A pilot study of novel duodenal covered self-expandable metal stent fixation.

Migration of duodenal covered self-expandable metal stents (C-SEMSs) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction (mGOO). Because endoscopic SEMS placement is frequently selected in patients with poor performance status, we concurrently focused on the safety of the treatment. This pilot study included 15 consecutive patients with mGOO who underwent duodenal partially covered SEMS (PC-SEMS) placement with fixation using an over-the-scope-clip (OTSC). Technical feasibility, clinical success for oral intake estimated by the Gastric Outlet Obstruction Scoring System (GOOSS) score, and adverse events including stent migration were retrospectively assessed. All procedures were successful, and clinical success was achieved in 86.7% (13/15). Mean GOOSS scores were improved from 0.07 to 2.53 after the procedure (P < 0.001). Median survival time was 84 days, and all patients were followed up until death. Stent migration occurred in one case (6.7%) at day 17, which was successfully treated by removal of the migrated PC-SEMS using an enteroscope. For fixation using an OTSC, additional time required for the procedure was 8.9 ± 4.1 min and we did not observe OTSC-associated adverse events. Poor performance status was associated with clinical success (P = 0.03), but we could provide the treatment safely and reduce mGOO symptoms even in patients with poor performance status. In conclusion, duodenal PC-SEMS fixation using an OTSC is feasible for preventing stent migration in patients with mGOO including those with poor performance status.

Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer.

BACKGROUND: The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO. METHODS: The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS). RESULTS: The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS. CONCLUSION: In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.

Influence of peritoneal carcinomatosis on perioperative outcome in palliative gastric bypass for malignant gastric outlet obstruction - a retrospective cohort study.

BACKGROUND: Malignant gastric outlet obstruction (GOO) is commonly associated with the presence of peritoneal carcinomatosis (PC) and preferably treated by surgical gastrojejunostomy (GJJ) in patients with good performance. Here, we aim to investigate the role of PC as a risk factor for perioperative morbidity and mortality in patients with GOO undergoing GJJ. METHODS: Perioperative data of 72 patients with malignant GOO who underwent palliative GJJ at our institution between 2010 and 2019 were collected within an institutional database. To compare perioperative outcomes of patients with and without PC, extensive group analyses were carried out. RESULTS: A set of 39 (54.2%) patients was histologically diagnosed with concomitant PC while the remaining 33 (45.8%) patients showed no clinical signs of PC. In-house mortality due to surgical complications was significantly higher in patients with PC (9/39, 23.1%) than in patients without PC (2/33, 6.1%, p = .046). Considerable differences were observed in terms of surgical complications such as anastomotic leakage rates (2.8% vs. 0%, p = .187), delayed gastric emptying (33.3% vs. 15.2%, p = .076), paralytic ileus (23.1% vs. 9.1%, p = .113), and pneumonia (17.9% vs. 12.1%, p = .493) without reaching the level of statistical significance. CONCLUSIONS: PC is an important predictor of perioperative morbidity and mortality patients undergoing GJJ for malignant GOO.

Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction.

BACKGROUND: Malignant gastric outlet obstruction is the clinical and pathological consequence of cancerous disease causing a mechanical obstruction to gastric emptying. It usually occurs when malignancy is at an advanced stage; therefore, people have a limited life expectancy. It is of paramount importance to restore oral intake to improve quality of life for the person in a manner that has a minimal risk of complications and a short recovery period. OBJECTIVES: To assess the benefits and harms of endoscopic stent placement versus surgical palliation for people with symptomatic malignant gastric outlet obstruction. SEARCH METHODS: In May 2018 we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and Ovid CINAHL. We screened reference lists from included studies and review articles. SELECTION CRITERIA: We included randomised controlled trials comparing stent placement with surgical palliation for people with gastric outlet obstruction secondary to malignant disease. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes, mean difference (MD) or standardised mean difference (SMD) with 95% CI for continuous outcomes and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where meaningful. We assessed the quality of evidence using GRADE criteria. MAIN RESULTS: We identified three randomised controlled trials with 84 participants. Forty-one participants underwent surgical palliation and 43 participants underwent duodenal stent placement. There may have been little or no difference in the technical success of the procedure (RR 0.98, 95% CI 0.88 to 1.09; low-quality evidence), or whether the time to resumption of oral intake was quicker for participants who had undergone duodenal stent placement (MD -3.07 days, 95% CI -4.76 to -1.39; low-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved all-cause mortality and median survival postintervention.The time to recurrence of obstructive symptoms may have increased slightly following duodenal stenting (RR 5.08, 95% CI 0.96 to 26.74; moderate-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved serious and minor adverse events. The heterogeneity for adverse events was moderately high (serious adverse events: Chi² = 1.71; minor adverse events: Chi² = 3.08), reflecting the differences in definitions used and therefore, may have impacted the outcomes. The need for reintervention may have increased following duodenal stenting (RR 4.71, 95% CI 1.36 to 16.30; very low-quality evidence).The length of hospital stay may have been shorter (by approximately 4 to 10 days) following stenting (MD -6.70 days, 95% CI -9.41 to -3.98; moderate-quality evidence). AUTHORS' CONCLUSIONS: The use of duodenal stent placement in malignant gastric outlet obstruction has the benefits of a quicker resumption of oral intake and a reduced inpatient hospital stay; however, this is balanced by an increase in the recurrence of symptoms and the need for further intervention.It is impossible to draw further conclusions on these and the other measured outcomes, primarily due to the low number of eligible studies and small number of participants which resulted in low-quality evidence. It was not possible to analyse the impact on quality of life each intervention had for these participants.

Combined use of single-balloon enteroscope and colonoscope for self-expandable metal stent placement in patients with malignant small intestinal obstruction: a single-center comparative clinical observation.

Small intestinal obstruction is a common complication of primary gastrointestinal cancer or metastatic cancers. Patients with this condition are often poor candidates for surgical bypasses, and placement of self-expanding metal stent (SEMS) can be technically challenging. In this study, we examined the feasibility of combined application of single-balloon enteroscope (SBE) and colonoscope for SEMS placement in patients with malignant small intestinal obstruction. Thirty-four patients were enrolled in this study, among which 22 patients received SEMS placement by using SBE and colonoscope, while the other 12 patients received conservative medical treatment. The patients were followed up for one year. Stent placement was technically feasible in 95.5% (21/22). Clinical improvement was achieved in 86.4% (19/22). For the 19 clinical success cases, the average time of benefits from a gastric outlet obstruction scoring system (GOOSS) increase ≥1 was 111.9±89.5 days. For the 12 patients receiving conservative medical treatment, no significant improvement in GOOSS score was observed. Moreover, a significant increase of Short-Form-36 health survey score was observed in the 19 patients at time of 30 days after stent placement. By Kaplan-Meier analysis, a significant survival improvement was observed in patients with successful SEMS placement, compared with patients receiving conservative medical treatment. Taken together, combined use of SBE and colonoscope makes endoscopic stent placement feasible in patients with malignant small intestinal obstruction, and patients can benefit from it in terms of prolonged survival and improved quality of life.

Prognostic Scoring System for Patients Who Present with a Gastric Outlet Obstruction Caused by Advanced Pancreatic Adenocarcinoma.

BACKGROUND: Gastroenterostomy and stent placement are the most common palliative procedures for patients with a gastric outlet obstruction caused by advanced pancreatic adenocarcinoma. Gastroenterostomy is regarded as the optimum treatment for patients in whom a longer survival is expected, while stent placement is preferred for patients whose survival is likely to be relatively short. However, prognosis of such patients has not been fully evaluated. METHODS: This study included patients undergoing gastroenterostomy or duodenal stent placement for gastric outlet obstruction caused by advanced pancreatic adenocarcinoma between 2002 and 2015. Prognostic factors found to be significant based on a multivariate analysis were given a prognostic score according to their hazard ratios (HR). The overall survivals stratified according to the total prognostic score were compared. RESULTS: The median survival time of all cohorts was 4.2 months. The multivariate analyses demonstrated a neutrophil-to-lymphocyte ratio (NLR) ≥ 4 (HR = 4.01, p < 0.001), presence of liver metastases (HR = 1.90, p = 0.002), and presence of cancer pain (HR = 2.08, p < 0.001) to be significant prognostic factors. Regarding the HR, NLR ≥ 4, liver metastases and cancer pain were subsequently scored as 2, 1, and 1, respectively. The median survival time was 9.4 months in patients with a score of 0 or 1 and 3.3 months in patients with a score of 2-4, respectively. CONCLUSION: The scoring system clearly demonstrates the patient survival. Patients with scores of 0 or 1 are favorable candidates for gastroenterostomy, while patients with scores of 2-4 are candidates for stent placement.

Palliative gastrojejunostomy versus endoscopic stent placement for gastric outlet obstruction in patients with unresectable gastric cancer: a propensity score-matched analysis.

BACKGROUND: It remains unclear whether selection of treatment modality affects the survival of patients with malignant gastric outlet obstruction (GOO). We compared the effect of gastrojejunostomy (GJ) and endoscopic self-expandable metallic stent (SEMS) placement on the long-term outcomes of patients with malignant GOO caused by unresectable gastric cancer. METHOD: We conducted a retrospective study of gastric cancer patients undergoing GJ or endoscopic SEMS placement for the palliation of malignant GOO. To reduce the effect of selection bias, we performed a propensity score-matching analysis between two groups. RESULTS: In a propensity-matched analysis (45 and 99 in GJ and SEMS groups, respectively), clinical success rates were comparable between the GJ and SEMS groups (95.6 and 96.0%), while the SEMS group showed significantly shorter hospital stays than the GJ group. The GJ group showed a significantly longer reintervention period and overall survival (393 and 129 days) compared to the SEMS group. In multivariate Cox regression analysis, GJ, low ECOG scale (good performance status), and additional chemo- or radiation therapy were identified as independent favorable predictors of overall survival. GJ was also identified as an independent protective predictor against reintervention. CONCLUSION: We found that palliative GJ was significantly associated with longer overall survival and lower risk of reintervention than SEMS placement in patients with malignant GOO caused by unresectable gastric cancer. Given very limited expected survival in selected patients with unresectable gastric cancer and more favorable short-term outcomes in cases of SEMS placement, individualized approach might be required in treatment decision between palliative GJ and SEMS placement.

Significance of Stent Abutment in Gastroduodenal Stent Placement for Gastric Outlet Obstructions.

PURPOSE: To evaluate the frequency, severity, and clinical significance of stent abutment (SA) after gastroduodenal stent placement in patients with gastric outlet obstruction caused by unresectable gastric cancer. MATERIALS AND METHODS: A retrospective study was conducted in a single tertiary referral university hospital to identify the incidence and clinical significance of SA in 318 patients who underwent self-expandable metallic stent placement. SA was defined as abutment of the distal end of the stent to the duodenal wall and/or superior duodenal flexure. The outcomes included technical and clinical success, complications, repeat intervention, stent patency, and survival. RESULTS: A total of 318 patients, 107 with SA (33.6%) and 211 without, were included. SA occurred partially (n = 64; 59.8%) and completely (n = 43; 40.2%). The technical and clinical outcomes and survival were similar in the groups with and without SA. Food impaction and resultant repeat intervention rates were higher in the SA group than in the non-SA group (P < .001 and P < .001, respectively), and were associated with complete SA (P = .007). Stent patency rate was lower in the SA group than in the non-SA group (P = .003). CONCLUSIONS: SA was associated with increased food impaction, resulting in a greater incidence of stent malfunction and shorter stent patency compared with a lack of SA. The concept of SA may be useful for the improvement of stent patency and avoidance of food impaction.

Self-expanding metal stents for the palliation of malignant gastric outlet obstruction in patients with peritoneal carcinomatosis.

AIM: To evaluate the efficacy of self-expanding metal stents (SEMS) for the palliation of malignant gastric outlet obstruction in patients with and without peritoneal carcinomatosis (PC). METHODS: We performed a retrospective analysis of 62 patients who underwent SEMS placement for treatment of malignant gastroduodenal obstruction at our hospital over a six-year period. Stents were deployed through the scope under combined fluoroscopic and endoscopic guidance. Technical success was defined as successful stent placement and expansion. Clinical success was defined as an improvement in the obstructive symptoms and discharge from hospital without additional parenteral nutrition. According to carcinomatosis status, patients were assigned into groups with or without evidence of peritoneal disease. RESULTS: In most cases, obstruction was caused by pancreatic (47%) or gastric cancer (23%). Technical success was achieved in 96.8% (60/62), clinical success in 79% (49/62) of all patients. Signs of carcinomatosis were identified in 27 patients (43.5%). The diagnosis was confirmed by pathology or previous operation in 7 patients (11.2%) and suspected by CT, MRI or ultrasound in 20 patients (32.2%). Presence of carcinomatosis was associated with a significantly lower clinical success rate compared to patients with no evidence of peritoneal disease (66.7% vs 88.6%, P = 0.036). There was no significant difference in overall survival between patients with or without PC (median 48 d vs 70 d, P = 0.21), but patients showed significantly longer survival after clinical success of SEMS placement compared to those experiencing clinical failure (median 14.5 d vs 75 d, P = 0.0003). CONCLUSION: Given the limited therapeutic options and a clinical success rate of at least 66.7%, we believe that SEMS are a reasonable treatment option in patients with malignant gastric outlet obstruction with peritoneal carcinomatosis.

Palliative Therapy for Gastric Outlet Obstruction Caused by Unresectable Gastric Cancer: A Meta-analysis Comparison of Gastrojejunostomy with Endoscopic Stenting.

BACKGROUND: Gastrojejunostomy (GJJ) and endoscopic stenting (ES) are palliative treatments for gastric outlet obstruction (GOO) caused by gastric cancer. We compared the outcomes of GJJ with ES by performing a meta-analysis. METHODS: Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis. Procedure time, time to resumption of oral intake, duration of hospital stay, patency duration, and overall survival days were compared using weighted mean differences (WMDs). Technical success, clinical success, procedure-related mortality, complications, the rate of re-obstruction, postoperative chemotherapy, and reintervention were compared using odds ratios (OR s). RESULTS: Nine studies were included in the analysis. Technical success and clinical success were not significantly different between the ES and GJJ groups. The ES group had a shorter procedure time (WMD = -80.89 min, 95% confidence interval [CI] = -93.99 to -67.78,P < 0.001), faster resumption of oral intake (WMD = -3.45 days, 95% CI = -5.25 to -1.65,P < 0.001), and shorter duration of hospital stay (WMD = -7.67 days, 95% CI = -11.02 to -4.33,P < 0.001). The rate of minor complications was significantly higher in the GJJ group (OR = 0.13, 95% CI = 0.04-0.40,P < 0.001). However, the rates of major complications (OR = 6.91, 95% CI = 3.90-12.25,P < 0.001), re-obstruction (OR= 7.75, 95% CI = 4.06-14.78,P < 0.001), and reintervention (OR= 6.27, 95% CI = 3.36-11.68,P < 0.001) were significantly lower in the GJJ group than that in the ES group. Moreover, GJJ was significantly associated with a longer patency duration (WMD = -167.16 days, 95% CI = -254.01 to -89.31,P < 0.001) and overall survival (WMD = -103.20 days, 95% CI = -161.49 to -44.91, P= 0.001). CONCLUSIONS: Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer. ES is associated with better short-term outcomes. GJJ is preferable to ES in terms of its lower rate of stent-related complications, re-obstruction, and reintervention. GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.

Endoscopic self-expandable metallic stenting for palliation of malignant gastric outlet obstruction in Southeast Asia.

BACKGROUND: Malignant gastric outlet obstruction (GOO) is a pre-terminal event in the natural history of gastric and pancreaticobiliary cancers. The use of endoscopic placement of self-expandable metallic stents (SEMS) is a less invasive alternative palliative option for these patients. This is the first study in Southeast Asia to evaluate the clinical efficacy and safety of endoscopic SEMS placement in patients with malignant GOO. METHODS: A retrospective review of our department's database in endoscopic SEMS placement for the treatment of malignant GOO was performed. Twenty-four patients with advanced or metastatic malignancy that underwent placement of SEMS for treatment of malignant GOO between January 2003 and July 2013 were analysed. The GOO severity score was used as an objective means of assessing patients' oral intake. RESULTS: Technical success rate was 100%. All patients resumed oral intake of liquids within the same day of stent placement. Clinical success was achieved in 21 patients (87.5%). There was a significant improvement of GOO severity score from 0.62 ± 1.0 (mean ± standard deviation) before stent placement to 2.04 ± 0.86 after stent placement (P < 0.001). Complication rate was 12.5%. Stent-related complications observed include stent migration (two patients) and tumour ingrowth (one patient). Serious complications such as gastrointestinal haemorrhage or perforation did not occur in any patients. The median survival after stent placement was 57 days (95% confidence interval, 12.2-101.8 days). None of the patients died from stent-related complications. CONCLUSION: Endoscopic SEMS placement is a minimally invasive, safe and effective option for the palliation of malignant GOO.

Impact of Carcinomatosis on Clinical Outcomes after Self-Expandable Metallic Stent Placement for Malignant Gastric Outlet Obstruction.

BACKGROUND: It is still unclear whether the peritoneal carcinomatosis had a negative effect on the clinical outcomes of patients who underwent self-expandable metallic stent (SEMS) placement for malignant gastric outlet obstruction (GOO). Although carcinomatosis may be associated with the development of multifocal gastrointestinal (GI) tract obstruction or decreased bowel movement, previous studies investigated the occurrence of stent failure only and thus had limitation in evaluating clinical outcomes of patients with carcinomatosis. METHODS: Between 2009 and 2013, 155 patients (88 patients without carcinomatosis and 67 patients with carcinomatosis) underwent endoscopic SEMS placement for malignant GOO. Factors affecting clinical success and obstructive symptom-free survival (time period between SEMS placement and the recurrence of obstructive symptoms due to multifocal GI tract obstruction or decreased bowel movement as well as stent failure) were assessed. RESULTS: Patients with carcinomatosis showed higher Eastern Cooperative Oncology Group (ECOG) scale than those without carcinomatosis. Clinical success rates were 88.1% in patients with carcinomatosis and 97.7% in patients without carcinomatosis. In multivariate analysis, only ECOG scale was identified as an independent predictor of clinical success. During follow-up period, patients with carcinomatosis showed significantly shorter obstructive symptom-free survival than those without carcinomatosis. In multivariate analysis, the presence of carcinomatosis, chemotherapy or radiation therapy after SEMS placement, and obstruction site were identified as independent predictors of obstructive symptom-free survival. For patient without carcinomatosis, stent failure accounted for the recurrence of obstructive symptoms in 84.6% of cases. For patients with carcinomatosis, multifocal GI tract obstruction or decreased bowel movement accounted for 37.9% of cases with obstructive symptom recurrence and stent failure accounted for 44.8% of cases. CONCLUSIONS: Carcinomatosis predicts unfavorable long-term clinical outcomes in patients undergoing SEMS placement for malignant GOO. This is mainly due to the development of multifocal GI tract obstructions or decreased bowel movement as well as stent failure.

[STENTING VERSUS PALLIATIVE SURGERY IN PATIENTS WITH MALIGNANT GASTROINTESTINAL STENOSIS].

AIM: Retrospective analysis of the results of stenting versus surgical palliation in patients with malignant gastrointestinal stenosis. MATERIAL AND METHODS: 85 patients underwent endoscopic stenting (41) or surgical intervention (44). Level of stenosis: gastric outlet (23/38), multi-level gastric obstruction (2/3), duodenum or jejunum (12/3), gastrojejunoanastomosis (3/0) and gastroduodenoanastomosis (1/0). 49 self-expanding metal stents were implanted in 41 patients. 41 gastroenteroanastomoses and 3 jejunostomas were performed in surgical group. RESULTS: Stents were successfully inserted in all patients. Early complications were observed in 3 (7.3%) patients after stenting and in 9 (20.5%) after surgical palliation, p = 0.0755. Postoperative lethality was 2,4% (1 patient) after stenting and 31.8% (14 patients) after surgery, p = 0.0003. Mean hospital stay was 15 days in stenting group and 23 days in surgical group, p < 0.001. There was no statistically significant difference in long-term results, neither in late complications (p = 0.3691), nor in survival (p =0.3697). CONCLUSION: Endoscopic placement of self-expanding stents is an effective method of restoration of oral intake in patients with malignant gastrointestinal obstruction. Stenting is associated with equal rates of early and late complications, lower mortality and decreased in-hospital stay as compared with surgery, and therefore may be recommended as a final palliation in inoperable patients.

Non-centralised service for palliative stenting of malignant gastric outlet obstruction.

INTRODUCTION: Malignant gastric outlet obstruction (GOO) is a common, debilitating and frequently pre-terminal symptom of intra-abdominal malignancies. Traditional 'gold standard' treatment has been palliative surgical gastro-enterostomy. Over the past two decades, use of self-expanding metallic stents (SEMSs) to relieve malignant GOO has become first-line treatment. We present the results from a single district general hospital in the UK in which malignant GOO was treated with SEMSs over a six-year period. METHODS: All patients who underwent palliative stenting for malignant gastro-duodenal tumours in our centre for six years up to January 2013 were assessed retrospectively. Outcomes were assessed with regard to: technical and clinical success; return to oral nutrition; prevalence of complications and re-intervention; and overall survival. RESULTS: Thirty-two stents were implanted in 29 patients. Technical success was 100%. Clinical success and return to oral nutrition were both 91%. The prevalence of complications was 16%. The prevalence of re-intervention was 13%. Mean survival was 91 (range, 5-392) days. Median wait from decision to implant a stent to stent implantation was 1 (range, 0-14) day. Overall, 25 covered and nine uncovered stents were implanted. CONCLUSION: Stent implantation for GOO in this patient group is an established and preferable alternative to surgical intervention. Much of the treatment for malignancies of the upper gastrointestinal tract has now been centralised. Our data showed comparable results with published data for these procedures, with a high prevalence of success and low prevalence of major complications. It is of considerable benefit to these patients not to have to travel to a regional centre for stent implantation.

Bowel obstruction in recurrent gynecologic malignancies: defining who will benefit from surgical intervention.

AIM: To define factors that could help select, in a cohort of gynecologic cancer patients with malignant gastro-intestinal obstruction, those most likely to benefit from palliative surgery. METHODS: In this retrospective study of patients with malignant gastro-intestinal obstruction who underwent palliative surgery in our institute over 7 years, outcome measures were oral intake, chemotherapy, and 30-day, 60-day and overall survival. Based on Cox proportional-hazards regression models and Kaplan-Meier curves with log-rank tests, a prognostic score was developed to identify those most likely to benefit from surgery. RESULTS: Sixty-eight palliative surgeries were performed in 62 patients with ovarian (69.1%), primary-peritoneal (8.8%), cervical (11.8%) or uterine (10.3%) malignancies. Procedures were colostomy (26.5%), ileostomy (39.7%), colonic stent (1.5%), gastrostomy (7.3%), gastroenterostomy (5.9%) and bypass/resection and anastomosis (19.1%). Eighteen patients died prior to discharge, within 3-81 days (median 25 days). The 30-day and 60-day mortality rates were 14.7% and 29.4%, respectively. Postoperative oral-intake and chemotherapy rates were 65% and 53%, respectively, with albumin level identified on multivariate analysis as the only significant predictor of both. Median postoperative survival was 106 days (3-1342). Bypass/resection and anastomosis was associated with improved survival. Ascites below 2 L, younger age, ovarian primary tumor, and higher blood albumin correlated with longer postoperative survival. A prognostic index based on these factors was found to identify patients with increased 30-day and 60-day mortality. CONCLUSIONS: Our proposed prognostic index, based on age, primary tumor, albumin and ascites, might help select those gynecological cancer patients most likely to benefit from palliative surgery.

Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases.

BACKGROUND: Gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. There is a paucity of published data on this subject in our setting. This study was undertaken to highlight the etiological spectrum and treatment outcome of gastric outlet obstruction in our setting and to identify prognostic factors for morbidity and mortality. METHODS: This was a descriptive prospective study which was conducted at Bugando Medical Centre between March 2009 and February 2013. All patients with a clinical diagnosis of gastric outlet obstruction were, after informed consent for the study, consecutively enrolled into the study. Statistical data analysis was done using SPSS computer software version 17.0. RESULTS: A total of 184 patients were studied. More than two-third of patients were males. Patients with malignant gastric outlet obstruction were older than those of benign type. This difference was statistically significant (p < 0.001). Gastric cancer was the commonest malignant cause of gastric outlet obstruction where as peptic ulcer disease was the commonest benign cause. In children, the commonest cause of gastric outlet obstruction was congenital pyloric stenosis (13.0%). Non-bilious vomiting (100%) and weight loss (93.5%) were the most frequent symptoms. Eighteen (9.8%) patients were HIV positive with the median CD 4+ count of 282 cells/µl. A total of 168 (91.3%) patients underwent surgery. Of these, gastro-jejunostomy (61.9%) was the most common surgical procedure performed. The complication rate was 32.1 % mainly surgical site infections (38.2%). The median hospital stay and mortality rate were 14 days and 18.5% respectively. The presence of postoperative complication was the main predictor of hospital stay (p = 0.002), whereas the age > 60 years, co-existing medical illness, malignant cause, HIV positivity, low CD 4 count (<200 cells/µl), high ASA class and presence of surgical site infection significantly predicted mortality ( p< 0.001). The follow up of patients was generally poor as more than 60% of patients were lost to follow up. CONCLUSION: Gastric outlet obstruction in our setting is more prevalent in males and the cause is mostly malignant. The majority of patients present late with poor general condition. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with gastric outlet obstruction are to be avoided.

Elevated preoperative neutrophil-to-lymphocyte ratio as a predictor of survival after gastroenterostomy in patients with advanced pancreatic adenocarcinoma.

BACKGROUND: There is increasing evidence that the presence of an ongoing systemic inflammatory response, especially a high preoperative neutrophil-to-lymphocyte ratio (NLR), is associated with a poor outcome for a variety of common solid tumors. However, few studies have investigated the clinical value of the NLR in patients undergoing gastroenterostomy for advanced pancreatic cancer. METHODS: A total of 83 patients who had symptoms of gastric outlet obstruction due to advanced pancreatic cancer and underwent gastroenterostomy were analyzed. The prognostic significance of the NLR was analyzed. The relationship between the NLR value and postoperative outcome was also evaluated. RESULTS: The median survival time was 9.4 months in patients with an NLR of <4, whereas it was 3.4 months in patients with an NLR of ≥4 (P < 0.001). The multivariate analysis revealed that an NLR of ≥4, the presence of liver metastases, daily pain, and lack of postoperative chemotherapy were significant prognostic factors. A higher NLR was associated with postoperative morbidity; 13 % of patients with an NLR of <4 and 36 % of those with an NLR of ≥4 (P = 0.012) developed morbidities. With regard to quality of life, 96 % of patients with an NLR of <4 and 36 % of patients with an NLR of ≥4 had adequate oral intake of solid food without any support with intravenous nutrition for at least 1 month after surgery (P < 0.001). CONCLUSIONS: The preoperative NLR offers important prognostic information for patients who have gastric outlet obstruction due to advanced pancreatic adenocarcinoma.

Clinical outcome and indications for palliative gastrojejunostomy in unresectable advanced gastric cancer: multi-institutional retrospective analysis.

BACKGROUND: Palliative gastrojejunostomy (GJJ) for gastric outlet obstruction (GOO) associated with unresectable advanced gastric cancers (UAGC) is the most commonly used treatment modality, but its indication remains controversial. In this multi-institutions study, we investigated the clinical outcome of GJJ for UAGC and predictors of outcome and survival. METHODS: A retrospective analysis was performed on 211 patients who underwent palliative GJJ for GOO caused by UAGC from 29 institutions between 2007 and 2009. Operative outcome including postoperative morbidity, mortality, assessment of oral intake by GOO Scoring System (GOOSS) and survival time were recorded. Prognostic factors for overall survival and risk factors for hospital death were investigated by univariate and multivariate analyses. RESULTS: Postoperative oral food intake was recorded in 203 (96 %) patients. The average GOOSS improved from 1.1 at baseline to 2.5 at 1 month after surgery and remained above 2 for up to 6 months. Overall morbidity, 30-day mortality and hospital death rates were 22, 6 and 11 %, respectively. Median survival time was 228 days and 1-year survival rate was 31 %. Poor performance status (PS), prior chemotherapy and high C-reactive protein (CRP) level were significant independent predictors of poor survival. Poor PS and high CRP were also identified as significant risk factors of hospital death. CONCLUSIONS: Palliative GJJ is beneficial for GOO caused by UAGC in terms of improvement of oral food intake, with acceptable morbidity and mortality. However, its indication for patients with poor PS, high CRP level, and a history of chemotherapy is less clear.

Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery.

BACKGROUND: In patients with gastric outlet obstruction (GOO) caused by gastric cancer, choosing between self-expandable metal stent (SEMS) placement and gastrojejunostomy (GJJ) is of concern, especially in those with good performance status. OBJECTIVE: To compare SEMS placement and GJJ. DESIGN: Retrospective study. SETTING: Single tertiary referral center. PATIENTS: Patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 who had GOO caused by unresectable gastric cancer. INTERVENTIONS: SEMS placement and GJJ. MAIN OUTCOME MEASUREMENTS: Success rate, adverse events, patency, and survival duration. RESULTS: Of the 113 patients in this study, 72 underwent SEMS placement and 41 underwent GJJ. The 2 groups did not differ in the technical and clinical success and incidence of early adverse events. However, the rate of late adverse events was significantly higher in the SEMS group (44.4% vs 12.2%; P < .001). The median patency duration was shorter after SEMS placement than after GJJ (125 days vs 282 days; P = .001), even after additional SEMS placement (210 days vs 282 days; P = .044). The median survival was also significantly shorter after SEMS placement than after GJJ (189 days vs 293 days; P = .003). Survival differed between treatments in patients with ECOG 0-1 (P = .006) but not in those with an ECOG performance status of 2 (P = .208). LIMITATIONS: Retrospective and single-center study. CONCLUSIONS: GJJ is preferable to SEMS placement for the palliation of GOO caused by unresectable or metastatic gastric cancer in patients with a good performance status, especially ECOG 0-1.

What is the ideal stent as initial intervention for malignant gastric outlet obstruction?

BACKGROUND: Self-expandable metal stents are effective palliation for malignant gastric outlet obstruction. The aims of study were to evaluate efficacy and safety of double-layered Comvi, uncovered and covered stent to find out protocols which enhance stent patency. METHODS: We retrospectively analysed data from 224 patients who underwent endoscopic stent placement for malignant gastric outlet obstruction caused by stomach cancer from 2006 to 2011. Technical and clinical success rates were evaluated and clinical outcomes were compared according to stent types and chemotherapy. RESULTS: The overall technical and clinical success rates were achieved in 99.6% and 80.4%, respectively without immediate complications. The clinical success rate was not significantly different between three groups. The median stent patency time was 156 days [interquartile range 66-279] without differences between groups. The 4-, 8-, and 12-week patency rates were 89.4%, 77.3%, and 61.2%, respectively with no differences between groups. The re-stenosis of stent frequently occurred in the case of the uncovered stents, while migration was more likely to be observed for the covered and Comvi stent. Chemotherapy significantly lowered re-intervention rates, especially in uncovered stents. CONCLUSIONS: Patency rates are significantly improved by combining the use of uncovered stent with follow-up chemotherapy treatment, which retains the advantages of the mechanical and chemical aspects of stent and chemotherapy, respectively.