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Malignant obstruction of the stomach or duodenum presents a clinical challenge. Patients with such obstructions often are not surgical candidates because of underlying disease, and even those who do undergo surgical bypass have substantial morbidity and extended hospital stays.
Expandable metallic stents, which can be placed with endoscopic or radiographic guidance, are highly efficacious for alleviating gastric obstruction and lowering morbidity. However, stents can migrate or become occluded by compression or overgrowth of the tumor. To identify clinical factors that are associated with complications of expandable stents in patients with malignant gastric-outlet obstructions, investigators in Korea prospectively followed 213 patients with malignant gastric-outlet obstructions who were treated with expandable metal stents that were placed with fluoroscopic guidance.
The initial technical success rate for alleviating obstructions was 94%. Second attempts at stent placement using endoscopic assistance for wire placement increased the success rate to 98%. Mean and median survival times were 159 and 99 days, respectively. Mean and median stent patency times were 324 and 270 days, respectively. Complications occurred in 21% of patients, including 16% of patients with recurrent obstruction.
Eight variables (mainly demographic and lesion characteristics) were included in a Cox multivariate analysis to identify factors associated with recurrent obstruction or stent migration. Only receiving chemotherapy was a significant factor — it was associated with greater duration of stent patency but also with higher risk for stent migration. The authors concluded that enteral stent therapy is an effective treatment for unresectable malignant gastric-outlet obstruction.
Kim JH et al. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: Prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc 2007 Aug; 66:256.
Comment
These results are consistent with those of other studies on enteric stent therapy for malignant gastric-outlet obstruction. Although no control group was evaluated in this study, the high rate of technical success and the low rates of stent migration and obstruction support the clinical effectiveness of this approach. Both technical success and patency rates are somewhat better than those that have been reported previously, perhaps because multiple stents commonly were inserted at the time of initial therapy, and because double-layer stents (a partially coated outer wire sleeve to anchor the stent in the stricture and to reduce tumor ingrowth, plus a bare inner sheath) were used.