Outcomes of endoscopic pyloric stenting in malignant gastric outlet obstruction: a retrospective study

Pyloric stent insertion in malignant gastric outlet obstruction: moving beyond palliation

Background:

Self-expandable metallic stents have not only largely replaced surgical gastrojejunostomy for unresectable gastric cancers, but their role as bridging therapy for resectable obstructing tumours is also evolving.

Objective:

To evaluate the efficacy and safety of pyloric stents in gastric outlet obstruction in patients with gastric cancer and assess survival in patients with resectable obstructing gastric tumours in whom stents were inserted as a bridge to surgery.

Methods:

We retrospectively reviewed the electronic medical records of patients who underwent self-expandable metallic stent insertion for gastric outlet obstruction due to gastric cancer from January 2014 to March 2019.

Results:

Out of 161 patients, clinical improvement was observed in 159 (99%) and 156 (97%) at 1 and 12 weeks of stent placement, respectively. None of these patients experienced serious complications, such as perforation or aspiration pneumonia. Of these 161 patients, enteral stents were placed as bridging therapy prior to surgery in 40 (24.8%). Among these, 35 (87.5%) of 40 underwent neo-adjuvant chemotherapy followed by curative surgery. Of the 35 patients, 3 failed to follow-up. One-year survival following curative surgery was 87.5%. Stent helped to reduce vomiting and improve nutrition, measured by the body mass index (p = 0.36) and serum albumin (p = 0.05), over a 4-week period following stent insertion.

Conclusion:

Pyloric stents are useful in relieving malignant gastric outlet obstruction, maintaining nutrition during neo-adjuvant treatment and improving survival without additional risk of postoperative complications. They have traditionally been used for palliation, but should also be considered as bridging therapy for obstructing resectable gastric tumours during neo-adjuvant treatment.

Management of gastric outlet obstruction: Focusing on endoscopic approach

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.

Is noncurative gastrectomy always a beneficial strategy for stage IV gastric cancer?

Purpose

The purpose of this study is to suggest a treatment strategy for stage IV gastric cancer by investigating the behavioral difference between initially and recurrent metastatic disease.

Methods

We reviewed the medical records of the patients who underwent chemotherapy alone for metastatic gastric cancer between January 2006 and September 2013. Patients were divided into those who underwent chemotherapy for metastatic disease since initial diagnosis (IM group) and for metastatic recurrence after curative surgery (RM group). Survival and causes of death were compared between the 2 groups, and significant prognostic factors were also investigated.

Results

A total of 170 patients were enrolled in this study. Of these patients, 104 were included in the IM group and 66 in the RM group. Overall survival of the IM group did not differ from that of RM (P = 0.569). In the comparison of the causes of death, the IM group had a greater tendency to die from bleeding (P = 0.054) and pneumonia (P = 0.055). In multivariate analysis, bone metastasis (P < 0.001; HR = 2.847), carcinoma peritonei (P = 0.047; HR = 1.766), and the frequency of chemotherapy (P < 0.001; HR = 0.777) were significantly associated with overall survival of IM group.

Conclusion

Disease-burden mainly contributes to the prognosis of metastatic gastric cancer, although noncurative gastrectomy may be helpful in reducing the mortality of initially metastatic disease. Therefore, disease-burden should be also prioritized in determining the treatment strategies for stage IV gastric cancer.

Factors associated with clinical failure of self-expandable metal stent for malignant gastroduodenal obstruction

OBJECTIVE

Endoscopic self-expandable metal stent (SEMS) placement has emerged as an effective palliative treatment for inoperable malignant gastric outlet obstruction (GOO). In spite of successful stent placement, some patients complain of ongoing dysphagia and vomiting. Most reported data on SEMS to date are about technical success of different types of stents and low complication rates. The aim of this study was to evaluate the associated factors of clinical failure after endoscopic SEMS placement for inoperable malignant GOO.

METHODS

A total 122 patients who underwent successful endoscopic SEMS placement for malignant GOO in an academic referral center were included in the analyses. We retrospectively evaluated variables associated with clinical outcomes after successful SEMS placement.

RESULTS

The clinical success rate was 81.1%. The common causes of GOO were pancreatic (39%) and gastric cancers (32%). The mean length of the stents (± standard deviation) was 10.06 ± 2.42 cm. Multivariate analysis revealed that gallbladder cancer (p = 0.016, OR 6.486, 95% CI, 1.509-59.655), poor performance status (ECOG ≥ 3) (p = 0.001, OR 10.200, 95% CI, 2.435-42.721), the presence of carcinomatosis peritonei (p < 0.001, OR 35.714, 95% CI, 5.556-250.000) and the failure of endoscope passage (p = 0.039, OR 6.945, 95% CI, 1.101-43.818).

CONCLUSION

Our results suggest that gallbladder cancer, poor performance status (ECOG ≥ 3) and the presence of carcinomatosis peritonei related with clinical failure of palliative SEMS placement.

Outcomes of endoscopically inserted self-expandable metal stents in malignancy according to the type of stent and the site of obstruction

BACKGROUND/AIMS

Self-expandable metal stents (SEMSs) can be used for the palliation of malignant obstruction in the upper gastrointestinal tract. This study assessed the feasibility and efficacy of endoscopically inserted SEMSs for the palliation of malignant obstruction in the stomach and duodenum.

METHODS

Between January 2011 and April 2014, 220 patients with gastric or duodenal obstruction due to malignancy underwent endoscopic SEMS insertion at Asan Medical Center. The associations of technical/clinical outcomes and complications with the type of stent and site of obstruction were analyzed.

RESULTS

The 220 patients included 125 men (56.8 %) and 95 women (43.2 %); median patient age was 63 years. Fully covered, partially covered, and uncovered SEMSs were inserted into 16, 77, and 120 patients, respectively. Obstructions were located in the gastric outlet, including the duodenal bulb, in 106 patients, and in the duodenal second and third portions in 114 patients. Technical success was achieved in 213 of 220 patients (96.8 %) and clinical success in 184 of 213 (86.4 %). Clinical success rates were similar to the type of stent, but were significantly greater for gastric outlet (95/104, 91.3 %) than for duodenal (89/109, 81.7 %) obstructions (p = 0.039). Stent migration was observed in 20 patients (9.1 %) and stent obstruction in 51 (23.2 %). Rates of stent migration were significantly higher for fully covered (6/16, 37.5 %) than for partially covered (7/77, 9.1 %) and uncovered (7/120, 5.8 %) SEMSs (p < 0.001) and were significantly higher for gastric outlet (16/104, 15.4 %) than for duodenal (4/109, 1.2 %) obstructions (p = 0.003). Rates of stent obstruction were similar for fully covered (2/16, 12.5 %), partially covered (17/77, 22.1 %), and uncovered (32/120, 26.7 %) SEMSs (p = 0.409) and in patients with gastric outlet (26/104, 25.0 %) and duodenal (25/109, 22.9 %) obstruction (p = 0.724).

CONCLUSIONS

SEMS selection for malignant obstruction of the upper gastrointestinal tract depends on the site of obstruction.

Etiology and non-surgical treatment of pyloric obstruction

Pyloric stenosis is a common type of upper gastrointestinal obstruction, which is a result of progression of many diseases. This paper will review the common causes of pyloric stenosis and its non-surgical treatments, mainly endoscopic treatment, in recent years. With the development of endoscopic technology, endoscopic treatment will gradually replace surgical treatment for treatment of pyloric obstruction.