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Palliative management of malignant gastric outlet obstruction

with endoscopically inserted self-expanding metal stentsJ. Garca-Cano, N. Snchez-Manjavacas, M. Viuelas Chicano, C. Jimeno Aylln, R. Martnez Fernndez,C. J. Gmez Ruiz, J. I. Prez Garca, E. Redondo Cerezo, M. J. Morillas Ario, M. G. Prez Vigaraand A. Prez Sola

Gastroenterology Department. Virgen de la Luz Hospital. Cuenca, Spain

1130-0108/2008/100/6/320-326REVISTA ESPAOLA DE ENFERMEDADES DIGESTIVASCopyright 2008 ARN EDICIONES, S. L.

REV ESP ENFERM DIG (Madrid)Vol. 100. N. 6, pp. 320-326, 2008

Received: 02-01-08.Accepted: 26-02-08.

Correspondence: Jess Garca-Cano. Seccin de Aparato Digestivo. Hospital Virgen de la Luz. Hermandad de Donantes de Sangre, 1. 06002 Cuenca, Spain.e-mail: [email protected]

ORIGINAL PAPERS

ABSTRACT

Aim and background: the insertion of self-expanding metalstents to palliate malignant gastric outlet obstruction is a minimal-ly invasive procedure that is being increasingly used. We discussexperience with this technique in a level-II hospital in the SpanishNational Health System.

Patients and methods: a retrospective five-year study(2003-2007) was conducted in 23 patients who underwent 27procedures aimed at resolving malignant gastric outlet obstruction(mean, 0.45 procedures per month) using endoscopically insertednoncovered stents (Wallstent and Wallflex).

Results: insertion was technically feasible in all 27 (100%) at-tempts, with satisfactory clinical results in 25 cases (92.5%). En-doscopy alone was used 10 times (37%), and both endoscopy and

fluoroscopy on 17 (63%) occasions. After stent insertion, one pa-tient was intervened for treatment, and a patient with an unsuc-cessful prosthesis received a palliative surgical bypass. Four stentsbecame obstructed by tumoral ingrowth, and patency was reestab-lished by inserting a new stent. Obstructive jaundice caused bystents covering the papilla of Vater occurred in three cases. Therewere no other complications or mortality due to the procedure.Mean survival was 104 days (range 28-400, SD 94).

Conclusions: in our experience endoscopic insertion of self-expanding metal stents appears to be a safe and efficient palliativemethod for malignant gastric outlet obstruction, and can be per-formed successfully in a center with our characteristics.

Key words: Enteral stent. Gastrojejunostomy. Malignant gastricoutlet obstruction. Palliative treatment. Pancreatic cancer.

RESUMEN

Antecedentes y objetivo: la insercin de prtesis metlicas au-toexpandibles para paliar la obstruccin tumoral del vaciamiento gs-trico es un procedimiento mnimamente invasivo, que cada vez seutiliza con ms frecuencia. Presentamos la experiencia de esta tcni-ca en un hospital de nivel II del Sistema Nacional de Salud.

Pacientes y mtodos: estudio retrospectivo de un periodo decinco aos (2003-2007), en los que se trat de resolver la obstruc-cin tumoral del vaciamiento gstrico en 27 ocasiones a 23 pacien-tes (media de 0,45 procedimientos por mes), mediante la insercinendoscpica de prtesis no recubiertas (Wallstent y Wallflex).

Resultados: la insercin fue tcnicamente posible en el 100%de los 27 intentos. Se obtuvo un buen resultado clnico en 25 oca-siones (92,5%). Se utiliz slo endoscopia 10 (37%) veces y en las

otras 17 (63%) tambin fluoroscopia. Tras la insercin de la pr-tesis se intervino a un paciente con intencin curativa y a otro, enel que la prtesis no funcion, para realizar una derivacin paliati-va. Cuatro prtesis se obstruyeron por crecimiento tumoral, reca-nalizndose mediante la insercin de nuevas prtesis. En tres oca-siones se produjo ictericia obstructiva en prtesis que cubran lapapila de Vater. No hubo otras complicaciones. Tampoco morta-lidad derivada del procedimiento. La media de supervivencia fuede 104 das (rango 28-400, DE 94).

Conclusiones: en nuestra experiencia, la insercin endosc-pica de prtesis metlicas autoexpandibles parece un mtodo se-guro y eficaz en el tratamiento paliativo de la obstruccin tumoraldel vaciamiento gstrico y puede llevarse a cabo con xito en uncentro de nuestras caractersticas.

Palabras clave: Prtesis enterales. Gastroyeyunostoma. Obs-truccin tumoral del vaciamiento gstrico. Tratamiento paliativo.Cncer de pncreas.

Garca-Cano J, Snchez-Manjavacas N, Viuelas Chicano M, Jimeno Aylln C, Martnez Fernndez R, Gmez Ruiz CJ, Prez GarcaJI, Redondo Cerezo E, Morillas Ario MJ, Prez Vigara MG, Prez Sola A. Palliative management of malignant gastric outlet obs-truction with endoscopically inserted self-expanding metal stents. Rev Esp Enferm Dig 2008; 100: 320-326.


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INDRODUCTION

Obstruction is a pathological phenomenon common toall tubular organs of the body. Pathophysiological conse-quences vary in relation to the anatomical location of the

obstruction. Technological advances allow the use of differ-ent materials to build self-expanding metal prostheses orstents (SEMS). SEMS are meshed cylindrical tubes of vari-ous lengths and widths that can be inserted folded. Thisproperty allows their passage beyond severe strictures, usu-ally without the need for previous dilation. Once inside theobstructed area, SEMS are opened by a release mechanismthat provides sufficient diameter to re-canalize the stenosedarea. SEMS can be modified according to anatomic loca-tions, and are used to achieve patency in the obstruction oftubular structures such as the coronary arteries, trachea, andmost of the digestive tract and bile duct (1).

SEMS are being used to palliate malignant gastric out-

let obstruction (MGOO) since the nineteen-nineties (2-8).Due to technological improvement, stent models can nowbe specifically designed to re-canalize tumoral obstruc-tions of the gastric outlet (antrum, pylorus, and duode-num). The term enteral SEMSincludes prostheses for thetreatment of MGOO and malignant colorectal obstruc-tions (MCRO). Usually, the design in both cases is simi-lar, although the prosthesis has an end wider than the restof the stent, which is located orally in relation to the ob-struction to help prevent SEMS migration. Since stentsfor MGOO are inserted by upper endoscopic techniques,and colorectal ones via the anus, this wider portion is al-ready located in the folded prosthesis in a different end.

SEMS for MGOO as opposed to stents for MCRO (9)are usually inserted with a palliative purpose (10). Theconcept of using SEMS as a bridge to surgery is not yetclearly established for the stents for MGOO. Unlike acutecolonic obstruction, which needs urgent treatment, ob-struction of the gastric outlet can be managed with nihilper os (NPO), with sometimes aspiration by a nasogastrictube if surgery is not delayed too much. This study de-scribes the palliative management of MGOO usingSEMS insertion in our center.

PATIENTS AND METHODS

Patients with MGOO and treated by SEMS insertionwere analysed retrospectively over a five-year period(2003-2007). MGOO was diagnosed by gastroscopy inpatients having typical clinical symptoms (vomiting andfood intolerance). Radiological barium contrast studieswere also performed occasionally. According to theSurgery and Oncology departments, when a surgical pro-cedure was not possible, MGOO was palliated by the in-sertion of SEMS. The gastric cavity was cleaned of re-tained food as much as possible to facilitate theendoscopic procedure and to avoid aspiration. The patientwas on NPO and occasionally had a nasogastric tube.

The most critical step for SEMS insertion is the pas-sage of a guidewire through the tumoral stricture to placeit beyond the tumor, in healthy tissue. The undeployedstent is then glided over this guidewire and may then beopened inside the tumor thus solving the obstruction. To

ensure that the guidewire was properly positioned, twotechniques were used:1. Fluoroscopy was used if a fluoroscopic device was

available (Fig. 1). The endoscope with a therapeuticworking channel (usually a colonoscope, because a thera-peutic gastroscope was not available) was located in theproximal part of the tumor. A guidewire of 0.035 inches(0.875 mm) in diameter fitted with an atraumatic hy-drophilic tip was passed through the working channel tomake it through the whole stenosed segment. This pas-sage was confirmed by fluoroscopy. A biliary catheterused for endoscopic retrograde cholangiopancreatogra-phy (ERCP) was introduced over the guidewire and the

obstruction was delineated by contrast injection. Thecatheter was then withdrawn and the prosthesis was al-ways inserted over the guidewire. Once the SEMS wasinside the stricture, it was gradually opened up to place itcorrectly with proximal and distal ends located in healthyareas. The proximal end of the stent was always locatedin the prepyloric distal antrum, which is called thetranspyloric position (Fig. 2), except when the obstruc-tion was in the more distal duodenum (Fig. 3). Both typesof stents were inserted, stainless steel Wallstent and niti-nol Wallflex (both from Boston Scientific). They hadlengths of 6 or 9 cm, and minimal diameters of 22-25 mmonce fully open.

2. The second technique was the use of anultrathin en-doscope (UTE) able to go beyond strictures. The difficultythat many gastroenterologists face is having appropriatefluoroscopy devices to help in performing endoscopic pro-cedures safely, which has led to develop only endoscopicmethods that can provide the reassurance fluoroscopybrings. Several models of very small caliber endoscopesare available that can go beyond many strictures in the di-gestive tract. According to our previously described tech-nique (11), once the tumor is traversed by a 6 mm diameterendoscope (Pentax EG-1870 K) a guidewire is left inplace through the UTE working channel. Subsequently theUTE is removed, leaving the guidewire in place beyond

the stenosis. This guidewire is then inserted in a retrogrademanner in the therapeutic endoscope working channel, anda SEMS is placed over it.

The SEMS that were employed (Wallstent and Wall-flex) have no cover over the mesh, and this allows thetumor to penetrate the metal cells, thus decreasing migra-tion. However, a tumor can grow into the stent and ob-struct it over time.

After SEMS insertion, patients were usually kept inhospital for 24 hours, and their tolerance to liquids wastried the next day. Clinical improvement in patients was as-sessed, and possible complications were evaluated. Pa-tients received instructions to start a normal diet gradually.

Vol. 100. N. 6, 2008 PALLIATIVE MANAGEMENT OF MALIGNANT GASTRIC OUTLET OBSTRUCTION 321WITH ENDOSCOPICALLY INSERTED SELF-EXPANDING METAL STENTS

REV ESP ENFERM DIG 2008; 100 (6): 320-326


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The resolution of gastric outlet obstruction syndromeafter stent insertion without significant complications suchas need for surgery was considered a clinical success.

RESULTS

Twenty-seven enteral SEMS insertions were attemptedin 23 patients during a study period of 60 months (0.45

procedures per month). There were 15 men (65%) and 8(35%) women with a mean age of 75 years (range 46-19,SD 12). Patient characteristics are depicted in table I.Tumor obstruction was due to primary gastric adenocar-cinomas in 16 (69.5%) patients. The rest of cancers cor-responded to three duodenal neoplasms, two pancreaticneoplasms, and two common bile duct cholangiocarcino-mas that had extended into the duodenum. Obstructionswere antropyloric (14 patients or 61%), duodenal (6 or

23%), and pyloroduodenal (3 or 13%) (Fig. 4).Endoscopy alone was used in 10 (37%) procedures ac-cording to the UTE method. Endoscopy with fluoroscop-ic monitoring was used in the other 17 (53%). SEMSwere inserted successfully in the obstructed zone in all 27(100%) attempts. In general, conscious sedation with mi-dazolam was employed but occasionally dolantine andsometimes buscapine were added to relax gastroduodenalmotility.

Two overlapped SEMS were needed in three patientsto completely open the stricture in its entire length. Nosignificant complications (hemorrhage or perforation)were observed during the first few days after the proce-

dure, and patients did not need any special analgesia.Complete clinical improvement of the MGOO syndromewas achieved on 25 (92.5%) occasions. However, in onepatient improvement was partial and in another a pallia-tive gastrojejunostomy had to be performed due to totallack of improvement.

SEMS were inserted as a definitive palliative treat-ment in all patients. Nevertheless, a patient with a duode-nal tumor was re-evaluated after stent insertion in anotherhospital and underwent surgery several months later.Meanwhile he was able to have a normal diet. Mean sur-vival was of 104 days (range 28-400, SD 94) excludingsurgically intervened patients. In three patients the stent

322 J. GARCA-CANO ET AL. REV ESP ENFERM DIG (Madrid)


Fig. 1. Insertion technique of a self-expanding metal stent to palliate a duodenal obstruction secondary to pancreatic cancer. A. Endoscopic view of thestricture in the bulbar apex crossed by a guide wire. B. Radiological view. The guidewire is located at the angle of Treitz is passing the tumor. C. Toopen the whole stricture, two overlapped Wallstent prostheses were used from the pylorus up to the third portion of the duodenum. Previously, a Zil-ver stent had been placed in the common bile duct to palliate the patients obstructive jaundice.

Fig. 2. A Wallflex stent immediately after release. The yellow rod inwhich it was mounted and folded may be seen. The end is in the gas-tric antrum outside the pylorus. This is called the transpyloric positionfor stents located for duodenal strictures. This kind of stent has bluntends to avoid damaging the mucosa.


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was re-obstructed by tumor ingrowth, and they weretreated with repeat SEMS insertion. A third stent wasneeded for a 91-year-old patient (Table I) who survivedfor 400 days (Fig. 5).

Three patients with stents covering the papilla of Vaterarea showed jaundice several weeks after the insertion.No therapeutic procedure was performed because of theiradvanced condition and according to the wishes of pa-tients and their families.

DISCUSSION

Patients with MGOO show a significant decline intheir quality of life. Initially, the symptoms of MGOOsyndrome, such as nausea, vomiting, dehydration andweight loss, can be mistakenly attributed to advancedneoplastic disease and to various oncology treatments(chemotherapy, opiates, etc.). Due to stomach distensionthe diagnosis of MGOO is sometimes delayed. Tradition-ally the only choices for MGOO patients were surgicalpalliative techniques. Derivative surgery, usually a gas-trojejunostomy, does not offer satisfactory results, andhas high morbidity and mortality rates (12). Moreover,these patients usually have a very poor clinical condition

that is contraindicative for a surgical procedure.The therapeutic management of MGOO has progres-

sively changed since the 1990s, when SEMS were begin-ning to be used to palliate neoplastic gastric outlet ob-struction. A review on the use of stents to palliate MGOOthat included 606 patients showed that stents were insert-ed correctly in 97% of cases while clinical improvementwith the possibility of oral intake was achieved in 89% ofcases (13).

Nowadays, insertion of SEMS is the palliative treatmentof choice for MGOO. When compared to surgery, stentsare at least as efficient as gastrojejunostomy, although thecost of the procedure is lower. Patients have to stay in hos-



Fig. 3. A. A patient with a tumoral stricture in the inferior duodenal angle. The barium contrast also reveals the common bile duct. B. A Wallstent im-mediately after placement between the second and third duodenal portions.

Fig. 4. Location and causes for our 23 patients with tumoral stricturesof the gastric outlet.


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pital for a shorter period and after the endoscopic proce-dure they can start oral diets earlier after SEMS insertionthan after surgery (10,14-17).

In Spain, a multicenter study performed at 13 centersshowed that the annual mean number of stent insertionsfor MGOO treatment was 0.45 stents per month (18). Ourcenters stent insertion rate is similar. It is important tokeep in mind that our hospital is a level-II site in the Na-tional Health System (and may be considered a commu-nity hospital), whereas some hospitals that participated inthe study are tertiary referral centers. If surgical and on-

cology teams understand the advantages of this minimal-ly invasive procedure to solve gastric outlet obstructionby means of stents, the use of this technique is likely toproliferate even further.

Endoscopic SEMS insertion, at either the gastroduode-nal, colonic (9) or esophageal (19) level, in the context ofthe difficulties that every interventional technique im-plies, seems to us a simpler procedure than ERCP (20).SEMS insertion has a shorter learning curve. However, toobtain acceptable success rates (successful rate insertionsaround 100%) special dedication is needed. Taking intoconsideration that, in our institution, the mean rate ofgastroduodenal stent insertions is slightly less than one



Table I. Characteristics of patients with tumoral obstruction of the gastric outlet palliated by the endoscopic insertion of self-expanding metal stents

Patient Gender/age (1) Location of the Type of Stent type/ Clinical stricture (2) tumor lenght (cm) success

1 M/78 Antropyloric Gastric Wallstent 6 cm Yes

2 M/55 Pyloroduodenal Duodenal Wallstent 9 cm Yes3 M/67 Duodenum Cholangio Wallstent 9 cm Yes4 M/87 Antropyloric Gastric Wallstent 9 cm Yes5 F/91 Antropyloric Gastric Wallstent 9 cm Yes6 M/77 Duodenum Pancreas Wallstent 9 cm Yes7 F/85 Antropyloric Gastric Wallstent 6 cm Yes8 M/77 Duodenum Duodenal Wallstent 9 cm Yes9 F/84 Pyloroduodenal Gastric Wallstent 9 cm Yes

10 F/90 Antropyloric Gastric Wallstent 9 cm Yes11 M/46 Antropyloric Gastric Wallstent 9 cm Yes12 M/79 Antropyloric Gastric Wallstent 9 cm Yes13 M/78 Antropyloric Gastric Wallstent 9 cm Yes14 M/91 Duodenum Duodenal Wallstent 6 cm Yes15 F/87 Pyloroduodenal Gastric Wallflex 9 cm Yes16 F/62 Antropyloric Gastric Wallflex 6 cm Yes

17 M/80 Antropyloric Gastric Wallflex 6 cm Yes18 M/86 Antropyloric Gastric Wallflex 9 cm Partial19 M/78 Duodenum Pancreas 2 Wallstent 9 cm Yes20 M/72 Antropyloric Gastric 2 Wallflex 9 cm No21 M/62 Antropyloric Gastric 2 Wallflex 6 cm Yes22 M/78 Antropyloric Gastric Wallflex 6 cm Yes23 F/53 Duodenum Cholangio Wallflex 6 cm Yes

In four cases stents became obstructed and new ones were inserted to solve the obstruction, for a total number of procedures of 27.(1) M = male, F = female.(2) Gastric and duodenal tumors were carcinomas originating in these organs. Cholangio (cholangiocarcinomas) corresponded to duodenal extension of tumors originatedin the common bile duct.

Fig. 5. When a stent becomes obstructed the easier way to re-canalize isby inserting another stent within the initial one. This image correspondsto the patient in figure 2, who lived more than a year after the insertionof the first stent. It then became obstructed and was re-canalized.


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every two months, the performance of this techniqueshould be limited to few physicians. In addition, the ex-perience with instruments used for ERCP such ascatheters and guidewires is very useful for a successfulinsertion of digestive stents (21). Also, in contrast to

acute colonic obstruction, a stent is never urgently need-ed for MGOO.In our opinion, the endoscopic insertion of stents

should always be performed with fluoroscopic monitor-ing. Nonetheless, gastroenterologists experience frequentdifficulties in using adequate radiological devices. Untilthis problem is eventually solved, UTEs may be an alter-native method (11). Also, it would be very useful thatevery center had a gastroscope with therapeutic channelfor insertion techniques and many other endoscopic pro-cedures (such as higher aspiration capacity in gastroin-testinal hemorrhage).

Serious complications of stent insertion are few, but if

a gastroduodenal perforation occurs during insertion, anurgent procedure will probably be needed under difficultconditions. Recently, the closure of a perforation due to agastroduodenal SEMS by means of another coveredSEMS has been reported (22). The obstruction of stentsby tumor growth into mesh cells can be easily solved en-doscopically by the insertion of new stents (Fig. 5). Oc-casionally, covered stents, which prevent or delay suchobstruction, can be used, but their tendency to migrate ishigher (23). In our study we used uncovered baredWallstents and Wallflex stents, and no migration wasrecorded.

Three of our patients developed obstructive jaundice

several weeks after the insertion. Bile flow obstructionthrough the papilla due to epithelial covering of the pros-thesis some time after its placement cannot be discardedas a cause. Insertion of a biliary transpapillary stentthrough the duodenal prosthesis is usually very difficultand frequently needs the use of transhepatic techniques(interventional radiology) or, nowadays, transhepatic ul-trasonographically-guided biliary drainage from the up-per body of the stomach. Our patients conditions wereclinically unstable and, therefore, other bile drainage in-terventions were not considered.

In conclusion, gastroduodenal SEMS insertion to treatMGOO was possible in 100% of cases. Complete clinical

improvement was achieved with 92.5% of insertions, andonly two patients showed no relief. One patient requiredsurgical gastrojejunoscopy while another patient had acomplete liquid diet and prokinetics administered. Noimmediate complications occurred after the procedures.

Radiologists can also place gastroduodenal SEMS(24). Although no comparative study between efficaciesafter endoscopic or radiological insertions has been con-ducted, according to radiological studies published theeffectiveness seems to be similar. The endoscopic inser-tion of gastroduodenal stents may be easier due to the sta-bility that an endoscope provides in passing guidewires,catheters, and prostheses themselves. Also, if no endo-

scopes with therapeutic channels in which stents may fitare available, endoscopes with a diagnostic caliber can beuseful to advance stents to the obstruction (25). This isalso useful for placing esophageal stents that cannot beintroduced in any endoscope working channels.

In view of the good results achieved by this and previ-ous studies, the insertion of self-expanding metal stentsmay generally be considered the treatment of choice formalignant gastric outlet obstruction. This technique canbe performed successfully in a center such as ours.

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