Comparison of big funnel and individualized stents for management of stomach cancer with gastric outlet obstruction

Maximizing oral intake tolerance in malignant gastric outlet obstruction - a Markov decision tree analysis comparing duodenal stenting, endoscopic ultrasound-guided gastroenterostomy and surgical gastrojejunostomy based on a meta-analysis of randomized controlled trials

INTRODUCTION

Malignant gastric outlet obstruction (GOO) has a significant impact on quality of life. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has shown promising results. Traditional isolated outcome measures do not sufficiently address critical considerations for end-of-life patients like oral intake tolerance. This study aimed to determine via a probabilistic approach, the optimal management strategy for GOO patients that maximizes their oral intake tolerance.

METHODS

A Markov decision model was developed, with input variables based on a systematic review and meta-analysis of randomized controlled trials (RCT) comparing duodenal stenting (DS), EUS-GE and surgical gastrojejunostomy (GJ). A prospective cohort study with a comparator group was also included for EUS-GE model given the scarcity of RCTs. Model assumption was a patient with malignant GOO, with equal probabilities of being allocated to 1 of 3 treatment options. Each data point was evaluated using pooled probabilities from the meta-analysis of clinical outcomes. Primary outcome was successful oral intake tolerance at various time points of 1-6 months post-intervention.

RESULTS

Fifteen studies were included into the Markov model. Based on 10 000 simulations in each arm, at a survival of 1-month, DS and EUS-GE had the highest likelihood of oral intake (81.2% and 80.4%) compared to GJ (75.5%). However, at a survival of 6-month, EUS-GE and GJ were better at palliating GOO, with likelihood of oral intake at 23.8% and 25.2%, compared to 21.3% for DS.

CONCLUSION

For patients with a prognosis of more than 1-month, a surgical GJ, or EUS-GE if technical expertise is available, is preferred for GOO palliation.

Self-expandable metal stent of esophagogastric junction versus pyloric area obstruction in advanced gastric cancer patients: Retrospective, comparative, single-center study

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.

Big End Double-Layer Stents for the Treatment of Gastric Outlet Obstruction Caused by Stomach Cancer

Objectives

This study is aimed at evaluating the efficacy and safety of the big end double-layer uncovered self-expanding metal stents (SEMS) for the treatment of gastric outlet obstruction (GOO) caused by distal stomach cancer.

Methods

Seventy three patients receiving big end double-layer uncovered SEMS for the treatment of GOO caused by distal gastric cancer will be included in this multicenter prospective clinical trial. The main outcome measures included the functional outcome, the complications, the reinterventional rates, the average treatment charges, and the mean survival time. Monthly telephone calls were needed to assess the food intake until the patients died.

Results

The technical and the clinical success rates were 98.6%. The stent obstruction caused by tumor ingrowth was observed in one patient (1.4%). The incidence of food impaction was 2.9% (2/70) and the reinterventional rate was 4.3% (3/70). However, stent migration and obstruction caused by overgrowth were not observed. No perforation and severe bleeding were observed. The median cost of endoscopic stenting and total hospitalization (including reinterventions) for the big end double-layer uncovered SEMS in this study was $2945 and $3408, respectively. The mean survival time was 212.5 days.

Conclusions

The placement of big end double-layer uncovered SEMS is a safe and effective modality and has the potential to be one of the options for the treatment of GOO caused by the distal gastric cancer.