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Abstract
Malignant gastric outlet obstruction (MGOO) is a late complication of advanced malignancies, mostly occurring due to gastrointestinal cancers or external compression outside the lumen. It causes nausea, vomiting, poor appetite, weight loss, and decreased quality of life. In the past, surgical bypass was the gold standard for the management of MGOO. However, the introduction of self-expandable metallic stent (SEMS) provides several advantages over surgical bypass, including earlier oral intake, rapid symptom relief, less invasiveness, and shorter hospital stays; therefore, it has replaced surgical bypass as the mainstream management approach in most situations. Although SEMS placement is a safe and effective way for palliation of MGOO, stent dysfunction with obstruction or migration limits the utilization and increases repeated intervention. Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stent has emerged as an alternative way to bypass the obstruction site and restore the oral intake of patients. Although a lower stent dysfunction rate was reported, further prospective studies are warranted to validate its effectiveness and safety.
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Affiliation(s)
- Bing-Wei Ye
- Division of Gastroenterology, Department of Medicine, Taiwan Adventist Hospital, Taipei, Taiwan, ROC
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
| | - Ming-Chih Hou
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan, ROC
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Orr J, Lockwood R, Gamboa A, Slaughter JC, Obstein KL, Yachimski P. Enteral Stents for Malignant Gastric Outlet Obstruction: Low Reintervention Rates for Obstruction due to Pancreatic Adenocarcinoma Versus Other Etiologies. J Gastrointest Surg 2021; 25:720-727. [PMID: 32077045 DOI: 10.1007/s11605-019-04512-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/29/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND AIM Enteral stents (ES) have emerged as first-line therapy for the treatment of malignant gastric outlet obstruction (GOO). Stent occlusion arising from tissue ingrowth may require endoscopic or surgical reintervention. The objective of this study was to compare rates of reintervention following palliative ES for patients with GOO due to pancreatic adenocarcinoma (PDAC) versus other malignant etiologies. METHODS Patients who had undergone ES for palliation of malignant GOO between 2009 and 2018 were retrospectively identified and demographic, clinical, and procedural data were collected. Primary outcome was procedural reintervention for recurrent symptomatic GOO following ES placement. RESULTS Forty-three patients were included in the study cohort. 62.8% (27/43) of patients had PDAC while 37.2% (16/43) of patients had other malignant etiologies. 11.6% (5/43) of patients were alive at follow-up. Thirty-day and 90-day mortality rates were 22.8% and 70.7% for PDAC and 25% and 56.3% for other malignant etiologies, respectively. Seven patients required reintervention for symptomatic GOO: 14.3% (1/7) had PDAC and 85.7% (6/7) had GOO due to other malignancy (P < .01). Ninety-six percent (26/27) of patients with PDAC required no further intervention for GOO prior to death or end of follow-up. On multivariate analysis, patients with PDAC were significantly less likely to require reintervention than patients with other malignant etiologies (OR 0.064, 95% CI 0.01-0.60). CONCLUSION ES offer durable symptom palliation without requirement for reintervention for the overwhelming majority of patients with malignant GOO due to PDAC. Reintervention rates are higher following ES placement for GOO due to other malignant etiologies and future study may be needed to define the optimal palliative intervention for this group of patients.
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Affiliation(s)
- Jordan Orr
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA.
| | - Robert Lockwood
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
| | - Anthony Gamboa
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
| | - James C Slaughter
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, 37232-5280, USA
| | - Keith L Obstein
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
| | - Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 1660 The Vanderbilt Clinic, 1301 Medical Center Drive, Nashville, TN, 37232-5280, USA
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Grunwald D, Cohen J, Bartley A, Sheridan J, Chuttani R, Sawhney MS, Pleskow DK, Berzin TM, Mizrahi M. The location of obstruction predicts stent occlusion in malignant gastric outlet obstruction. Therap Adv Gastroenterol 2016; 9:815-822. [PMID: 27803736 PMCID: PMC5076776 DOI: 10.1177/1756283x16667893] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastric outlet obstruction (GOO) can occur with locally invasive or metastatic cancer involving the upper gastrointestinal tract at the pylorus or the duodenum. Endoscopic management with self-expanding metal stents (SEMSs) is often the preferred palliative approach. Stent occlusion is a common reason for failure and reintervention. We set out to determine whether the location of the malignant obstruction is associated with the angulation of the stent and can predict stent occlusion. METHODS We performed a retrospective review of consecutive patients who underwent successful duodenal stenting with SEMS for malignant GOO between 2006 and 2015 at a large advanced endoscopy referral center. We determined the location of obstruction, the stent angle, and the rate of technical and clinical success of stent placement. We then identified cases of subsequent stent occlusion confirmed by endoscopic evaluation. RESULTS A total of 100 consecutive patients were included in the study; 91 of these patients had enough data to evaluate SEMS occlusion. A total of 21 patients (23%) developed stent occlusion with a median time of 39 days. The risk of occlusion sequentially increased as the obstruction occurred more distally from the antrum to the third or fourth portion of the duodenum (p = 0.006). This relationship was maintained after controlling for stent angle (p = 0.05). CONCLUSIONS A distal location of malignant GOO was strongly predictive of stent occlusion, independent of stent angle. This may be due to longer and more complex distal obstructions, along with foreshortening of the stent during placement and tumor infiltration. If replicated, these results will have implications for endoscopic practice and future device development.
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Affiliation(s)
| | - Jonah Cohen
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Anthony Bartley
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Jennifer Sheridan
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ram Chuttani
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Mandeep S. Sawhney
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Douglas K. Pleskow
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Tyler M. Berzin
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Meir Mizrahi
- Center for Advanced Endoscopy, Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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Park CH, Park JC, Kim EH, Chung H, An JY, Kim HI, Shin SK, Lee SK, Cheong JH, Hyung WJ, Lee YC, Noh SH, Kim CB. Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy. Gastrointest Endosc 2015; 81:321-32. [PMID: 25085332 DOI: 10.1016/j.gie.2014.06.024] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/04/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Self-expandable metal stent (SEMS) placement and palliative gastrojejunostomy (GJJ) are palliative treatment options for malignant gastric outlet obstruction. OBJECTIVE To compare clinical outcomes of palliative treatments for gastric outlet obstruction caused by unresectable gastric cancer. DESIGN Retrospective study. SETTING University-affiliated tertiary-care hospital in the Republic of Korea. PATIENTS Two hundred fifty-six patients with gastric outlet obstruction caused by unresectable gastric cancer. INTERVENTION SEMS placement and palliative GJJ. MAIN OUTCOME MEASUREMENTS Patency duration and overall survival duration. RESULTS In total, 217 and 39 patients underwent SEMS placement and palliative GJJ, respectively, as an initial palliative treatment. Treatment modality affected reobstruction after clinical success (hazard ratio [HR] [95% confidence interval {CI}], 0.5 [0.3-0.8] of palliative GJJ). In addition, carcinomatosis with ascites was an independent associated factor of clinical success and reobstruction (HR [95% CI], 0.3 [0.1-0.7] and 1.4 [1.0-2.0], respectively). In a subgroup of patients with good performance who had neither carcinomatosis nor ascites, patency duration and overall survival duration did not differ between the 2 groups (P = .079 and P = .290, respectively). In patients with good performance who had carcinomatosis without ascites, patency duration was longer in the palliative GJJ group than in the SEMS placement group (P = .016). Overall survival, however, did not differ between the 2 groups (P = .062). In a subgroup of patients with good performance who had carcinomatosis with ascites, both patency duration and overall survival were longer in the palliative GJJ group than in the SEMS placement group (P = .007 and P = .012, respectively). LIMITATIONS Nonrandomized, retrospective study. CONCLUSION Long-term clinical outcomes of the palliative treatment modality for gastric outlet obstruction caused by unresectable gastric cancer were affected by carcinomatosis and ascites status.
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Affiliation(s)
- Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyunsoo Chung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Yeong An
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyoung-Il Kim
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae-Ho Cheong
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Woo Jin Hyung
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Chan Lee
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Hoon Noh
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Choong Bae Kim
- Department of Surgery, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
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Zhou WZ, Yang ZQ. Stenting for malignant gastric outlet obstruction: Current status. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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