.23.e11] [Citation(s) in RCA: 72] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/09/2023] Open
Abstract
Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.
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Affiliation(s)
- Tae-Han Kim
- Department of Surgery, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - In-Ho Kim
- Division of Medical Oncology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Joo Kang
- Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center Seoul, Seoul, Korea
| | - Miyoung Choi
- National Evidence-based Healthcare Collaborating Agency (NECA), Seoul, Korea
| | - Baek-Hui Kim
- Department of Pathology, Korea University Guro Hospital, Seoul, Korea
| | - Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Bum Jun Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Hallym University Medical Center, Hallym University College of Medicine, Anyang, Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Seoul, Korea
| | - Chang In Choi
- Department of Surgery, Pusan National University Hospital, Pusan, Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seungnam, Korea
| | - Chung Hyun Tae
- Department of Internal Medicine, Ewha Woman’s University College of Medicine, Seoul, Korea
| | - Chung sik Gong
- Division of Gastrointestinal Surgery, Department of Surgery, Asan Medical Center and University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Jin Kim
- Department of Surgery, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | | | - Eun Jeong Gong
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Geum Jong Song
- Department of Surgery, Soonchunhyang University, Cheonan, Korea
| | - Hyeon-Su Im
- Department of Hematology and Oncology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hye Seong Ahn
- Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, University of Hallym College of Medicine, Anyang, Korea
| | - Hyung-Don Kim
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joon Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Il Yu
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University, School of Medicine, Seoul, Korea
| | - Jeong Won Lee
- Department of Nuclear Medicine, Catholic Kwandong University, College of Medicine, Incheon, Korea
| | - Ji Yeon Park
- Department of Surgery, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jwa Hoon Kim
- Division of Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kyoung Doo Song
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University, Seoul, Korea
| | - Minkyu Jung
- Division of Medical Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Mi Ran Jung
- Department of Surgery, Chonnam National University Medical School, Gwangju, Korea
| | - Sang-Yong Son
- Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Shin-Hoo Park
- Department of Surgery, Korea University Anam Hospital, Seoul, Korea
| | - Soo Jin Kim
- Department of Radiology, National Cancer Center, Goyang, Korea
| | - Sung Hak Lee
- Department of Hospital Pathology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae-Yong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Woo Kyun Bae
- Division of Hematology-Oncology, Department of Internal Medicine, Chonnam National University Medical School and Hwasun Hospital, Hwasun, Korea
| | - Woong Sub Koom
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Korea
| | - Yeseob Jee
- Department of Surgery, Dankook University Hospital, Cheonan, Korea
| | - Yoo Min Kim
- Department of Surgery, Severance Hospital, Seoul, Korea
| | - Yoonjin Kwak
- Department of Pathology, Seoul National University Hospital, Seoul, Korea
| | - Young Suk Park
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Sook Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
| | - Su Youn Nam
- Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, Korea.
| | - Seong-Ho Kong
- Department of Surgery, Seoul National University Hospital and Seoul National University College of Medicine Cancer Research Institute, Seoul, Korea.
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11
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Hodo Y, Takatori H, Komura T, Asahina Y, Chiba T, Takabatake H, Hasatani K, Nishino R, Yano M, Takata Y, Suda T, Shugo H, Nakanishi H, Yamada K, Miwa K, Kaji K, Nishitani M, Miyazawa M, Yamashita T. Prognostic impact of clinical outcome after endoscopic gastroduodenal stent placement for malignant gastric outlet obstruction: a multicenter retrospective cohort study using a time-dependent analysis. Therap Adv Gastroenterol 2023; 16:17562848231156279. [PMID: 36895284 PMCID: PMC9989375 DOI: 10.1177/17562848231156279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/24/2023] [Indexed: 03/08/2023] Open
Abstract
Background Endoscopic gastroduodenal stent (GDS) placement is widely used as a safe and effective method to rapidly improve gastrointestinal symptoms of malignant gastric outlet obstruction (MGOO). While previous studies reported the utility of chemotherapy after GDS placement for prognosis improvement, they did not fully address the issue of immortal time bias. Objectives To examine the association between prognosis and clinical course following endoscopic GDS placement, using a time-dependent analysis. Design Multicenter retrospective cohort study. Methods This study included 216 MGOO patients who underwent GDS placement between April 2010 and August 2020. Data of patient baseline characteristics, including age, gender, cancer type, performance status (PS), GDS type and length, GDS placement location, gastric outlet obstruction scoring system (GOOSS) score, and history of chemotherapy before GDS were collected. The clinical course following GDS placement was evaluated by GOOSS score, stent dysfunction, cholangitis, and chemotherapy. A Cox proportional hazards model was used to identify prognostic factors after GDS placement. Stent dysfunction, post-stent cholangitis, and post-stent chemotherapy were analyzed as time-dependent covariates. Results Mean GOOSS scores before and after GDS were 0.7 and 2.4, respectively, with significant improvement after GDS placement (p < 0.001). The median survival time after GDS placement was 79 [95% confidence interval (CI): 68-103] days. In multivariate Cox proportional hazards model with time-dependent covariates, PS 0-1 [hazard ratio (HR): 0.55, 95% CI: 0.40-0.75; p < 0.001], ascites (HR: 1.45, 95% CI: 1.04-2.01; p = 0.028), metastasis (HR: 1.84, 95% CI: 1.31-2.58; p < 0.001), post-stent cholangitis (HR: 2.38, 95% CI: 1.37-4.15; p = 0.002), and post-stent chemotherapy (HR: 0.01, 95% CI: 0.002-0.10; p < 0.001) significantly affected prognosis after GDS placement. Conclusion Post-stent cholangitis and tolerability to receive chemotherapy after GDS placement influenced prognosis in MGOO patients.
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Affiliation(s)
- Yuji Hodo
- Department of Gastroenterology, Saiseikai Kanazawa Hospital, Kanazawa, Ishikawa, Japan
| | - Hajime Takatori
- Department of Endoscopy, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa 921-8641, Japan
| | - Takuya Komura
- Department of Gastroenterology, National Hospital Organization Kanazawa Medical Center, Kanazawa, Ishikawa, Japan
| | - Yoshiro Asahina
- Department of Gastroenterology, National Hospital Organization Kanazawa Medical Center, Kanazawa, Ishikawa, Japan
| | - Tomoyoshi Chiba
- Department of Gastroenterology, Public Central Hospital of Matto Ishikawa, Hakusan, Ishikawa, Japan
| | - Hisashi Takabatake
- Department of Gastroenterology, Kanazawa Red Cross Hospital, Kanazawa, Ishikawa, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Fukui, Japan
| | - Ryuhei Nishino
- Department of Gastroenterology, Hakui General Hospital, Hakui, Ishikawa, Japan
| | - Masaaki Yano
- Department of Gastroenterology, Toyama Prefectural Central Hospital, Toyama, Toyama, Japan
| | - Yoshiko Takata
- Department of Gastroenterology, Tonami General Hospital, Tonami, Toyama, Japan
| | - Tsuyoshi Suda
- Department of Gastroenterology, Kanazawa Municipal Hospital, Kanazawa, Ishikawa, Japan
| | - Haruhiko Shugo
- Department of Gastroenterology, Keiju Medical Center, Nanao, Ishikawa, Japan
| | - Hiroyoshi Nakanishi
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Kazutoshi Yamada
- Department of Gastroenterology, Toyama City Hospital, Toyama, Toyama, Japan
| | - Kazuhiro Miwa
- Department of Gastroenterology, Komatsu Municipal Hospital, Komatsu, Ishikawa, Japan
| | - Kiichiro Kaji
- Department of Gastroenterology, Komatsu Sophia Hospital, Komatsu, Ishikawa, Japan
| | - Masaki Nishitani
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Masaki Miyazawa
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Taro Yamashita
- Department of Gastroenterology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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12
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Khamar J, Lee Y, Sachdeva A, Anpalagan T, McKechnie T, Eskicioglu C, Agzarian J, Doumouras A, Hong D. Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis. Surg Endosc 2022:10.1007/s00464-022-09572-5. [PMID: 36138247 DOI: 10.1007/s00464-022-09572-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada
| | - Anjali Sachdeva
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tharani Anpalagan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - John Agzarian
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada. .,Department of Surgery, McMaster University, Hamilton, ON, Canada.
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13
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Di Mitri R, Amata M, Mocciaro F, Conte E, Bonaccorso A, Scrivo B, Scimeca D. EUS-guided biliary drainage with LAMS for distal malignant biliary obstruction when ERCP fails: single-center retrospective study and maldeployment management. Surg Endosc 2022; 36:4553-4569. [PMID: 34724586 DOI: 10.1007/s00464-021-08808-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 10/17/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND EUS-guided biliary drainage (EUS-BD) with Lumen Apposing Metal Stent (LAMS) is a mini-invasive approach for jaundice palliation in distal malignant biliary obstruction (D-MBO) not amenable to ERCP, with good efficacy and not exiguous adverse events. AIMS AND METHODS From January 2015 to December 2019, we retrospectively enrolled all the EUS-BD with electrocautery-enhanced LAMS for biliary decompression in unresectable D-MBO and failed ERCP. Primary study aims were to evaluate technical/clinical success and AEs rate. In case of maldeployment, we estimated the efficacy of an intra-operative rescue therapy. Secondary aims were to assess the jaundice recurrence and gastric outlet obstruction symptoms. RESULTS Thirty-six EUS-BD were enrolled over a cohort of 738 patients (ERCP cannulation failure rate was 2.6%): 31 choledocho-duodenostomy and 5 cholecystogastrostomy. A pre-loaded guidewire through the LAMS was systematically used in case of common bile duct ≤ 15 mm or scope instability for a safe/preventive biliary entryway in case of intra-procedural complications. Technical success was 80.6% (29/36 patients). Seven cases of LAMS maldeployment during EUS-guided choledocho-duodenostomy were successfully treated with RT by an over-the-wire fully-covered Self-Expandable Metal Stent (FC-SEMS). The FC-SEMS was released through the novel fistula tract in endoscopic fashion in 5/7 cases and transpapillary in percutaneous-transhepatic-endoscopic rendezvous (1/7) and laparoscopic-endoscopic rendezvous (1/7) in the two remaining cases. The total efficacy of rescue therapy was 100%. Same-session duodenal SEMS was placed in 17 patients with optimal gastric outlet obstruction management. Final clinical success was 100% and no other late adverse events or FC-SEMS migration were observed. CONCLUSION EUS-BD with LAMS is effective for jaundice palliation after ERCP failure but with considerable adverse events. Maldeployment remains a serious complication with fatal evolution if not correctly recognized/managed. Rescue therapy must be promptly applied especially in tertiary-care centers with highly skilled endoscopists, interventional radiologist and dedicated surgeon.
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Affiliation(s)
- Roberto Di Mitri
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy
| | - Michele Amata
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy.
| | - Filippo Mocciaro
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy
| | - Elisabetta Conte
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy
| | - Ambra Bonaccorso
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy
| | - Barbara Scrivo
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy
| | - Daniela Scimeca
- Gastroenterology and Endoscopy Unit, ARNAS Civico-Di Cristina-Benfratelli Hospital, Piazza Nicola Leotta 4, 901200, Palermo, Italy
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14
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Hong J, Chen Y, Li J, Hu P, Chen P, Du N, Huang T, Chen J. Comparison of gastrojejunostomy to endoscopic stenting for gastric outlet obstruction: An updated Systematic Review and Meta-analysis. Am J Surg 2022; 223:1067-1078. [PMID: 34728070 DOI: 10.1016/j.amjsurg.2021.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study aimed to determine the optimal intervention modality for malignant GOO by comparing clinical outcomes after Gastrojejunostomy and endoscopic stenting. METHODS Two authors independently searched Web of Science, PubMed, Embase, and the Cochrane Library for articles before February 2021 to compare the clinical outcomes of GOO patients undergoing GJ or ES. RESULTS This meta-analysis included 31 articles with 2444 GOO patients. Although the GJ group outperformed the ES group in technical success (OR,3.79; P = 0.003), clinical success was not significantly different between the two groups (OR,1.25; P = 0.50). The GJ group had a longer hospitalization, lower re-obstruction and lower reintervention. Moreover, GJ had a better survival than ES in the gastric cancer group (HR, 0.33; P = 0.009). However, no significant statistical difference was observed in the pancreatic cancer group (HR, 0.55; P = 0.159). CONCLUSIONS Both GJ and ES are safe and effective intervention modalities for malignant GOO. GJ had significantly improved survival in gastric cancer patients with GOO, while no significant difference was observed between the two groups in pancreatic cancer patients with GOO.
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Affiliation(s)
- Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Yizhou Chen
- Emergency Medical Center, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China.
| | - Jiayu Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Peidong Hu
- Schools of Medicine & Nursing Sciences, Huzhou University, Huzhou, Zhejiang, China.
| | - Ping Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
| | - Nannan Du
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Jingjie Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
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15
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Kumar A, Chandan S, Mohan BP, Atla PR, McCabe EJ, Robbins DH, Trindade AJ, Benias PC. EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E448-E458. [PMID: 35433208 PMCID: PMC9010090 DOI: 10.1055/a-1765-4035] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Surgical gastroenterostomy (SGE) has been the mainstay treatment for gastric outlet obstruction (GOO). The emergence of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) presents a less invasive alternative for palliation of GOO. We conducted a comprehensive review and meta-analysis to compare the effectiveness and safety of EUS-GE compared to SGE. Methods Multiple electronic databases and conference proceedings up to April 2021 were searched to identify studies that reported on safety and effectiveness of EUS-GE in comparison to SGE. Pooled odds ratios (ORs) of technical success, clinical success, adverse events (AE) and recurrence, and pooled standardized mean difference (SMD) of procedure time and post-procedure length of stay (LOS) were calculated. Study heterogeneity was assessed using I 2 and Cochran Q statistics. Results Seven studies including 625 patients (372 EUS-GE and 253 SGE) were included. EUS-GE had lower pooled odds of technical success compared with SGE (OR 0.19, 95 % confidence interval [CI] 0.06-0.60, I 2 0 %). Among the technically successful cases, EUS-GE was superior in terms of clinical success (OR 4.73, 95 % CI 1.83-12.25, I 2 18 %), lower overall AE (OR 0.20, 95 % CI 0.10-0.37, I 2 39 %), and shorter procedure time (SMD -2.4, 95 % CI -4.1, -0.75, I 2 95 %) and post-procedure LOS (SMD -0.49, 95 % CI -0.94, -0.03, I 2 78%). Rates of severe AE (0.89, 95 % CI 0.11-7.36, I 2 67 %) and recurrence (OR 0.49, 95 % CI 0.18-1.38, I 2 49 %) were comparable. Conclusions Our results suggest EUS-GE is a promising alternative to SGE due to its superior clinical success, overall safety, and efficiency. With further evolution EUS-GE could become the intervention of choice in GOO.
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Affiliation(s)
- Anand Kumar
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Saurabh Chandan
- Division of Gastroenterology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Pradeep R. Atla
- Palmdale Regional Medical Center, Palmdale, California, United States
| | - Evin J. McCabe
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - David H. Robbins
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Arvind J. Trindade
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States,Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States
| | - Petros C. Benias
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States,Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States
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16
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Hashmi SSH, Trusty RK, Mora MCF, Abushahin A, Winters H. A Unique Case of Invasive Adenocarcinoma of the Body and Tail of the Pancreas Presenting as Gastric Outlet Obstruction. Cureus 2022; 14:e23154. [PMID: 35433144 PMCID: PMC9007278 DOI: 10.7759/cureus.23154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
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17
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Sirolimus-eluting cobalt-chrome alloy stent suppresses stent-induced tissue hyperplasia in a porcine Eustachian tube model. Sci Rep 2022; 12:3436. [PMID: 35236923 PMCID: PMC8891339 DOI: 10.1038/s41598-022-07471-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 02/11/2022] [Indexed: 11/09/2022] Open
Abstract
Various preclinical studies with developed Eustachian tube (ET) stents are in progress but have not yet been clinically applied. ET stent is limited by stent-induced tissue hyperplasia in preclinical studies. The effectiveness of sirolimus-eluting cobalt–chrome alloy stent (SES) in suppressing stent-induced tissue hyperplasia after stent placement in the porcine ET model was investigated. Six pigs were divided into two groups (i.e., the control and the SES groups) with three pigs for each group. The control group received an uncoated cobalt–chrome alloy stent (n = 6), and the SES group received a sirolimus-eluting cobalt–chrome alloy stent (n = 6). All groups were sacrificed 4 weeks after stent placement. Stent placement was successful in all ETs without procedure-related complications. None of the stents was able to keep its round shape as original, and mucus accumulation was observed inside and around the stent in both groups. On histologic analysis, the tissue hyperplasia area and the thickness of submucosal fibrosis were significantly lower in the SES group than in the control group. SES seems to be effective in suppressing stent-induced tissue hyperplasia in porcine ET. However, further investigation was required to verify the optimal stent materials and antiproliferative drugs.
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18
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Nevo Y, Morency D, Kammili A, Abdrabo L, Zullo K, Almatar S, Cools-Lartigue J, Ferri L, Mueller C. The Role of Palliative Surgery in Stage IV Gastric Cancer: A Retrospective Study. J Palliat Care 2022; 37:152-158. [PMID: 35128998 DOI: 10.1177/08258597221078382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: Palliative chemotherapy is the mainstay of treatment for metastatic gastric adenocarcinoma but in some patients, surgically correctable factors such as obstruction lead to intolerance of further systemic treatment. The aim of this study was to evaluate the role of selective palliative surgery in incurable gastric cancer. Methods: All patients with stage IV and locally advanced unresectable gastric adenocarcinoma treated at a single centre from March 2006 to January 2019 were included. Data were retrieved from a prospectively maintained database. Patients were categorized into palliative surgery (PS) and no surgery (NS). Results: Of 666 patients with gastric cancer treated over the study period, 146 patients had stage IV gastric adenocarcinoma and 121 patients met inclusion criteria. Sites of metastases were peritoneum (55; 46%), non-regional lymph nodes (10; 8%), solid organ (17, 14%), adjacent organ invasion (4, 3.3%) and a combination of factors (32, 26%). Forty-six (38%) patients underwent palliative surgery which included anatomical gastrectomy (total, subtotal, distal or proximal, 78%) gastro-jejunal bypass and feeding jejunostomy (12%). Thirty-day post-operative complications occurred in 24 patients (52%) with one mortality (2.1%). Following surgery, 52% received systemic chemotherapy. For the PS and NS groups respectively, median overall survival was 9.1 versus 9.4 months (p = 0.6) and median progression-free survival was 7.1 versus 6.7 months (p = 0.2) after a follow up period of 7.3 (4.7-13.1) versus 7.8 (2.6-13.4) months (p = 0.46). Conclusion: Targeted surgical intervention for incurable gastric cancer can be used to palliate symptoms and facilitate continuation of systemic therapy with acceptable risks and post-operative outcomes.
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Affiliation(s)
- Yehonatan Nevo
- Division of General Surgery, McGill University Health Centre, Montreal, Canada
| | - Dominque Morency
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, Canada
| | - Anitha Kammili
- Division of General Surgery, McGill University Health Centre, Montreal, Canada
| | - Lina Abdrabo
- Division of General Surgery, McGill University Health Centre, Montreal, Canada
| | - Kyle Zullo
- Division of General Surgery, McGill University Health Centre, Montreal, Canada
| | - Saleh Almatar
- Division of General Surgery, McGill University Health Centre, Montreal, Canada
| | | | - Lorenzo Ferri
- Division of General Surgery, McGill University Health Centre, Montreal, Canada.,Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, Canada
| | - Carmen Mueller
- Division of General Surgery, McGill University Health Centre, Montreal, Canada.,Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal, Canada
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19
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Abstract
Surgical palliation in oncology can be defined as "procedures employed with non-curative intent with the primary goal of improving symptoms caused by an advanced malignancy," and is an important aspect of the end-of-life care of patients with incurable malignancies. Palliative interventions may provide great benefit, but they also carry high risk for morbidity and mortality, which may be minimized with careful patient selection. This can be done by consideration of the patient and his or her indication for the given intervention via open communication, as well as prediction of benefits and risks to define the therapeutic index of the operation or procedure.
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Affiliation(s)
- Cassandra S Parker
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 443, Providence, RI 02903, USA
| | - Thomas J Miner
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, 593 Eddy Street, APC 443, Providence, RI 02903, USA.
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20
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Arnstadt B, Allescher HD. [Palliative endoscopy]. Chirurg 2021; 93:310-322. [PMID: 34137905 DOI: 10.1007/s00104-021-01426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/07/2022]
Abstract
Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.
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Affiliation(s)
- Benno Arnstadt
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland.
| | - Hans-Dieter Allescher
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland
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21
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Cheung SLH, Teoh AYB. Optimal Management of Gastric Outlet Obstruction in Unresectable Malignancies. Gut Liver 2021; 16:190-197. [PMID: 34039779 PMCID: PMC8924806 DOI: 10.5009/gnl210010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/17/2021] [Accepted: 03/26/2021] [Indexed: 11/28/2022] Open
Abstract
The aim of this article is to review the different treatment options for malignant gastric outlet obstruction (GOO) and compare their safety and efficacy. We describe the history and evolution of gastrojejunostomy (GJ), endoscopic stenting and endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) and analyze the current evidence regarding these three methods available in the literature, comparing their applicability, safety, complications and cost when used for the treatment of malignant GOO. We conclude that given the benefits of endoscopic techniques and the ability to place a stent away from the tumor, EUS-GE is a promising technique that may yield an efficacy similar to that of surgical GJ and duodenal stenting, with lower reintervention rates and fewer adverse events.
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Affiliation(s)
- Stephanie Lok Hang Cheung
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
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22
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Li J, Gong T, Tsauo J. Fluoroscopy-guided gastrojejunostomy: A work in progress. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jingui Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Gong
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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23
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Rodríguez JI, Kutscher M, Lemus M, Crovari F, Pimentel F, Briceño E. Palliative gastrojejunostomy in unresectable cancer and gastric outlet obstruction: a retrospective cohort study. Ann R Coll Surg Engl 2021; 103:197-202. [PMID: 33645283 DOI: 10.1308/rcsann.2020.7016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Palliative gastrojejunostomy is a surgical technique that allows restoration of oral intake among patients with gastric outlet obstruction (GOO) caused by unresectable neoplasms. Research suggests standard treatment for malignant GOO should be laparoscopic gastrojejunostomy (LGJ). This study presents the clinical outcomes of palliative gastrojejunostomy and compares results from LGJ and open gastrojejunostomy (OGJ) at our centre. METHODS We performed a retrospective analysis on patients who underwent palliative gastrojejunostomy for GOO caused by unresectable neoplasms between 2008 and 2018. We included demographic variables, time to recover intestinal transit, time to recover oral intake, hospital stay, complications and global survival. RESULTS A total of 39 patients underwent palliative gastrojejunostomy (20 OGJ, 19 LGJ). Patients in the LGJ group recovered oral intake and intestinal transit faster than those in the OGJ group (3 vs 5 days, p<0.05). There were no statistically significant differences in median operating time, hospital stay or postoperative complications between the two groups. No intraoperative complications occurred. The estimated global survival was 178 days, with no significant difference between the groups. CONCLUSIONS Palliative LGJ allows earlier restoration of oral intake and does not increase morbidity or mortality. Palliative LGJ should be considered the standard treatment for these patients.
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Affiliation(s)
- J I Rodríguez
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile.,Department of Medical Education, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - M Kutscher
- Medical School, Faculty of Medicine, Pontifical Catholic University of Chile,, Santiago, Chile
| | - M Lemus
- Medical School, Faculty of Medicine, Pontifical Catholic University of Chile,, Santiago, Chile
| | - F Crovari
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - F Pimentel
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
| | - E Briceño
- Department of Surgery, Faculty of Medicine, Pontifical Catholic University of Chile, Santiago, Chile
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24
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Jue TL, Storm AC, Naveed M, Fishman DS, Qumseya BJ, McRee AJ, Truty MJ, Khashab MA, Agrawal D, Al-Haddad M, Amateau SK, Buxbaum JL, Calderwood AH, DeWitt J, DiMaio CJ, Fujii-Lau LL, Gurudu SR, Jamil LH, Kwon RS, Law JK, Lee JK, Pawa S, Sawhney MS, Thosani NC, Yang J, Wani SB. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc 2021; 93:309-322.e4. [PMID: 33168194 DOI: 10.1016/j.gie.2020.07.063] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 07/31/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Terry L Jue
- Department of Gastroenterology, The Permanente Medical Group, San Francisco, California, USA
| | - Andrew C Storm
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam Naveed
- Advent Health Medical Group, Gastroenterology/Hepatology, Advent Health Hospital Altamonte Springs, Altamonte Springs, Florida, USA
| | - Douglas S Fishman
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Autumn J McRee
- Division of Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Mark J Truty
- Department of Surgical Oncology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Deepak Agrawal
- Department of Internal Medicine, Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Mohammed Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Stuart K Amateau
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Audrey H Calderwood
- Department of Gastroenterology and Hepatology, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - John DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | - Larissa L Fujii-Lau
- Department of Gastroenterology, The Queen's Medical Center, Honolulu, Hawaii, USA
| | - Suryakanth R Gurudu
- Department of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | - Laith H Jamil
- Section of Gastroenterology and Hepatology, Beaumont Health, Royal Oak, Michigan, USA
| | - Richard S Kwon
- Department of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joanna K Law
- Department of Gastroenterology and Hepatology, Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jeffrey K Lee
- Department of Gastroenterology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Nirav C Thosani
- Division of Gastroenterology, Hepatology and Nutrition, McGovern Medical School, UTHealth, Houston, Texas, USA
| | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sachin B Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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25
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Baldaque-Silva F. Stent-in-Stent for Malign Obstruction: Should We Go Back to a Place Where We Were Happy? GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:375-377. [PMID: 33251285 PMCID: PMC7670327 DOI: 10.1159/000510739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 01/16/2023]
Affiliation(s)
- Francisco Baldaque-Silva
- Endoscopy Unit, Department of Upper Abdominal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
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26
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Jaruvongvanich V, Chesta FNU, Baruah A, Oberoi M, Adamo D, Singh PG, Meyer A, Law RJ, Buttar N. Palliative treatment for malignant gastrointestinal obstruction with peritoneal carcinomatosis: enteral stenting versus surgery. Endosc Int Open 2020; 8:E1487-E1494. [PMID: 33043118 PMCID: PMC7541184 DOI: 10.1055/a-1237-3956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 07/07/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC. Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms. Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting ( P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure. Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.
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Affiliation(s)
| | - FNU Chesta
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Anushka Baruah
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Meher Oberoi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Daniel Adamo
- Division of Radiology, Mayo Clinic, Rochester, Minnesota, United States
| | - Prabh G. Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Alyssa Meyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Ryan J. Law
- University of Michigan, Gastroenterology and Hepatology, Ann Arbor, Michigan, United States
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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27
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Cohen JT, Fallon EA, Charpentier KP, Cioffi WG, Miner TJ. Improving the value of palliative surgery by optimizing patient selection: The role of long-term survival on high impact palliative intent operations. Am J Surg 2020; 221:1018-1023. [PMID: 32980077 DOI: 10.1016/j.amjsurg.2020.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In order to better characterize outcomes of palliative surgery (PS), we evaluated patients that experienced top quartile survival to elucidate predictors of high impact PS. METHODS All PS performed on advanced cancer patients from 2003 to 2017 were identified from a PS database. RESULTS 167 patients were identified. Multivariate analysis demonstrated the ability to rise from a chair was independently associated with top quartile survival (HR 7.61, 95% CI 2.12-48.82, p=0.008) as was the need for re-operation (HR 2.81, 95% CI 1.26-6.30, p=0.0012). Patients who were able to rise from a chair had significantly prolonged overall survival (320 vs 87 days, p < 0.001). CONCLUSIONS Although not the primary goal, long-term survival can be achieved following PS and is associated with re-operation and the ability to rise from a chair. These patients experience the benefits of PS for a longer period of time, which in turn maximizes value and positive impact. SUMMARY Long-term survival and symptom control can be achieved in highly selected advanced cancer patients following palliative surgery. The ability of the patient to independently rise from a chair and the provider to offer a re-operation when indicated are associated with long-term survival following a palliative operation.
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Affiliation(s)
- Joshua T Cohen
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Eleanor A Fallon
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kevin P Charpentier
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - William G Cioffi
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas J Miner
- Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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28
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Blumenthaler AN, Ikoma N, Blum M, Das P, Minsky BD, Mansfield PF, Ajani JA, Badgwell BD. Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer. J Surg Oncol 2020; 122:1373-1382. [PMID: 32810292 DOI: 10.1002/jso.26177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/07/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO. METHODS The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS). RESULTS The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS. CONCLUSION In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.
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Affiliation(s)
- Alisa N Blumenthaler
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prajnan Das
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Bruce D Minsky
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jaffer A Ajani
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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29
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Kim DY, Moon HS, Kwon IS, Park JH, Kim JS, Kang SH, Lee ES, Kim SH, Lee BS, Sung JK, Jeong HY. Self-expandable metal stent of esophagogastric junction versus pyloric area obstruction in advanced gastric cancer patients: Retrospective, comparative, single-center study. Medicine (Baltimore) 2020; 99:e21621. [PMID: 32872019 PMCID: PMC7437803 DOI: 10.1097/md.0000000000021621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Upper gastrointestinal stenting is a palliative treatment for relieving symptoms such as nausea, vomiting, and dietary intake in patients with obstruction due to inoperable advanced stomach cancer. Self-expandable metal stent (SEMS) implantation for malignant obstruction has recently become more effective, safer, and less expensive than operative modality. It also has better short-term outcomes, particularly a shorter hospital stay and a more rapid return to oral intake, than surgical treatment. However, there is no comparative analysis regarding the efficacy, side effects, and survival rate of stenting between the esophagogastric junction (EGJ) and pyloric obstructions.To compare the prognoses and complications after SEMS implantation between EGJ and pyloric obstructions in advanced gastric cancer.Among advanced gastric cancer patients with gastrointestinal obstruction diagnosed from January 2008 to December 2017 at the Gastroenterology Department of Chungnam National University Hospital, 42 and 76 patients presented with EGJ (EGJ obstruction group) and gastric pyloric obstructions (pyloric obstruction group), respectively. We retrospectively reviewed the survival period, changes in food intake, and complications of these patients before and after SEMS placement.The prevalences of aspiration pneumonia were 11.9% (5/42) and 2.6% (2/76) in the EGJ and pyloric obstruction groups, respectively, before SEMS placement (P value: .041). Other symptoms associated with gastric malignant obstruction were not statistically different between the groups. Success rate and adverse events did not significantly differ between the EGJ and pyloric obstruction groups. There was no difference in frequency of stent reinsertion procedures performed owing to reobstruction, but the reprocedure average period was statistically significantly longer in the EGJ obstruction group [EGJ obstruction: 158.3 days (±42.4); pyloric obstruction: 86.0 days (±29.1)] (P value: .022). As an index of improved dietary status, the Gastric Outlet Obstruction Scoring System score was not significantly different between the groups before and after SEMS placement.The EGJ and pyloric obstruction groups did not significantly differ in prognosis or complication rates. However, EGJ stent was more stable than pyloric stent when reobstruction was considered.
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Affiliation(s)
- Deok Yeong Kim
- Division of Gastroenterology, Department of Internal Medicine, Daejeon Veterans Hospital
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - In Sun Kwon
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, South Korea
| | - Jae Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Ju Seok Kim
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Sun Hyung Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Eaum Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Seok Hyun Kim
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Byung Seok Lee
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Jae Kyu Sung
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
| | - Hyun Yong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital
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30
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Li J, Gong T, Tsauo J, Zhao H, Zhang X, Sang M, Li X. Fluoroscopy-Guided Gastrojejunostomy Creation with Lumen-Apposing Metal Stent in a Porcine Model. Cardiovasc Intervent Radiol 2020; 43:1687-1694. [PMID: 32651622 DOI: 10.1007/s00270-020-02589-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/26/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE To evaluate the technical feasibility of fluoroscopy-guided gastrojejunostomy creation in a porcine model. METHODS Eight domestic female pigs (median, 15.6 kg; range, 14.5-16.3 kg) were included in this study. The proximal jejunum was punctured from the stomach using a Rösch-Uchida Transjugular Liver Access Set through the mouth, and a lumen-apposing metal stent was placed across the puncture tract between the stomach and the proximal jejunum. All animals were euthanized 6 weeks after the procedure. RESULTS The fistulous tract creation and stent insertion with confirmed patency were successful in eight animals, rendering a technical success rate of 100%. Gross inspection showed a matured and patent fistulous tract between the stomach and the proximal jejunum in seven animals. In one animal, the colon between the stomach and the proximal jejunum was inadvertently punctured followed by migration of the stent from the stomach into the colon after the procedure to form a delayed jejunocolostomy. A stent migration and an inadvertent traversing the tail of pancreas by the stent were observed in another two animals without signs of bleeding, infection, or pancreatitis. All animals survived until the end of this study without change in their behavior or appetite. Histological analysis showed that all the fistulous tracts had matured with continuity of submucosal, muscular, and serosal layers, and without destruction of epithelial layers. CONCLUSIONS Fluoroscopy-guided gastrojejunostomy creation is technically feasible in a porcine model but requires refinement of the targeting technique to avoid transgression of nontarget organs.
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Affiliation(s)
- Jingui Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Tao Gong
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Jiaywei Tsauo
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China.
| | - He Zhao
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Xiaowu Zhang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Mingchen Sang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 17 Panjiayuan Nanli, Chaoyang District, Beijing, 100021, China
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31
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Haga Y, Hiki N, Kinoshita T, Ojima T, Nabeya Y, Kuwabara S, Seto Y, Yajima K, Takeuchi H, Yoshida K, Kodera Y, Fujiwara Y, Baba H. Treatment option of endoscopic stent insertion or gastrojejunostomy for gastric outlet obstruction due to gastric cancer: a propensity score-matched analysis. Gastric Cancer 2020; 23:667-676. [PMID: 31982964 DOI: 10.1007/s10120-020-01040-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 01/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There are currently two treatment options for gastric outlet obstruction (GOO) due to gastric cancer, endoscopic stenting and surgical gastrojejunostomy. However, their therapeutic effects have not yet been established. Therefore, the present study was undertaken to examine these effects. METHODS The Japanese Gastric Cancer Association invited its delegates to participate in a retrospective multicenter cohort study on patients with GOO due to gastric cancer who underwent stent therapy or gastrojejunostomy in 2015. RESULTS We obtained data from 85 patients undergoing stent therapy and 94 undergoing gastrojejunostomy from 42 hospitals. Baseline data revealed that stent patients had lower food intake, poorer performance status, and worse prognostic indices than gastrojejunostomy patients. Postoperative food intake and survival times were worse in stent patients than in gastrojejunostomy patients. We performed propensity score matching to select pairs of patients with similar baseline characteristics in the two treatment groups. After matching, the frequency of postoperative complications was significantly less in stent patients (3%, 1/33) than in gastrojejunostomy patients (21%, 7/34; p = 0.03). A low residue or full diet was achieved by 97% of stent patients (32/33) and 97% of gastrojejunostomy patients (33/34) (p = 0.98). Median survival times were 7.8 months in stent patients and 4.0 months in gastrojejunostomy patients (p = 0.38). CONCLUSIONS Propensity score matching demonstrated that endoscopic stent placement resulted in less postoperative morbidity than and a similar food intake and equivalent survival times to gastrojejunostomy. These results suggest the utility of stent therapy.
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Affiliation(s)
- Yoshio Haga
- Department of Surgery, Japan Community Healthcare Organization Amakusa Central General Hospital, 101 Higashi-machi, Amakusa-shi, 8630033, Japan.
| | - Naoki Hiki
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takahiro Kinoshita
- Gastric Surgery Division, National Cancer Center Hospital East, Kashiwa, Japan
| | - Toshiyasu Ojima
- Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Japan
| | - Yoshihiro Nabeya
- Division of Esophago-Gastrointestinal Surgery, Chiba Cancer Center, Chiba, Japan
| | - Shirou Kuwabara
- Department of Digestive Surgery, Niigata City General Hospital, Niigata, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Kazuhito Yajima
- Department of Surgery, Sainokuni Higashiomiya Medical Center, Saitamashi, Japan
| | - Hiroya Takeuchi
- Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yasuhiro Kodera
- Department of Gastroenterological Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshiyuki Fujiwara
- Department, of Surgery, School of Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Abstract
INTRODUCTION Proactive palliative care can effectively relieve symptoms early and effectively as well as improve the quality of life of patients with gastric adenocarcinoma (GAC). AREAS COVERED The review summarizes palliative care for GAC. GAC caused specific symptoms, such as malignant gastric outlet obstruction (GOO), bleeding, weight loss, and/or ascites, therefore, these symptoms must be addressed specifically. EXPERT OPINION Palliative care should start early to control general symptoms, thus may improve the patient's condition to make the patient eligible for anti-cancer treatment. As some stage IV GAC patients can now live longer, palliative interventions become more important. A multimodality interdisciplinary approach is strongly encouraged.
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Jeong SJ, Lee J. Management of gastric outlet obstruction: Focusing on endoscopic approach. World J Gastrointest Pharmacol Ther 2020; 11:8-16. [PMID: 32550041 PMCID: PMC7288729 DOI: 10.4292/wjgpt.v11.i2.8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
Gastric outlet obstruction (GOO) is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction. The obstructions typically involved in GOO can be benign or malignant. Peptic ulcer disease is the most common cause of benign GOO, and malignant causes include gastric cancer, lymphoma, and gastrointestinal stromal tumor. With the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors, the predominant causes have changed from benign to malignant diseases. Treatment of GOO depends on the underlying cause: Proton pump inhibitors, H. pylori eradication, endoscopic treatments including balloon dilatation or the placement of self-expandable stents, or surgery.
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Affiliation(s)
- Su Jin Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan 48108, South Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan 48108, South Korea
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Fisher AV, Hanlon B, Fernandes-Taylor S, Schumacher JR, Lawson EH, Ronnekleiv-Kelly SM, Minter RM, Weber SM, Abbott DE. Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction. HPB (Oxford) 2020; 22:529-536. [PMID: 31519358 DOI: 10.1016/j.hpb.2019.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 08/13/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes. METHODS Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured. RESULTS A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028). CONCLUSION In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.
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Affiliation(s)
- Alexander V Fisher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Bret Hanlon
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Sara Fernandes-Taylor
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Jessica R Schumacher
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Elise H Lawson
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States
| | - Sean M Ronnekleiv-Kelly
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Rebecca M Minter
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Sharon M Weber
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States
| | - Daniel E Abbott
- University of Wisconsin Institute for Surgical Outcomes Research (WiSOR), 600 Highland Avenue, Madison, WI 53792, United States; University of Wisconsin, Department of Surgery, Division of Surgical Oncology, H4/710 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, United States.
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Park JH, Kim MT, Kim KY, Bakheet N, Kim TH, Jeon JY, Park W, Lopera JE, Kim DH, Song HY. Local Heat Treatment for Suppressing Gastroduodenal Stent-Induced Tissue Hyperplasia Using Nanofunctionalized Self-Expandable Metallic Stent in Rat Gastric Outlet Model. ACS Biomater Sci Eng 2020; 6:2450-2458. [PMID: 33455352 DOI: 10.1021/acsbiomaterials.0c00307] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Despite the promising results from the placement of covered or uncovered self-expandable metallic stent (SEMS) as a nonsurgical therapeutic option for the malignant gastric outlet obstruction (GOO), the long patency of the stent is still limited because of stent-induced tissue hyperplasia. Here, a local heat treatment using a nanofunctionalized SEMS is proposed for suppressing stent-induced tissue hyperplasia during GOO treatment. Highly efficient photothermal gold nanoparticle (GNP) transducer-coated SEMSs (GNP-SEMSs) were prepared for local heat treatment in rat gastric outlet. The in vivo heating temperature in rat gastric outlet model was evaluated and compared with in vitro heating temperature. Three groups of our developed 45 rat gastric outlet models were used: group A, noncoated SEMS only; group B, GNP-SEMS plus local heating; and group C, GNP-SEMS only to investigate in vivo efficacy of GNP-SEMS mediated local heating. Ten rats per group were sacrificed for 4 weeks, and five rats per group were sacrificed immediately after local heat treatment. The in vivo heating temperature was found to be 10.8% lower than the in vitro heating temperatures. GNP-SEMSs were successfully placed through a percutaneous approach into the rat gastric outlet (n = 45). The therapeutic effects of GNP-SEMS were assessed by histologic examination including hematoxylin-eosin, Masson trichrome, immunohistochemistry (TUNEL and CD31), and immunofluorescence (Ki67), and the results showed significant prevention of tissue hyperplasia following stent placement without adjacent gastrointestinal tissue damage. GNP-SEMS-mediated local heating could be an alternative therapeutic option for the suppression of tissue hyperplasia following stent placement in benign and malignant GOOs.
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Affiliation(s)
- Jung-Hoon Park
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.,Biomedical Engineering Research Center, Asan Institute for Life Sciences, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Min Tae Kim
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea.,Department of Radiologic Technology, Cheju Halla University, 38, Halladaehak-ro, Jeju-si, Jeju-do 63092, Republic of Korea
| | - Kun Yung Kim
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Nader Bakheet
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Tae-Hyung Kim
- Department of Radiological Science, Kangwon National University, 346 Hwangjo-gil, Dogye-eup, Samcheok-si, Kangwon-do 25949, Republic of Korea
| | - Jae Yong Jeon
- Rehabilitation, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
| | - Wooram Park
- Department of Biomedical Chemical Engineering, The Catholic University of Korea, 43 Jibong-ro, Bucheon-si, Gyeonggi 14662, Republic of Korea
| | - Jorge E Lopera
- Department of Radiology, UT Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78229, United States
| | - Dong-Hyun Kim
- Department of Radiology, Feinberg School of Medicine, and Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois 60611, United States
| | - Ho-Young Song
- Departments of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
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Surgery for Gastric Cancer: State of the Art. Indian J Surg 2020. [DOI: 10.1007/s12262-019-02061-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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37
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Mintziras I, Miligkos M, Wächter S, Manoharan J, Bartsch DK. Palliative surgical bypass is superior to palliative endoscopic stenting in patients with malignant gastric outlet obstruction: systematic review and meta-analysis. Surg Endosc 2019; 33:3153-3164. [PMID: 31332564 DOI: 10.1007/s00464-019-06955-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Gastrojejunostomy (GJ) and self-expanding metal stents (SEMS) are the two most common palliative treatment options for patients with malignant gastric outlet obstruction (GOO). Randomised trials and retrospective studies have shown discrepant results, so that there is still a controversy regarding the optimal treatment of GOO. METHODS Medline, Web of Science and Cochrane Library were systematically searched for studies comparing GJ to SEMS in patients with malignant GOO. Primary outcomes were survival and postoperative mortality. Secondary outcomes were frequency of re-interventions, major complications, time to oral intake and length of hospital stay. RESULTS Twenty-seven studies, with a total of 2.354 patients, 1.306 (55.5%) patients in the SEMS and 1.048 (44.5%) patients in the GJ group, were considered suitable for inclusion. GJ was associated with significantly longer survival than SEMS (mean difference 43 days, CI 12.00, 73.70, p = 0.006). Postoperative mortality (OR 0.55, CI 0.27, 1.16, p = 0.12) and major complications (OR 0.73, CI 0.5, 1.06, p = 0.10) were similar in both groups. The frequency of re-interventions, however, was almost three times higher in the SEMS group (OR 2.95, CI: 1.70, 5.14, p < 0.001), whereas the mean time to oral intake and length of hospital stay were shorter in the SEMS group (mean differences - 5 days, CI - 6.75, - 3.05 days, p < 0.001 and - 10 days, CI - 11.6, - 7.9 days, p < 0.001, respectively). CONCLUSIONS Patients with malignant GOO and acceptable performance status should be primarily considered for a palliative GJ rather than SEMS.
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Affiliation(s)
- Ioannis Mintziras
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany.
| | - Michael Miligkos
- Laboratory of Biomathematics, University of Thessaly School of Medicine, Larissa, Greece
| | - Sabine Wächter
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Jerena Manoharan
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
| | - Detlef Klaus Bartsch
- Department of Visceral-, Thoracic- and Vascular Surgery, Philipps-University Marburg, Baldingerstrasse, 35043, Marburg, Germany
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López-Sánchez J, Marcos Martín ÁF, Abdel-Lah Fernández O, Quiñones Sampedro JE, Álvarez Delgado A, Esteban Velasco MC, Muñoz-Bellvís L, Parreño-Manchado FC. Stomach-partitioning gastrojejunostomy versus stent placement for the treatment of malignant gastric outlet obstruction. Cir Esp 2019; 97:385-390. [PMID: 31208728 DOI: 10.1016/j.ciresp.2019.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/01/2019] [Accepted: 04/14/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Gastric outlet obstruction is a complication of advanced tumors. It causes upper gastrointestinal obstruction, with progressive malnutrition and reduced survival. Currently, gastrojejunostomy or stent placement (SP) are feasible alternatives for the treatment of malignant gastric outlet obstruction. The aim of this study is to compare the efficacy and survival of both techniques. METHODS Single-center observational and prospective study of 58 patients with gastric outlet obstruction who underwent surgical treatment with stomach-partitioning gastrojejunostomy (SPGJ) or SP with self-expanding intraluminal prostheses between 2007 and 2018. RESULTS Thirty patients underwent SPGJ and 28 SP. The mean age of the first group was significantly lower (69 vs. 78 years, respectively; P=.001). There were no statistically significant differences in terms of sex, perioperative risk or tumor etiology. Postoperative complications were non-significantly higher in the SPGJ group (P=.156). SP was associated with a shorter hospital stay (P=.02) and faster oral intake (P<.0001). However, SP had significantly higher rates of persistent and recurrent obstruction (P=.048 and .01, respectively), poorer energy targets (P=.009) and shorter survival (9.61 vs. 4.47 months; P=.008). CONCLUSIONS SPGJ presents greater luminal permeability, better oral intake and greater survival than SP. SP is preferable for non-surgical patients with a limited short-term prognosis.
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Affiliation(s)
- Jaime López-Sánchez
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España.
| | - Ángel F Marcos Martín
- Servicio de Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Omar Abdel-Lah Fernández
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - José E Quiñones Sampedro
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - Alberto Álvarez Delgado
- Servicio de Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España
| | - María C Esteban Velasco
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España; Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, España
| | - Luis Muñoz-Bellvís
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España; Instituto de Investigación Biomédica de Salamanca (IBSAL), Universidad de Salamanca, Salamanca, España; Centro de Investigación Biomédica en Red de Oncología (CIBERONC), Madrid, España
| | - Felipe C Parreño-Manchado
- Servicio de Cirugía General y del Aparato Digestivo, Complejo Asistencial Universitario de Salamanca, Salamanca, España
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Jang S, Stevens T, Lopez R, Bhatt A, Vargo JJ. Superiority of Gastrojejunostomy Over Endoscopic Stenting for Palliation of Malignant Gastric Outlet Obstruction. Clin Gastroenterol Hepatol 2019; 17:1295-1302.e1. [PMID: 30391433 DOI: 10.1016/j.cgh.2018.10.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/21/2018] [Accepted: 10/26/2018] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio.
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - Rocio Lopez
- Department of Quantitative Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
| | - John J Vargo
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, Ohio
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40
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Adler DG. Should Patients With Malignant Gastric Outlet Obstruction Receive Stents or Surgery? Clin Gastroenterol Hepatol 2019; 17:1242-1244. [PMID: 30503965 DOI: 10.1016/j.cgh.2018.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Douglas G Adler
- Gastroenterology and Hepatology Division, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah
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41
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Cohen JT, Miner TJ. Patient selection in palliative surgery: Defining value. J Surg Oncol 2019; 120:35-44. [DOI: 10.1002/jso.25512] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 03/25/2019] [Accepted: 04/22/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Joshua T. Cohen
- Department of Surgery, Rhode Island HospitalWarren Alpert Medical School of Brown UniversityProvidence Rhode Island
| | - Thomas J. Miner
- Department of Surgery, Rhode Island HospitalWarren Alpert Medical School of Brown UniversityProvidence Rhode Island
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42
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Perinel J, Adham M. Palliative therapy in pancreatic cancer-palliative surgery. Transl Gastroenterol Hepatol 2019; 4:28. [PMID: 31231695 DOI: 10.21037/tgh.2019.04.03] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 04/15/2019] [Indexed: 12/19/2022] Open
Abstract
Pancreatic cancer is a highly lethal disease with a dismal prognosis. It will probably become the second leading cause of cancer-related death within the next decade in Western countries. Over 80% of patients undergo palliative treatment for unresectable pancreatic cancer due to locally advanced disease or metastases. Those patients often develop gastric outlet obstruction (GOO), obstructive jaundice and pain during the course of their disease. Symptoms such as vomiting, anorexia, pruritus and jaundice will impact the quality of life (QOL) and could delay the administration of the chemotherapy. Palliative therapy in pancreatic cancer aims to relieve the symptoms durably and to improve the QOL. Palliative surgery was traditionally considered as a gold standard with the "double by-pass" including biliary-digestive and gastro-jejunal anastomosis. However, since the development of endoscopic stenting and minimally invasive surgery, the choice of the best modalities remains debated. While there is still a place for surgical gastrojejunostomy (GJ) in case of duodenal or GOO, endoscopic biliary stenting during endoscopic retrograde cholangiopancreatography (ERCP) is now accepted as the gold standard in case of obstructive jaundice. In pain management, endoscopic ultrasound guided or percutaneous celiac plexus neurolysis is recommended. The selection of the best technique should consider the effectiveness and the morbidity of the treatment, the performance status of the patient and the disease stage. While endoscopic stenting is associated with earlier recovery and shorter length of stay, recurrence of symptoms and reintervention are less frequent after palliative surgery. Finally, controversy exists on whether to perform prophylactic palliative surgery in the absence of symptoms when unresectable disease is discovered during surgical exploration.
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Affiliation(s)
- Julie Perinel
- Department of Digestive Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Lyon Sud Faculty of Medicine, Claude Bernard University Lyon 1 (UCBL1), Lyon, France
| | - Mustapha Adham
- Department of Digestive Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France.,Lyon Sud Faculty of Medicine, Claude Bernard University Lyon 1 (UCBL1), Lyon, France
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43
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Uemura S, Iwashita T, Iwata K, Mukai T, Osada S, Sekino T, Adachi T, Kawai M, Yasuda I, Shimizu M. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology 2018; 18:601-607. [PMID: 29753623 DOI: 10.1016/j.pan.2018.04.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/27/2018] [Accepted: 04/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment. AIMS To compare the efficacy and safety of GJJ and DS for GOO with APC. METHODS Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis. RESULTS GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS. CONCLUSIONS There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.
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Affiliation(s)
- Shinya Uemura
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan.
| | - Keisuke Iwata
- Department of Gastroenterology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Tsuyoshi Mukai
- Department of Gastroenterology, Gifu Municipal Hospital, Gifu, Japan
| | - Shinji Osada
- Multidisciplinary Therapy for Hepato-Biliary-Pancreatic Cancer, Gifu University School of Medicine, Gifu, Japan
| | - Takafumi Sekino
- Department of General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | | | - Masahiko Kawai
- Department of Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Ichiro Yasuda
- Department of Gastroenterology, Teikyo University Mizonokuchi Hospital, Kanagawa, Japan
| | - Masahito Shimizu
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
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Yukimoto T, Morisaki T, Komukai S, Yoshida H, Yamaguchi D, Tsuruoka N, Miyahara K, Sakata Y, Shibasaki S, Tsunada S, Noda T, Yunotani S, Fujimoto K. The Palliative Effect of Endoscopic Uncovered Self-expandable Metallic Stent Placement Versus Gastrojejunostomy on Malignant Gastric Outlet Obstruction: A Pilot Study with a Retrospective Chart Review in Saga, Japan. Intern Med 2018; 57:1517-1521. [PMID: 29434131 PMCID: PMC6028667 DOI: 10.2169/internalmedicine.0171-17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective Endoscopic self-expandable metallic stent (SEMS) placement and gastrojejunostomy (GJY) are palliative treatments for malignant gastric outlet obstruction (GOO). The aim of the present study was to compare the palliative effects of these treatments and identify predictors of a poor oral intake after treatment. Methods and Patients In total, 65 patients with GOO at multiple centers in Saga, Japan, were evaluated. Thirty-eight patients underwent SEMS placement, and 27 underwent GJY from January 2010 to December 2016. The characteristics and outcomes of the two groups were compared to detect predictors of treatment failure. Results No significant differences in the technical success, clinical success, post-treatment total protein, hospital discharge, duration from eating disability to death, or post-treatment overall survival were present between the SEMS and GJY groups. More patients in the GJY group than in the SEMS group received chemotherapy (51.4% vs. 26.3%, respectively; p=0.042). The period from treatment to the first meal was longer in the GJY group than in the SEMS group (4.5 vs. 3.0 days, respectively; p=0.013). The present study did not identify any risk factors for failure of SEMS placement. Although the stent length tended to be associated with a poor prognosis, the correlation was not statistically significant (odds ratio: 0.60, 95% confidence interval: 0.36-1.01, p=0.053). Conclusion Patients with GOO started meals more promptly after SEMS than after GJY, but the clinical outcomes were not markedly different between the SEMS and GJY groups. These findings suggest that endoscopic uncovered SEMS placement might be a feasible palliative treatment for GOO.
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Affiliation(s)
- Takahiro Yukimoto
- Departments of Gastroenterology, National Hospital Organization Ureshino Medical Center, Japan
- Department of Internal Medicine, Saga Medical School, Japan
| | - Tomohito Morisaki
- Departments of Gastroenterology, National Hospital Organization Ureshino Medical Center, Japan
| | - Sho Komukai
- Department of Clinical Research Center, Saga Medical School, Japan
| | - Hisako Yoshida
- Department of Clinical Research Center, Saga Medical School, Japan
| | - Daisuke Yamaguchi
- Departments of Gastroenterology, National Hospital Organization Ureshino Medical Center, Japan
| | - Nanae Tsuruoka
- Department of Internal Medicine, Saga Medical School, Japan
| | - Koichi Miyahara
- Departments of Gastroenterology, Karatsu Red Cross Hospital, Japan
| | | | - Shinichi Shibasaki
- Departments of Surgery, National Hospital Organization Ureshino Medical Center, Japan
| | - Seiji Tsunada
- Departments of Gastroenterology, National Hospital Organization Ureshino Medical Center, Japan
| | - Takahiro Noda
- Departments of Gastroenterology, Karatsu Red Cross Hospital, Japan
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45
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Upchurch E, Ragusa M, Cirocchi R. Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction. Cochrane Database Syst Rev 2018; 5:CD012506. [PMID: 29845610 PMCID: PMC6494580 DOI: 10.1002/14651858.cd012506.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Emma Upchurch
- Gloucestershire Hospitals NHS Foundation TrustDepartment of Colorectal and Upper Gastrointestinal SurgerySandford RoadCheltenhamGloucestershireUKGL53 7AN
| | | | - Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
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Bekheet N, Kim MT, Park JH, Kim KY, Tsauo J, Zhe W, Lim YJ, Song HY. Fluoroscopic Gastroduodenal Stent Placement in 55 Patients with Endoscopic Stent Placement Failure. Cardiovasc Intervent Radiol 2018. [PMID: 29541839 DOI: 10.1007/s00270-018-1933-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE To evaluate the technical feasibility and clinical effectiveness of fluoroscopic self-expandable metal stent (SEMS) placement in malignant gastroduodenal obstructions after failed endoscopic SEMS placement. MATERIALS AND METHODS Between September 2010 and July 2017, 874 patients underwent endoscopic SEMS placement for dysphagia caused by malignant gastroduodenal obstructions. Endoscopic SEMS placement failed in 55 of 874 patients (6.3%). These patients were referred for fluoroscopic SEMS placement. In case of failed fluoroscopic SEMS placement, combined endoscopic and fluoroscopic SEMS placement was attempted at the same setting. RESULTS Fluoroscopic SEMS placement was technically successful in 40 of 55 patients (72.7%). Combined endoscopic and fluoroscopic SEMS placement was technically successful in 6 of 15 patients with fluoroscopic SEMS placement failure. Failures in the nine patients were due to complete obstruction (n = 5) and acute angulation at the stricture site (n = 4). The overall technical success rate was 83.6% (46/55). Clinical success was achieved in 95.6% of patients (44/46). Complications occurred in 7 of 46 patients (15.2%), including tumor overgrowth (n = 3), SEMS migration (n = 3), and bleeding (n = 1). The median SEMS patency and patient survival periods were 515 (95% confidence interval (CI), 266.6-761.5) and 83 (95% CI 60.6-105.4) days, respectively. CONCLUSIONS Fluoroscopic SEMS placement is technically feasible and clinically effective in cases of endoscopic SEMS placement failure. A combined endoscopic and fluoroscopic approach increases the technical success rate after failure of the endoscopic or fluoroscopic approach. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Nader Bekheet
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.,Gastrointestinal Endoscopy and Liver Unit, Kasr Al-Ainy, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Min Tae Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.,Department of Radiologic Technology, Cheju Halla University, Jeju, Republic of Korea
| | - Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.,Department of Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Kun Yung Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Wang Zhe
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Young Je Lim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Republic of Korea.
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McGrath C, Tsang A, Nithianandan H, Nguyen E, Bauer P, Dennis K. Malignant Gastric Outlet Obstruction from Pancreatic Cancer. Case Rep Gastroenterol 2017; 11:511-515. [PMID: 29033771 PMCID: PMC5637001 DOI: 10.1159/000480070] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/01/2017] [Indexed: 11/29/2022] Open
Abstract
Patients with advanced-stage pancreatic cancer are typically burdened by many symptoms that impair functioning and worsen quality of life. We report an exceptional case of a 73-year-old woman with T4N1M0 adenocarcinoma of the uncinate process of the pancreas who developed significant gastric outlet obstruction – an uncommon yet potentially life-threatening complication of disease progression. She developed progressive abdominal pain and emesis, and profound dilatation of her stomach was detected on a radiation therapy simulation CT scan that required urgent decompression. Malignant gastric outlet obstruction must be included in the differential diagnosis when patients with known advanced disease of the pancreas present with obstructive upper gastrointestinal symptoms.
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Affiliation(s)
- Clare McGrath
- Faculty of Science, Biomedical Science, University of Ottawa, Ottawa, Ontario, ON, Canada
| | - Adrian Tsang
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, ON, Canada
| | | | - Eric Nguyen
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, ON, Canada
| | - Patrick Bauer
- Division of Radiation Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, ON, Canada
| | - Kristopher Dennis
- Division of Radiation Oncology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, ON, Canada
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Abstract
OPINION STATEMENT Pancreas cancer is a fourth-leading cause of cancer death in the USA and its incidence is rising as the population is aging. The majority of patients present at an advanced stage due to the silent nature of the disease and treatment have focused more on palliation than curative intent. Gastroenterologists have become integral in the multidisciplinary care of these patients with a focus on providing endoscopic palliation of pancreas cancer. The three most common areas that gastroenterologists palliate endoscopically are biliary obstruction, cancer-related pain, and gastric outlet obstruction. To palliate biliary obstruction, the procedure of choice is to perform endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent placement. We tend to place covered self-expandable metal stents (SEMS) due to their longer patency and removability unless the patient has resectable disease. Pancreas cancer pain is a result of tumor infiltration of the celiac plexus and can be severe and poorly responsive to narcotics. To improve pain control, neurolysis of the celiac plexus has been performed for decades. Since 1996, neurolysis of the celiac area has been performed endoscopically by Endoscopic Ultrasound-Guided Celiac Plexus Neurolysis. This has proven to be as safe and effective as traditional non-endoscopic methods and has allowed the patients to decrease their narcotic use and improve their pain control. This should be done early on in the course of the disease to have maximal effect. Gastric outlet obstruction (GOO) occurs in approximately 15-20% of patients with pancreas cancer. Endoscopic palliation of GOO can be performed by placing uncovered metal enteral stents across the obstruction. This procedure has proven to be very effective in patients who have a short life expectancy (less than two to 6 months) while surgical bypass should be considered for patients with longer life expectancies because it offers better long-term symptom relief. This chapter will review the current literature, latest advancements, and optimal techniques for endoscopic palliation of pancreatic cancer.
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Affiliation(s)
- Vishal B Gohil
- Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Jason B Klapman
- Gastrointestinal Tumor Program, Section of Endoscopic Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.
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Laparoscopic Gastrojejunostomy for Patients with Unresectable Gastric Cancer with Gastric Outlet Obstruction. J Gastrointest Surg 2017; 21:1220-1225. [PMID: 28224464 DOI: 10.1007/s11605-017-3387-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/13/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND There have been no comparative studies of open gastrojejunostomy (OGJ) and laparoscopic gastrojejunostomy (LGJ) in gastric cancer (GC) patients with gastric outlet obstruction (GOO) to explore both short- and long-term outcomes. The aim of this study was to compare the safety and feasibility of short-term oral intake as well as the long-term oncological outcome of OGJ and LGJ. METHODS This was a retrospective study of 53 consecutive unresectable GC patients who underwent GJ for GOO in our institute. OGJ (n = 23) was performed between 2010 and 2012 and LGJ (n = 30) was performed between 2013 and 2015. RESULTS We found a higher rate of postoperative delayed gastric emptying in the OGJ group than in the LGJ group (26.1 vs 0%; P = 0.004). OGJ had more unfavorable results regarding the median time to resumption of oral feeding (4 vs 2 days; P < 0.001). Palliative LGJ did not offer survival benefit over OGJ in patients with unresectable GC with GOO. CONCLUSION LGJ is a useful and feasible alternative to OGJ regarding short-term outcomes.
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50
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Park JH, Tsauo J, Song HY. Self-expandable metal stent placement for recurrent cancer in a surgically-altered stomach. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jung-Hoon Park
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ho-Young Song
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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