Carcinomatosis is not a contraindication to enteral stenting in selected patients with malignant gastric outlet obstruction

doi:10.1016/j.gie.2011.01.042

Gastrointestinal Endoscopy

Volume 73, Issue 6, June 2011, Pages 1135-1140

https://doi.org/10.1016/j.gie.2011.01.042 Get rights and content

Background

Endoscopically inserted self-expandable metal stents (SEMSs) are used to palliate malignant gastric outlet obstruction (GOO). Peritoneal disease is considered a relative contraindication to SEMS placement given the risk of multifocal obstruction.

Objective

To evaluate the success of SEMSs placed in patients with GOO with carcinomatosis.

Design

Retrospective review of patients who underwent SEMS placement for malignant GOO.

Setting

Large, urban cancer center.

Patients

A total of 215 patients who were scheduled for SEMS placement for GOO.

Interventions

SEMS placement.

Main Outcome Measurements

Technical success, clinical success, early and late SEMS failure, and complications.

Results

Technical success was achieved in 192 of 201 patients (95.5%). Of the 9 patients who did not achieve technical success, 6 had carcinomatosis. Among the 116 patients (60%) with carcinomatosis, clinical success was achieved 94 of them (81%). Of these 94 patients, 17 (18%) required reinterventions: 4 for early SEMS failure and 13 for late SEMS failure. Among the 76 patients (40%) without carcinomatosis, clinical success was achieved in 64 of them (84%). Of these 64 patients, 17 (27%) required reinterventions: 4 for early SEMS failure and 13 for late SEMS failure. Complication rates were similar for both groups.

Limitations

This was a retrospective review with experienced clinicians selecting patients whom they thought would benefit from SEMS placement.

Conclusions

This is the first study to evaluate the effect of carcinomatosis on the technical and clinical success of SEMSs in the palliation of malignant GOO. We found clinical outcomes comparable to those without peritoneal disease. Carcinomatosis should not be considered a contraindication to SEMS placement in selected patients with malignant GOO.

Section snippets

Background

This is the first study to evaluate the effect of carcinomatosis on the technical and clinical success of SEMSs in the palliation of malignant GOO.

Methods

We performed a retrospective review of all patients at Memorial Sloan-Kettering Cancer Center (MSKCC) who underwent upper endoscopy with SEMS placement for malignant GOO between January 2001 and July 2009. Patients were identified by searching the MSKCC database for patients scheduled for procedures with CPT codes for upper GI endoscopy with transendoscopic stent placement and small-intestine enteroscopy with stent placement. Patients with esophageal obstruction were excluded.

By using the

Results

We identified 215 patients who were scheduled for SEMS placement for palliation of malignant GOO (Fig. 1). At the time of endoscopy, 201 patients (93.5%) were thought to be amenable to SEMS insertion. Of these, 192 patients (89%) (mean age, 64 years; 49% male) underwent successful SEMS placement. Patient demographics are shown in Table 1. The etiology of the obstruction was malignant obstruction from primary tumor in 94% of the patients and from extrinsic compression in 6% of the patients.

Discussion

Malignant GOO is often seen as a late complication of many GI and other metastatic cancers. Symptoms include nausea, vomiting, bloating, abdominal pain, and early satiety, which can lead to malnutrition and weight loss and can greatly reduce quality of life.

Treatment of malignant GOO remains a challenging task. Traditionally, patients with adequate performance status underwent surgical bypass for palliation with variable results, poor wound healing, and frequent postoperative complications.

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Cited by (52)

Duodenal stenting followed by systemic chemotherapy for patients with pancreatic cancer and gastric outlet obstruction
2016, Pancreatology
Citation Excerpt :
Third, they did not study chemotherapy following duodenal stent placement as a factor in analyzing predictive factors for clinical effectiveness of duodenal stent. Robin B. M. et al. also reported carcinomatosis was not contraindication to enteral stenting [43], and a multicenter study with a large cohort would provide a more accurate evaluation of the prognostic and predictive markers for advanced pancreatic cancer after duodenal stent placement. This study has some limitations.
Endoscopic duodenal stenting has recently been proposed as a substitute for surgical gastrojejunostomy for the treatment of gastric outlet obstruction. We aimed to evaluate the efficacy and safety of duodenal stenting followed by systemic chemotherapy for patients with advanced pancreatic cancer with gastric outlet obstruction.
This was a single-center, retrospective cohort study, conducted at an academic medical center, of 71 patients with advanced pancreatic cancer and gastric outlet obstruction (mean age: 67.6 years; range: 31–92 years) who underwent duodenal stenting with or without subsequent chemotherapy. Overall survival, duration of oral intake of foods, the rate of introduction of chemotherapy, progression-free survival, and adverse events were evaluated.
Stent placement was technically successful in 69 (97%) patients. Thirty-six (51%) patients were treated with chemotherapy: 17 with gemcitabine alone, 15 with S-1 alone, 3 with FOLFIRINOX, and 1 with paclitaxel. Median progression-free survival and overall survival after chemotherapy were 2.6 months (95% confidence interval: 1.3–3.9 months) and 4.7 months (95% confidence interval: 2.6–6.8 months), respectively. Cases of grade 3 anemia were frequently observed during chemotherapies following duodenal stenting (32%). Tumor stage, performance status, neutrophil-to-lymphocyte ratio, and introduction of chemotherapy were independent prognostic factors for survival (hazard ratios of 3.73, 2.21, 2.69, and 1.85 with p-values of <0.001, 0.010, <0.001, and 0.045, respectively).
The findings of this study suggest that endoscopic duodenal stenting is an advantageous treatment in advanced pancreatic cancer patients with gastric outlet obstruction regarding its safety and smooth conduction of subsequent chemotherapies.
Factors predicting through-the-scope gastroduodenal stenting outcomes in patients with gastric outlet obstruction: a large multicenter retrospective study in West Japan
2016, Gastrointestinal Endoscopy
Endoscopic gastroduodenal stenting for malignant gastric outlet obstruction recently has become more effective, but the factors that predict gastroduodenal stenting outcomes are poorly defined. This multicenter retrospective cohort study evaluated the clinical outcomes of gastroduodenal stenting in malignant gastroduodenal obstruction and identified factors predicting clinical ineffectiveness, stent dysfunction, and adverse events.
All consecutive patients with malignant gastroduodenal obstruction who underwent through-the-scope gastroduodenal stenting from 2009 to 2014 at 4 tertiary-care medical centers were identified. Clinically ineffective stenting was defined as symptom recurrence and a gastric outlet obstruction scoring system (GOOSS) score <2.
Of the 278 patients (mean age ± standard deviation [SD] 71.7 ± 11.4 years), 121 (43.5%) and 87 (31.3%) had pancreatic and gastric cancer, respectively. Technical success was achieved in 277 patients (99.6%). GOOSS scores rose from 0.5 ± 0.6 to 2.6 ± 0.8. Stenting was ineffective in 32 patients (12.6%). Stent dysfunction that caused symptom recurrence during follow-up developed in 46 patients (16.6%). Adverse events occurred in 49 patients (17.7%). Three or more stenosis sites (odds ratio [OR] = 6.11; P < .01) and Karnofsky performance scores ≤50 (OR = 6.63; P < .01) predicted clinical ineffectiveness. Karnofsky performance scores ≤50 predicted stent dysfunction (hazard ratio [HR] = 3.63; P < .01). Bile duct stenosis (HR = 9.55; P = .02) and liver metastasis (HR = 9.42; P < .01) predicted stent overgrowth. Covered stent predicted stent migration (HR = 12.63; P < .01). Deployment of 2 stents predicted perforation (HR = 854.88; P < .01).
Through-the-scope gastroduodenal stenting tended to be ineffective in patients with poor performance status and long stenosis sites. Stent dysfunction occurred more frequently in patients with poorer performance status. Deployment of 2 stents was a risk factor for perforation. Identification of these risk variables may help yield better gastroduodenal stenting outcomes.
Survival and clinical outcome after endoscopic duodenal stent placement for malignant gastric outlet obstruction: Comparison of pancreatic cancer and nonpancreatic cancer
2015, Gastrointestinal Endoscopy
Data on endoscopic stenting of malignant gastric outlet obstruction (GOO) are based on studies predominantly involving patients with pancreatic adenocarcinoma.
To compare survival and clinical outcome after stent placement for GOO due to pancreatic cancer compared with nonpancreatic cancer.
Retrospective study.
Single tertiary hospital.
A total of 292 patients with malignant GOO.
Stent placement.
Post–stent placement survival and clinical outcome.
In 196 patients with pancreatic cancer and 96 with nonpancreatic cancer, median post–stent placement survival was similar (2.7 months in pancreatic cancer vs 2.4 months in nonpancreatic cancer). Overall survival was shorter in patients with pancreatic cancer (13.7 vs 17.1 months; P = .004). Clinical success rates at 2 months (71% vs 91%) and reintervention rates (30% vs 23%) were comparable. Post–stent placement chemotherapy and the absence of distant metastasis were associated with better post–stent placement survival in both groups (pancreatic cancer: chemotherapy vs no chemotherapy, 5.4 vs 1.5 months, P < .0001; metastasis vs no metastasis, 1.8 vs 4.6, P = .005; nonpancreatic cancer: chemotherapy vs no chemotherapy, 9.2 vs 1.8, P = .001; metastasis vs no metastasis, 2.1 vs 6.1, P = .009).
Retrospective study.
In this large series of patients undergoing stent placement for malignant GOO in North America, we observed no difference in post–stent placement survival despite better overall survival in patients with nonpancreatic cancer. GOO is a marker for poor survival in malignancy, regardless of the type. Chemotherapy and the absence of distant metastasis were associated with better post–stent placement survival in both groups.
Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction
2020, Revista de Gastroenterologia de Mexico
Los stents metálicos autoexpandibles (SEMS) son el tratamiento ideal de la obstrucción de salida gástrica maligna (OSGM) en pacientes con expectativa de vida corta, sin embargo, su disfunción es frecuente. El objetivo principal fue conocer los factores predictores de disfunción del SEMS en OSGM y los objetivos secundarios conocer el éxito técnico, éxito clínico y el impacto nutricional posterior al SEMS.
Estudio longitudinal, retrospectivo en el departamento de endoscopia gastrointestinal del Instituto Nacional de Cancerología de la Ciudad de México. Se incluyeron pacientes con diagnóstico de OSGM con colocación de SEMS de enero de 2015 a mayo de 2018. Utilizamos el sistema de puntuación de obstrucción de salida gástrica (GOOSS) para establecer éxito clínico y disfunción del SEMS.
Incluimos 43 pacientes, el éxito técnico fue 97.7% (n = 42) y el éxito clínico 88.3% (n = 38). La disfunción del SEMS se presentó en el 30.2% (n = 13), de estos pacientes en el 53.8% (n = 7) la disfunción ocurrió en < 6 meses posterior a su colocación. En el análisis univariado el subtipo histológico adenocarcinoma gástrico difuso (p = 0.02) y uso de SEMS no cubiertos (p = 0.02) fueron las variables asociadas a disfunción. La albúmina sérica y el índice de masa corporal (IMC) no aumentaron posterior al SEMS. El seguimiento medio fue 5.8 meses (1-24 meses).
Los SEMS tienen una adecuada eficacia técnica y clínica en el tratamiento de la OSGM. La disfunción del SEMS es frecuente y el tipo histológico cáncer gástrico difuso y el uso de SEMS no cubiertos parecen ser predictores de disfunción.
Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement.
A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction.
The study included 43 patients, technical success was 97.7% (n = 42), and clinical success was 88.3% (n = 38). SEMS dysfunction presented in 30.2% (n = 13) of the patients, occurring in < 6 months after placement in 53.8% (n = 7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p = 0.02) and the use of uncovered SEMS (p = 0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months).
SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors.
Efficacy and safety of self-expandable metal stent placement for treatment of primary and metastatic gastric outlet obstruction
2023, Irish Journal of Medical Science
Optimizing the Continuum of Care in Gastric Cancer
2023, OncoTargets and Therapy

View all citing articles on Scopus

: DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: Dr. Gerdes: consultant to Olympus and Genentech; Dr. DiMaio: consultant to Boston Scientific; Dr. Schattner, consultant to Boston Scientific. The other authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr. Mendelsohn at [email protected].

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Original articleClinical endoscopyCarcinomatosis is not a contraindication to enteral stenting in selected patients with malignant gastric outlet obstruction

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Background

Methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Surg

Matched study of three methods for palliation of malignant pyloroduodenal obstruction

Br J Surg

Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation

World J Surg

Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy

J Gastroenterol

Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation

Surg Endosc

Palliative management of malignant antro-pyloric stricturesGastroenterostomy vs. endoscopic stenting. A randomized prospective trial

Anticancer Res

Prospective randomized trial of laparoscopic gastrojejunostomy vs. duodenal stenting for malignant gastric outflow obstruction

Surg Endosc

Gastrojejunostomy versus stent placement in patients with malignant gastric outlet obstruction: a comparison in 95 patients

J Surg Oncol

Original article
Clinical endoscopy
Carcinomatosis is not a contraindication to enteral stenting in selected patients with malignant gastric outlet obstruction