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Hofmann FO, Sirtl S, Heiliger C, Werner J. [Patient safety in palliative surgery]. CHIRURGIE (HEIDELBERG, GERMANY) 2025; 96:179-183. [PMID: 39808186 DOI: 10.1007/s00104-024-02202-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/15/2024] [Indexed: 01/16/2025]
Abstract
Palliative surgery aims to improve the quality of life for patients with incurable diseases. This patient group is vulnerable due to the underlying illness, prior treatment and comorbidities, which increase the risk of complications that can negatively impact the course of the disease and quality of life. Palliative surgical interventions often provide effective long-term symptom control but are more invasive than conservative, interventional endoscopic or interventional radiological alternatives. This article exemplary discusses frequent palliative visceral surgical procedures and less invasive alternatives. In practice, a close interdisciplinary collaboration, open and realistic communication, optimized perioperative care and in particular the minimization of cumulative invasiveness are crucial to maximize the quality of life and safety for oncological patients.
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Affiliation(s)
- Felix O Hofmann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU Klinikum München, Marchioninistraße 15, 81377, München, Deutschland
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Standort München, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutschland
| | - Simon Sirtl
- Medizinische Klinik und Poliklinik II, LMU Klinikum München, Marchioninistraße 15, 81377, München, Deutschland
| | - Christian Heiliger
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU Klinikum München, Marchioninistraße 15, 81377, München, Deutschland
| | - Jens Werner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU Klinikum München, Marchioninistraße 15, 81377, München, Deutschland.
- Deutsches Konsortium für Translationale Krebsforschung (DKTK), Standort München, Deutsches Krebsforschungszentrum (DKFZ), Heidelberg, Deutschland.
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2
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Lee H, Park KH, Rosas U, El Helou MO, Lee JM, Bancila L, Jamil LH, Liu Q, Watson RR, Gaddam S, Lo SK. Predictive factors for early mortality after EUS-guided gastroenterostomy in malignant gastric outlet obstruction. Endosc Int Open 2025; 13:a24749802. [PMID: 39958672 PMCID: PMC11827758 DOI: 10.1055/a-2474-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 11/15/2024] [Indexed: 02/18/2025] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emerged as a potential treatment option for malignant gastric outlet obstruction (mGOO), with a relatively long duration of patency and low rate of reintervention. Its intrinsic risk for serious adverse events and high procedure cost mandates careful patient selection beyond the common safety profiles. This study aimed to assess for predictors of early post-EUS-GE mortality. Patients and methods We conducted a retrospective analysis of all patients with unresectable mGOO who underwent EUS-GE. Predictive factors for postoperative 30-day mortality with crude and adjusted hazard ratios were examined using univariate and multivariate penalized likelihood Firth logistic regression analyses. Results Technical and clinical success was achieved in 96.7% and 93.1% of the patients, respectively. The 30-day mortality rate after the procedure was 11.7%, and no procedure complications were observed. The 30-day mortality group had a significantly low rate of initial clinical success (66.7% vs. 96.2%, P = 0.007). Univariate analysis identified significantly higher postoperative 30-day mortality in patients with poor baseline ECOG performance status scale (≥ 2) and ascites. Presence of grade 2 ascites was confirmed as an independent predictive factor in the multivariate analysis (adjusted hazard ratio 52.41, 95% confidence interval 1.55 to 1775.64, P = 0.024). Conclusions EUS-GE should be carefully considered for patients with ascites which was an independent predictor for early mortality after procedure in mGOO, especially those with grade 2 or higher level of ascites.
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Affiliation(s)
- Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kenneth Hyunsoo Park
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Ulysses Rosas
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Mohamad Othman El Helou
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Jae Min Lee
- Department of Internal Medicine, Institute of Digestive Disease and Nutrition, Korea University College of Medicine, Seoul, Korea (the Republic of)
| | - Liliana Bancila
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Laith H Jamil
- Gastroenterology and Hepatology, William Beaumont Hospital - Royal Oak, Royal Oak, United States
| | - Quin Liu
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Rabindra R. Watson
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Srinivas Gaddam
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
| | - Simon K Lo
- Karsh Division of Digestive Diseases and Hepatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, United States
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3
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Kwak S, Duncan M, Johnston FM, Bever K, Cha E, Fishman EK, Gawande R. Cross-sectional imaging of gastric cancer: pearls, pitfalls and lessons learned from multidisciplinary conference. Abdom Radiol (NY) 2024; 49:4400-4415. [PMID: 38886219 DOI: 10.1007/s00261-024-04392-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 06/20/2024]
Abstract
Gastric cancer is rising in prevalence associated with high mortality, primarily due to late-stage detection, underscoring the imperative for early and precise diagnosis. Etiology involves an interplay of genetic susceptibilities and environmental factors with a prominent role of Helicobacter pylori infection. Due to its often-delayed symptom presentation, prompt and accurate diagnosis is necessary. A multimodal imaging approach, including endoscopic ultrasound (EUS), multi-detector computed tomography (MDCT), and magnetic resonance imaging (MRI) is critical for accurate staging. Each modality contributes unique advantages and limitations, highlighting the importance of integrating diagnostic strategy. Moreover, multidisciplinary conferences offer a vital collaborative platform, bringing together specialists from diverse fields for treatment planning. This synergistic approach not only enhances diagnostic precision but also improves patient outcome. This review highlights the critical role of imaging in diagnosis, staging, and management and advocates for interdisciplinary collaboration in early detection and comprehensive management of gastric cancer, aiming to reduce mortality.
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Affiliation(s)
- Stephen Kwak
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA.
| | - Mark Duncan
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Fabian M Johnston
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Katherine Bever
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Eumee Cha
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Elliot K Fishman
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA
| | - Rakhee Gawande
- Johns Hopkins University, 1800 Orleans St., Baltimore, MD, 21287, USA
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4
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Jiang L, Chen XP. Treatment of choice for malignant gastric outlet obstruction: More than clearing the road. World J Gastrointest Endosc 2024; 16:587-594. [PMID: 39600555 PMCID: PMC11586723 DOI: 10.4253/wjge.v16.i11.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2024] [Revised: 10/02/2024] [Accepted: 10/20/2024] [Indexed: 10/30/2024] Open
Abstract
In this editorial, we comment on the in-press article in the World Journal of Gastrointestinal Endoscopy concerning the treatment of malignant gastric outlet obstruction (mGOO). The original theory of treatment involves bypassing the obstruction or reenabling the patency of the passage. Conventional surgical gastroenterostomy provides long-term relief of symptoms in selected patients, with substantial morbidity and a considerable rate of delayed gastric emptying. Endoscopic stenting was introduced as an alternative minimally invasive procedure with less procedural morbidity and rapid clinical improvement; however, it presented a high rate of long-term recurrence. Therefore, challenges remain in the treatment of mGOO patients to improve clinical outcomes. Endoscopic ultrasound-guided gastroenterostomy has recently emerged as a promising method because of the combined effects of surgery and endoscopy, whereas stomach-partitioning gastrojejunostomy has been reported as a modified surgical procedure to reduce the rate of delayed gastric emptying. In decision-making regarding the treatment of choice, it should be taken into account that mGOO might be accompanied by a variety of pathological conditions, including cancer cachexia, anorexia, malabsorption, and etc., all of which can also lead to the characteristic symptoms and poor nutritional status of mGOO. The treatment plan should consider comprehensive aspects of patients to achieve practical improvements in prognosis and the quality of life.
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Affiliation(s)
- Li Jiang
- Department of Biliary-Pancreatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
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5
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Lim SG, Kim CG. Endoscopic stenting for malignant gastric outlet obstruction: focusing on comparison of endoscopic stenting and surgical gastrojejunostomy. Clin Endosc 2024; 57:571-580. [PMID: 38389304 PMCID: PMC11474473 DOI: 10.5946/ce.2023.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 02/24/2024] Open
Abstract
Malignant gastric outlet obstruction (GOO) is a condition characterized by blockage or narrowing where the stomach empties its contents into the small intestine due to primary malignant tumors or metastatic diseases. This condition leads to various symptoms such as nausea, vomiting, abdominal pain, and weight loss. To manage malignant GOO, different treatment options have been employed, including surgical gastrojejunostomy (SGJ), gastroduodenal stenting (GDS) using self-expandable metallic stent (SEMS), and endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ). This review focuses on comparing the clinical outcomes of endoscopic stenting (GDS and EUS-GJ) with SGJ for malignant GOO. Studies have shown that GDS with SEMS provides comparable clinical outcomes and safety for the palliation of obstructive symptoms. The choice between covered and uncovered SEMS remains controversial, as different studies have reported varying results. EUS-GJ, performed via endoscopic ultrasound guidance, has shown promising efficacy and safety in managing malignant GOO, but further studies are needed to establish it as the primary treatment option. Comparative analyses suggest that GDS has higher recurrence and reintervention rates compared to EUS-GJ and SGJ, with similar overall procedural complications. However, bleeding rates were lower with GDS than with SGJ. Randomized controlled trials are required to determine the optimal treatment approach for malignant GOO.
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Affiliation(s)
- Sun Gyo Lim
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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6
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Song Y, Chen E, Ikoma N, Mansfield PF, Bruera E, Badgwell BD. Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes. Ann Surg Oncol 2024; 31:5252-5262. [PMID: 38743284 DOI: 10.1245/s10434-024-15416-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population. PATIENTS AND METHODS Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated. RESULTS Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months. CONCLUSIONS Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.
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Affiliation(s)
- Yun Song
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eunise Chen
- John P. and Katherine G. McGovern Medical School at UT Health, Houston, TX, USA
| | - Naruhiko Ikoma
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paul F Mansfield
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brian D Badgwell
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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7
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Lim H. [Treatment Strategies for Gastric Cancer Patients with Gastric Outlet Obstruction]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 84:3-8. [PMID: 39049459 DOI: 10.4166/kjg.2024.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 06/18/2024] [Indexed: 07/27/2024]
Abstract
Gastric cancer frequently leads to gastric outlet obstruction (GOO), causing significant symptoms and complications. Surgical bypass and stenting are two representative palliative treatments for GOO by gastric cancer. This study reviews clinical guidelines for malignant GOO treatment, highlighting differences in recommendations based on patient survival expectations and systemic health. A meta-analysis of surgical bypass and stenting in gastric cancer patients revealed no significant difference in technical and clinical success rates between the two treatments. However, stenting allowed faster resumption of oral intake and shorter hospital stays but had higher rates of major complications and reobstruction. Despite these differences, overall survival did not significantly differ between the two groups. Emerging techniques like EUS-guided gastrojejunostomy show promise but require further research and experienced practitioners. Ultimately, treatment should be tailored to patient preferences and the specific benefits and drawbacks of each method to improve quality of life and outcomes.
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Affiliation(s)
- Hyun Lim
- Department of Gastroenterology, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, Anyang, Korea
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8
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Walshaw J, Smith HG, Lee MJ. Small bowel obstruction. Br J Surg 2024; 111:znae167. [PMID: 39041721 DOI: 10.1093/bjs/znae167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/16/2024] [Indexed: 07/24/2024]
Affiliation(s)
- Josephine Walshaw
- Leeds Institute of Medical Research, St James's University Hospital, University of Leeds, Leeds, UK
| | - Henry G Smith
- Abdominalcenter K, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Matthew J Lee
- Institute for Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Trauma and Emergency General Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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9
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Martinet E, Gonzalez JM, Thobois M, Hamouda I, Hardwigsen J, Chopinet S, Pauleau G, Vanbiervliet G, Onana P, Moutardier V, Gasmi M, Barthet M, Birnbaum DJ. Surgical versus endoscopic gastroenterostomy for gastric outlet obstruction: a retrospective multicentric comparative study of technical and clinical success. Langenbecks Arch Surg 2024; 409:192. [PMID: 38900214 DOI: 10.1007/s00423-024-03365-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Gastric outlet obstruction (GOO) is mainly due to advanced malignant disease. GOO can be treated by surgical gastroenterostomy (SGE), endoscopic enteral stenting (EES), or endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to improve the quality of life. METHODS Between 2009 and 2022, patients undergoing SGE or EUS-GE for GOO were included at three centers. Technical and clinical success rates, post-procedure adverse events (AEs), length of hospital stay (LOS), 30-day all-cause mortality, and recurrence of GOO were retrospectively analyzed and compared between SGE and EUS-GE. Predictive factors for technical and clinical failure after SGE and EUS-GE were identified. RESULTS Of the 97 patients included, 56 (57.7%) had an EUS-GE and 41 (42.3%) had an SGE for GOO, with 62 (63.9%) GOO due to malignancy and 35 (36.1%) to benign disease. The median follow-up time was 13,4 months (range 1 days-106 months), with no difference between the two groups (p = 0.962). Technical (p = 0.133) and clinical (p = 0.229) success rates, severe morbidity (p = 0.708), 30-day all-cause mortality (p = 0.277) and GOO recurrence (p = 1) were similar. EUS-GE had shorter median procedure duration (p < 0.001), lower post-procedure ileus rate (p < 0.001), and shorter median LOS (p < 0.001) than SGE. In univariate analysis, no risk factors for technical or clinical failure in SGE were identified and abdominal pain reported before the procedure was a risk factor for technical failure in the EUS-GE group. No risk factor for clinical failure was identified for EUS-GE. In the subgroup of GOO due to benign disease, SGE was associated with better technical success (p = 0.035) with no difference in clinical success rate compared to EUS-GE (p = 1). CONCLUSION EUS-GE provides similar long-lasting symptom relief as SGE for GOO whether for benign or malignant disease. SGE may still be indicated in centers with limited experience with EUS-GE or may be reserved for patients in whom endoscopic technique fails.
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Affiliation(s)
- Eugénie Martinet
- Department of Digestive Surgery, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | | | - Maxime Thobois
- Department of Gastroenterology and Hepatology, Hôpital L'Archet 2, Nice, France
| | - Ilyes Hamouda
- Public Health Laboratory of the Faculty of Medical and Paramedical Sciences; Epidemiology and Health Economics Department, Hôpital Timone, Marseille, France
| | | | | | - Ghislain Pauleau
- Department of Digestive Surgery, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | | | - Philippe Onana
- Department of Gastroenterology and Hepatology, Hôpital L'Archet 2, Nice, France
| | | | | | | | - David Jérémie Birnbaum
- APHM Digestive Department, Marseille, France.
- Hôpital Nord, Chemin des Bourrely, Marseille cedex 20, 13915, France.
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10
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Cobb W, Harris S, Xavier J, de la Fuente SG. Systematic review of long-term effectiveness of endoscopic gastrojejunostomy in patients presenting with gastric outlet obstruction from periampullary malignancies. Surg Endosc 2024:10.1007/s00464-024-10943-3. [PMID: 38886233 DOI: 10.1007/s00464-024-10943-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 05/19/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Recently, endoscopic ultrasound-guided (EUS) gastrojejunostomy (GJ) has emerged as an alternative option to surgical palliation and endoscopic duodenal stenting for malignant gastric outlet obstruction (GOO). Although early success rates are commonly reported with the technique, there is a paucity of data regarding the long-term efficacy of this approach. In this study, we investigated long-term outcomes in patients that underwent EUS-guided GJ for palliation of periampullary malignancies. METHODS From a total of 192 studies that were reviewed, 6 studies with a follow-up time frame of a minimum of 5 months were analyzed, totaling 238 patients. Outcome variables included technical success rate, clinical success rate, adverse events, symptom recurrence, and re-intervention rates. RESULTS The cohort of 238 patients had a technical success rate of 93.7% and a clinical success rate of 92.9%. A total of 25 patients (10.5%) experienced adverse events associated with EUS-GJ. A total of 14 patients (5.9%) experienced recurrence of GOO symptoms within 5 months. A total of 14 patients (5.9%) underwent re-intervention with the first 5 months. CONCLUSIONS This systematic review shows that data are scarce regarding long-term effectiveness of EUS-guided GJ. Even though early success rates have been reported, further studies are needed to focus on long-term efficacy of this approach. Until such studies become available, surgical palliation should continue to be the treatment of choice for patients with malignant GOO with a prolonged life expectancy.
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Affiliation(s)
- William Cobb
- Department of Surgery, AdventHealth Orlando, Orlando, FL, USA
| | - Shelby Harris
- Department of Surgery, AdventHealth Orlando, Orlando, FL, USA
| | - Jonathan Xavier
- School of Medicine, Loma Linda University, Loma Linda, CA, USA
| | - Sebastian G de la Fuente
- Department of Surgery, AdventHealth Orlando, Orlando, FL, USA.
- School of Medicine, Loma Linda University, Loma Linda, CA, USA.
- Department of Surgical Oncology, 2415 N. Orange Ave, Suite 400, Orlando, FL, 32804, USA.
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11
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Fugazza A, Andreozzi M, Asadzadeh Aghdaei H, Insausti A, Spadaccini M, Colombo M, Carrara S, Terrin M, De Marco A, Franchellucci G, Khalaf K, Ketabi Moghadam P, Ferrari C, Anderloni A, Capretti G, Nappo G, Zerbi A, Repici A. Management of Malignant Gastric Outlet Obstruction: A Comprehensive Review on the Old, the Classic and the Innovative Approaches. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:638. [PMID: 38674284 PMCID: PMC11052138 DOI: 10.3390/medicina60040638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/31/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
Gastrojejunostomy is the principal method of palliation for unresectable malignant gastric outlet obstructions (GOO). Gastrojejunostomy was traditionally performed as a surgical procedure with an open approach butrecently, notable progress in the development of minimally invasive procedures such as laparoscopic gastrojejunostomies have emerged. Additionally, advancements in endoscopic techniques, including endoscopic stenting (ES) and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are becoming more prominent. ES involves the placement of self-expandable metal stents (SEMS) to restore luminal patency. ES is commonly the first choice for patients deemed unfit for surgery or at high surgical risk. However, although ES leads to rapid improvement of symptoms, it carries limitations like higher stent dysfunction rates and the need for frequent re-interventions. Recently, EUS-GE has emerged as a potential alternative, combining the minimally invasive nature of the endoscopic approach with the long-lasting effects of a gastrojejunostomy. Having reviewed the advantages and disadvantages of these different techniques, this article aims to provide a comprehensive review regarding the management of unresectable malignant GOO.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Marta Andreozzi
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Hamid Asadzadeh Aghdaei
- Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Agustin Insausti
- Department of Gastroenterology and Digestive Endoscopy, Medical Association Hospital, IGEA Institute, Patricios 347, Bahia Blanca B8000, Argentina;
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Maria Terrin
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Alessandro De Marco
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Gianluca Franchellucci
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada;
| | - Pardis Ketabi Moghadam
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Chiara Ferrari
- Division of Anaesthesiology, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
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Paredero-Pérez I, Jimenez-Fonseca P, Cano JM, Arrazubi V, Carmona-Bayonas A, Covela-Rúa M, Fernández-Montes A, Martín-Richard M, Gironés-Sarrió R. State of the scientific evidence and recommendations for the management of older patients with gastric cancer. J Geriatr Oncol 2024; 15:101657. [PMID: 37957106 DOI: 10.1016/j.jgo.2023.101657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
Gastric cancer is one of the most frequent and deadly tumours worldwide. However, the evidence that currently exists for the treatment of older adults is limited and is derived mainly from clinical trials in which older patients are poorly represented. In this article, a group of experts selected from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Group for the Treatment of Digestive Tumours (TTD), and the Spanish Multidisciplinary Group on Digestive Cancer (GEMCAD) reviews the existing scientific evidence for older patients (≥65 years old) with gastric cancer and establishes a series of recommendations that allow optimization of management during all phases of the disease. Geriatric assessment (GA) and a multidisciplinary approach should be fundamental parts of the process. In early stages, endoscopic submucosal resection or laparoscopic gastrectomy is recommended depending on the stage. In locally advanced stage, the tolerability of triplet regimens has been established; however, as in the metastatic stage, platinum- and fluoropyrimidine-based regimens with the possibility of lower dose intensity are recommended resulting in similar efficacy. Likewise, the administration of trastuzumab, ramucirumab and immunotherapy for unresectable metastatic or locally advanced disease is safe. Supportive treatment acquires special importance in a population with different life expectancies than at a younger age. It is essential to consider the general state of the patient and the psychosocial dimension.
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Affiliation(s)
- Irene Paredero-Pérez
- Lluís Alcanyís de Játiva Hospital, Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Valencia, Spain
| | - Paula Jimenez-Fonseca
- Asturias Central University Hospital (HUCA), Health Research Institute of the Principality of Asturias (ISPA), Spanish Cooperative Group for the Treatment of Digestive Tumours (TTD), Oviedo, Spain
| | - Juana María Cano
- Ciudad Real University Hospital, Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Ciudad Real, Spain.
| | - Virginia Arrazubi
- Navarra University Hospital, Navarra Institute for Health Research (IdiSNA), Spanish Society of Medical Oncology (SEOM), Pamplona, Spain
| | - Alberto Carmona-Bayonas
- IMIB Morales Meseguer University Hospital, Murcia University (UMU), Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Murcia, Spain
| | - Marta Covela-Rúa
- Lucus Agusti University Hospital (HULA), Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Lugo, Spain
| | - Ana Fernández-Montes
- Ourense University Hospital Complex (CHUO), Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Orense, Spain
| | - Marta Martín-Richard
- Institut Català d'Oncologia (ICO) - Duran i Reynals University Hospital, Multidisciplinary Spanish Group of Digestive Cancer (GEMCAD), Barcelona, Spain.
| | - Regina Gironés-Sarrió
- Polytechnic la Fe University Hospital, Spanish Society of Medical Oncology (SEOM) Oncogeriatrics Section, Valencia, Spain
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13
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Conti Bellocchi MC, Gasparini E, Stigliano S, Ramai D, Bernardoni L, Di Matteo FM, Facciorusso A, Frulloni L, Crinò SF. Endoscopic Ultrasound-Guided Gastroenterostomy versus Enteral Stenting for Malignant Gastric Outlet Obstruction: A Retrospective Propensity Score-Matched Study. Cancers (Basel) 2024; 16:724. [PMID: 38398115 PMCID: PMC10887005 DOI: 10.3390/cancers16040724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen apposing metal stent has emerged as a minimally invasive treatment for the management of malignant gastric outlet obstruction (mGOO). We aimed to compare EUS-GE with enteral stenting (ES) for the treatment of mGOO. METHODS Patients who underwent EUS-GE or ES for mGOO between June 2017 and June 2023 at two Italian centers were retrospectively identified. The primary outcome was stent dysfunction. Secondary outcomes included technical success, clinical failure, safety, and hospital length of stay. A propensity score-matching analysis was performed using multiple covariates. RESULTS Overall, 198 patients were included (66 EUS-GE and 132 ES). The stent dysfunction rate was 3.1% and 16.9% following EUS-GE and ES, respectively (p = 0.004). Using propensity score-matching, 45 patients were allocated to each group. The technical success rate was 100% for both groups. Stent dysfunction was higher in the ES group compared with the EUS-GE group (20% versus 4.4%, respectively; p = 0.022) without differences in clinical efficacy (p = 0.266) and safety (p = 0.085). A significantly shorter hospital stay was associated with EUS-GE compared with ES (7.5 ± 4.9 days vs. 12.5 ± 13.0 days, respectively; p = 0.018). Kaplan-Meier analyses confirmed a higher stent dysfunction-free survival rate after EUS-GE compared with ES (log-rank test; p = 0.05). CONCLUSION EUS-GE offers lower rates of stent dysfunction, longer stent patency, and shorter hospital stay compared with ES.
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Affiliation(s)
- Maria Cristina Conti Bellocchi
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Enrico Gasparini
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Serena Stigliano
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, 00128 Rome, Italy; (S.S.); (F.M.D.M.)
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Hospital, Salt Lake City, UT 84112, USA;
| | - Laura Bernardoni
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Francesco Maria Di Matteo
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, 00128 Rome, Italy; (S.S.); (F.M.D.M.)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy;
| | - Luca Frulloni
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
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14
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Tarasov SA, Yartsev PA, Rogal MM, Aksenova SO. [Complicated gastric cancer and modern treatment approaches]. Khirurgiia (Mosk) 2024:125-140. [PMID: 38634594 DOI: 10.17116/hirurgia2024041125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Among all patients with gastric cancer, 40% admit to the hospitals due to cancer-related complications. The most common complications of gastric cancer are bleeding (22-80%), malignant gastric outlet obstruction (26-60%), and perforation (less than 5%). The main treatment methods for gastric cancer complicated by bleeding are various forms of endoscopic hemostasis, transarterial embolization and external beam radiotherapy. Surgical treatment is possible in case of ineffective management. However, surgical algorithm is not standardized. Malignant gastric outlet stenosis requires decompression: endoscopic stenting, palliative gastroenterostomy. Surgical treatment is also possible (gastrectomy, proximal or distal resection of the stomach). The main problem for patients with complicated gastric cancer is the lack of standardized algorithms and abundance of potential surgical techniques. The aim of our review is to systematize available data on the treatment of complicated gastric cancer and to standardize existing methods.
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Affiliation(s)
- S A Tarasov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - P A Yartsev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - M M Rogal
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - S O Aksenova
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
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15
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Patel D, Bhullar FA, Tagliaferri AR, Melki G, Grossman MA. Palliative Stenting for Gastric Outlet Obstruction Secondary to Pancreatic Adenocarcinoma. Cureus 2024; 16:e53186. [PMID: 38425636 PMCID: PMC10901673 DOI: 10.7759/cureus.53186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Pancreatic cancer is one of the most fatal malignancies due to its advanced stages at the time of presentation. Often, it is only diagnosed when patients present with late-stage complications, such as gastric outlet obstruction (GOO). Many patients experience a poor quality of life due to the side effects of GOO, such as persistent nausea, vomiting, and an inability to tolerate an oral diet, and as such, patients deteriorate quickly after their diagnosis. Because pancreatic cancer is diagnosed at advanced stages, many patients are not surgical candidates, and thus treatment is tailored for palliative measures. With GOO specifically, gastrojejunostomy has been the mainstay of palliative management; however, endoscopic stent placement is a new, innovative, and minimally invasive alternative option. Herein, we present a case of GOO as a complication of pancreatic adenocarcinoma, treated with palliative endoscopic stent placement. Further research is warranted to identify patients who would most benefit from this modality of palliation in the treatment of advanced pancreatic cancer.
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Affiliation(s)
- Dhruv Patel
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | - Furqan A Bhullar
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | | | - Gabriel Melki
- Internal Medicine, St. Joseph's Regional Medical Center, Paterson, USA
| | - Matthew A Grossman
- Interventional Gastroenterology, St. Joseph's Regional Medical Center, Paterson, USA
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16
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On W, Ahmed W, Everett S, Huggett M, Paranandi B. Utility of interventional endoscopic ultrasound in pancreatic cancer. Front Oncol 2023; 13:1252824. [PMID: 37781196 PMCID: PMC10540845 DOI: 10.3389/fonc.2023.1252824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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17
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Del Nero L, Sheijani AD, De Ceglie A, Bruzzone M, Ceppi M, Filiberti RA, Siersema P, Conio M. A Meta-Analysis of Endoscopic Stenting Versus Surgical Treatment for Malignant Gastric Outlet Obstruction. World J Surg 2023; 47:1519-1529. [PMID: 36869171 DOI: 10.1007/s00268-023-06944-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND AND AIM Surgical gastrojejunostomy (GJJ) and endoscopic stenting (ES) are the two most available treatments for palliation of malignant gastric obstruction (MGOO). The aim of this study is to compare these two techniques regarding efficacy, safety, time of hospitalization and survival. METHODS We performed a literature search from January 2010 to September 2020 to identify available randomized controlled studies and observational studies that compared ES and GJJ for the treatment of MGOO. RESULTS A total of 17 studies were found. ES and GJJ showed similar technical and clinical success rate. ES was superior to obtain early oral re-feeding, shorter length of hospitalization and a lower incidence of complications than GJJ. Surgical palliation had a lower recurrence rate of obstructive symptoms and longer overall survival than ES. CONCLUSIONS Both procedures have advantages and disadvantages. Probably we should not find the best palliation but the best approach based on the patient characteristics and tumor type.
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Affiliation(s)
- Lorenzo Del Nero
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy.
| | - Afscin Djahandideh Sheijani
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy
| | - Antonella De Ceglie
- Gastroenterology Department, Sanremo General Hospital, ASL1 Imperiese, Sanremo, IM, Italy
| | - Marco Bruzzone
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Marcello Ceppi
- Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Peter Siersema
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy.,Gastroenterology Department, Sanremo General Hospital, ASL1 Imperiese, Sanremo, IM, Italy.,Clinical Epidemiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Massimo Conio
- Gastroenterology Department, Santa Corona Hospital, ASL 2 Savonese, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy
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18
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Zulfiqar M, Ludwig DR, Strnad B, McVay M, Rengarajan A, Kushnir V, Mellnick V. Imaging features of marginal ulcers on multidetector CT. Clin Radiol 2023; 78:227-233. [PMID: 36376111 DOI: 10.1016/j.crad.2022.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/28/2022] [Accepted: 10/02/2022] [Indexed: 11/13/2022]
Abstract
AIM To assess the inter-reader agreement and frequency of various imaging findings of marginal ulcers on computed tomography (CT) in a series of patients with endoscopically or surgically confirmed marginal ulcer disease. MATERIALS AND METHODS This was a institutional review board-approved retrospective analysis involving a single academic institution. Eighty patients with a gastro-enteric anastomosis with confirmed marginal ulcer on endoscopy or surgery and multidetector (MD)CT performed within a month reviewed by two fellowship-trained abdominal radiologists to assess for the presence or absence of predetermined imaging characteristics categorised under signs of inflammation, signs of penetration, signs of perforation, and signs of obstruction. Inter-rater reliability was assessed using the Cohen kappa test. RESULTS Findings of perforation had moderate to substantial agreement, including the presence of extraluminal air, extraluminal fluid, and leakage of oral contrast medium (kappa 0.83 [0.61, 1.05], 0.57 [0.35, 0.79] and 0.75 [0.18, 1.31], respectively) although these were present relatively infrequently (23-26%, 30-43%, 3-4%, respectively). Additional imaging characteristics with moderate agreement were the presence of perienteric fat stranding, a dilated stomach proximal to the anastomosis, and penetration into adjacent organ (kappa 0.45 [0.23, 0.69], 0.47 [0.26, 0.69], and 0.47 [0.25, 0.69], respectively) which were variably present (80-88%, 11-16%, 5%, respectively). Wall thickening and contour abnormalities, although frequently present (61-90% and 60-80%, respectively) had only slight to fair agreement (kappa 0.09 [-0.14, 0.30] and 0.29 [0.07, 0.51]). CONCLUSION Signs of perforation have high inter-reader agreement but occur relatively infrequently. Fat stranding, wall thickening, and contour abnormalities are much more common; however, only fat stranding had moderate agreement.
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Affiliation(s)
- M Zulfiqar
- Department of Radiology, Mayo Clinic Phoenix Arizona, AZ, USA.
| | - D R Ludwig
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - B Strnad
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - M McVay
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - A Rengarajan
- Department of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - V Kushnir
- Department of Gastroenterology, Washington University School of Medicine, St Louis, MO, USA
| | - V Mellnick
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
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19
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Nakano Y, Mizumoto Y, Endoh B, Shimogama T, Iwamoto S, Esaka N, Ohta Y, Murai K, Murata M, Miyamoto S. Analysis of prognostic factors in patients with self-expandable metallic stents for treatment of malignant gastric outlet obstruction. Scand J Gastroenterol 2023:1-8. [PMID: 36728729 DOI: 10.1080/00365521.2023.2173534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM Self-expandable metallic stents (SEMSs) are widely accepted as a less-invasive treatment for malignant gastric outlet obstruction (GOO). However, the factors related to prognosis and stent dysfunction after SEMS placement are not well known, and we aimed to investigate them. METHODS This was a single-center retrospective cohort study of 212 malignant strictures in 207 patients. Factors related to prolonged overall survival (OS) and time to recurrent GOO (TRGOO) after SEMS placement were evaluated. RESULTS Improvement of oral intake was confirmed in 179 patients (86%). The median OS was 65 days. A Cox proportional hazards model revealed that lower cancer stage, lower performance status score at the time of SEMS placement, and administration of chemotherapy after SEMS placement were significant predictive factors for prolonged OS. The median OS was 182 days in the group of SEMS followed by chemotherapy (group A) and 43 days in the group of SEMS alone (group B) (p< .0001). Chemotherapy after SEMS implantation contributed to the prolongation of survival in gastric cancer (hazard ratio (HR), 0.12) and pancreatic cancer (HR, 0.41). Furthermore, the cumulative incidence rates of stent dysfunction on day 120 after SEMS placement were 30% in group A and 61% in group B (p=.03). Notably, the preventive effect of chemotherapy on stent dysfunction was significant in pancreatic cancer. CONCLUSIONS SEMS is a treatment with high technical and clinical success rate for malignant GOO. Furthermore, subsequent chemotherapy prolongs OS especially in gastric cancer, and TRGOO in pancreatic cancer.
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Affiliation(s)
- Yoshiko Nakano
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshinori Mizumoto
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Bunji Endoh
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.,Seijinkai Hospital, Osaka, Japan
| | - Tsubasa Shimogama
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Satoru Iwamoto
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Naoki Esaka
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshiyuki Ohta
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Katsuyuki Murai
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Shin'ichi Miyamoto
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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20
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Adams AM, Reames BN, Krell RW. Morbidity and Mortality of Non-pancreatectomy operations for pancreatic cancer: An ACS-NSQIP analysis. Am J Surg 2023; 225:315-321. [PMID: 36088140 DOI: 10.1016/j.amjsurg.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/13/2022] [Accepted: 08/21/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients with pancreas cancer may undergo palliative gastrointestinal or biliary bypass. Recent comparisons of post-operative outcomes following such procedures are lacking. METHODS We analyzed patients undergoing exploration, gastrojejunostomy, biliary bypass or double bypass for pancreatic cancer using data from the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program. We compared 30-day mortality and complications across procedures and over time periods (2005-10, 2011-14, 2015-19) using multivariable regression models. Factors associated with postoperative mortality were identified. RESULTS Of 43,525 patients undergoing surgery with a postoperative diagnosis of pancreatic cancer, 5572 met inclusion criteria. Palliative operations included 1037 gastrojejunostomies, 792 biliary bypasses, 650 double bypasses, and 3093 explorations. The proportion of biliary and double bypass procedures decreased from 2005-10 to 2015-19. Gastrojejunostomy had higher 30-day mortality rate (11.5%) than other operations (p < 0.001). Adjusted 30-day mortality rates remained stable over time (7.8% vs 6.3%, p = 0.095), while rates of serious complications decreased over time (23.2% vs 17.1%, p < 0.001). CONCLUSIONS Palliative bypass for pancreatic cancer has not become safer over time, and 30-day mortality and complications remain high.
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Affiliation(s)
- Alexandra M Adams
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Bradley N Reames
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Robert W Krell
- Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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21
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Shigoka H, Toki M, Takahashi S, Takahara N, Kitamura K, Iwasaki E, Nakahara K, Isayama H, Nakai Y, Maetani I. Gastroduodenal Stenting with a Flexible Stent Demonstrates Favorable Clinical Effectiveness despite Gradual Expansion: A Multicenter Prospective Study. J Clin Med 2023; 12:jcm12030850. [PMID: 36769496 PMCID: PMC9918094 DOI: 10.3390/jcm12030850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
AIMS This study aimed to evaluate the effectiveness and safety of stenting with a flexible braided self-expandable metal stent (SEMS) for unresectable malignant gastric outlet obstruction (GOO). METHODS Palliative stenting was prospectively carried out at seven university hospitals between October 2017 and August 2020. All procedures were performed using a flexible branded SEMS of the same brand. The primary endpoint was clinical success rate at 7 days after stenting. Secondary endpoints were procedural success rate, adverse events, recurrent gastric outlet obstruction (RGOO), and patient survival time. RESULTS Sixty patients were enrolled. The procedural and clinical success rates were 100% and 90%, respectively. RGOO occurred in 15 cases (25%). Adverse events other than RGOO were found in seven cases (12%). The 50% survival time was 75.5 days (range: 52-97 days). Median expansion rates at 1, 3, and 7 days after stenting were 55%, 65%, and 75%, respectively. CONCLUSIONS A flexible braided stent woven with relatively thin wires was used for malignant GOO. Despite a gradual expansion with slightly lower expansile force, the stent functioned sufficiently well and showed favorable results. Clinical Trials Registry ID: UMIN000029496.
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Affiliation(s)
- Hiroaki Shigoka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
| | - Masao Toki
- Department of Gastroenterology and Hepatology, Kyorin University School of Medicine, Tokyo 181-8611, Japan
| | - Sho Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo 113-8421, Japan
| | - Naminatsu Takahara
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
| | - Katsuya Kitamura
- Department of Gastroenterology and Hepatology, Tokyo Medical University Hachioji Medical Center, Tokyo 193-0998, Japan
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine, Tokyo 142-8555, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo 160-8582, Japan
| | - Kazunari Nakahara
- Department of Gastroenterology and Hepatology, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo 113-8421, Japan
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-0033, Japan
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo 153-8515, Japan
- Correspondence:
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Vanella G, Bronswijk M, Arcidiacono PG, Larghi A, Wanrooij RLJV, de Boer YS, Rimbas M, Khashab M, van der Merwe SW. Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice. Endosc Ultrasound 2023; 12:16-28. [PMID: 36124531 PMCID: PMC10134933 DOI: 10.4103/eus-d-21-00177] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven; Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Paolo Giorgio Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS; Center for Endoscopic Research Therapeutics and Training, Catholic University, Rome, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, AGEM Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mihai Rimbas
- Department of Internal Medicine, Carol Davila University of Medicine, Bucharest, Romania
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
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23
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Sánchez-Aldehuelo R, Subtil Iñigo JC, Martínez Moreno B, Gornals J, Guarner-Argente C, Repiso Ortega A, Peralta Herce S, Aparicio JR, Rodríguez de Santiago E, Bazaga S, Juzgado D, González-Panizo F, Albillos A, Vázquez-Sequeiros E. EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video). Gastrointest Endosc 2022; 96:1012-1020.e3. [PMID: 35870508 DOI: 10.1016/j.gie.2022.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/29/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Traditionally, palliative treatment of malignant gastric outlet obstruction (GOO) has been surgical, but surgical treatment carries significant morbidity and mortality rates. Endoscopic placement of a duodenal self-expandable metal stent (D-SEMS) has been proven to be successful for this indication in the short term. However, D-SEMSs are likely to malfunction over time. EUS-guided gastroenterostomy (EUS-GE) may help overcome these limitations. We aimed to evaluate stent failure-free survival at 3 months. METHODS A nationwide multicenter, observational study of D-SEMS and EUS-GE procedures for patients with malignant GOO was conducted at 7 academic centers from January 2015 to June 2020. Stent failure-free survival at 1, 3, and 6 months; technical and clinical success; adverse events (AEs); and patient survival were evaluated in both groups and compared. RESULTS Ninety-seven patients were included in the D-SEMS group and 79 in the EUS-GE group. Pancreatic cancer was the main underlying malignancy in 53.4%. No statistically significant differences regarding technical (92.8% vs 93.7%) or clinical success (83.5% vs 92.4%) were found. AE rates did not differ between groups (10.3% vs 10.1%), although 2 events in the EUS-GE group required surgical management. Patients in the EUS-GE group had improved stent patency when compared with those patients in the D-SEMS group at 3 months (92.23% vs 80.6%; adjusted hazard ratio, .37; P = .033). CONCLUSIONS EUS-GE seems to have improved patency outcomes when compared with D-SEMS placement for palliative treatment of malignant GOO. Prospective trials are needed to fully compare their efficacy and AE profile.
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Affiliation(s)
- Rubén Sánchez-Aldehuelo
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | | | - Belén Martínez Moreno
- Unidad de Endoscopia, ISABIAL, Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joan Gornals
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carlos Guarner-Argente
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alejandro Repiso Ortega
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Sandra Peralta Herce
- Unidad de Endoscopia, Servicio de Digestivo, Clínica Universidad de Navarra, Pamplona, Spain
| | - José Ramón Aparicio
- Unidad de Endoscopia, ISABIAL, Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Enrique Rodríguez de Santiago
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Sergio Bazaga
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Diego Juzgado
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
| | - Fernando González-Panizo
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
| | - Agustín Albillos
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Enrique Vázquez-Sequeiros
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain; Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
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24
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Randhawa NK, Khalyfa A, Khan M, Ahsan N, Inamullah M, Ayub K. Safety and Efficacy of Fully Covered Self-Expandable Metal Stents for Benign Upper Gastrointestinal Strictures Beyond the Esophagus. Cureus 2022; 14:e31439. [DOI: 10.7759/cureus.31439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2022] [Indexed: 11/14/2022] Open
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25
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Rosa F, Schena CA, Laterza V, Quero G, Fiorillo C, Strippoli A, Pozzo C, Papa V, Alfieri S. The Role of Surgery in the Management of Gastric Cancer: State of the Art. Cancers (Basel) 2022; 14:cancers14225542. [PMID: 36428634 PMCID: PMC9688256 DOI: 10.3390/cancers14225542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/15/2022] Open
Abstract
Surgery still represents the mainstay of treatment of all stages of gastric cancer (GC). Surgical resections represent potentially curative options in the case of early GC with a low risk of node metastasis. Sentinel lymph node biopsy and indocyanine green fluorescence are novel techniques which may improve the employment of stomach-sparing procedures, ameliorating quality of life without compromising oncological radicality. Nonetheless, the diffusion of these techniques is limited in Western countries. Conversely, radical gastrectomy with extensive lymphadenectomy and multimodal treatment represents a valid option in the case of advanced GC. Differences between Eastern and Western recommendations still exist, and the optimal multimodal strategy is still a matter of investigation. Recent chemotherapy protocols have made surgery available for patients with oligometastatic disease. In this context, intraperitoneal administration of chemotherapy via HIPEC or PIPAC has emerged as an alternative weapon for patients with peritoneal carcinomatosis. In conclusion, the surgical management of GC is still evolving together with the multimodal strategy. It is mandatory for surgeons to be conscious of the current evolution of the surgical management of GC in the era of multidisciplinary and tailored medicine.
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Affiliation(s)
- Fausto Rosa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Carlo Alberto Schena
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Vito Laterza
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Correspondence:
| | - Giuseppe Quero
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Claudio Fiorillo
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Carmelo Pozzo
- Medical Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Papa
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sergio Alfieri
- Digestive Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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26
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Khamar J, Lee Y, Sachdeva A, Anpalagan T, McKechnie T, Eskicioglu C, Agzarian J, Doumouras A, Hong D. Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis. Surg Endosc 2022:10.1007/s00464-022-09572-5. [PMID: 36138247 DOI: 10.1007/s00464-022-09572-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO. METHODS MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed. RESULTS After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001). CONCLUSION ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.
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Affiliation(s)
- Jigish Khamar
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada
| | - Anjali Sachdeva
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Tharani Anpalagan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - John Agzarian
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Aristithes Doumouras
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Dennis Hong
- Division of General Surgery, Department of Surgery, McMaster University, St. Joseph's Healthcare, Room G814, 50 Charlton Ave. East, Hamilton, ON, Canada. .,Department of Surgery, McMaster University, Hamilton, ON, Canada.
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27
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Maetani I. How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction? Front Med (Lausanne) 2022; 9:967740. [PMID: 36017000 PMCID: PMC9395687 DOI: 10.3389/fmed.2022.967740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.
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28
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The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13030025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.
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29
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Guacho JAL, Flor MM, Ferreira MTGB, Perez CDA, Martins BDC, Maluf-Filho F. Endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Endoscopy 2022; 54:E441-E442. [PMID: 34535029 DOI: 10.1055/a-1625-2840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- John Alexander Lata Guacho
- Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo, Brazil
| | - Marcelo Mochate Flor
- Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo, Brazil
| | - Marina Tucci G B Ferreira
- Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo, Brazil
| | - Caio de Almeida Perez
- Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo, Brazil
| | - Bruno da Costa Martins
- Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo, Brazil
| | - Fauze Maluf-Filho
- Department of Gastroenterology, Endoscopy Division, Cancer Institute of the University of São Paulo, São Paulo, Brazil
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30
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Hong J, Chen Y, Li J, Hu P, Chen P, Du N, Huang T, Chen J. Comparison of gastrojejunostomy to endoscopic stenting for gastric outlet obstruction: An updated Systematic Review and Meta-analysis. Am J Surg 2022; 223:1067-1078. [PMID: 34728070 DOI: 10.1016/j.amjsurg.2021.10.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND This study aimed to determine the optimal intervention modality for malignant GOO by comparing clinical outcomes after Gastrojejunostomy and endoscopic stenting. METHODS Two authors independently searched Web of Science, PubMed, Embase, and the Cochrane Library for articles before February 2021 to compare the clinical outcomes of GOO patients undergoing GJ or ES. RESULTS This meta-analysis included 31 articles with 2444 GOO patients. Although the GJ group outperformed the ES group in technical success (OR,3.79; P = 0.003), clinical success was not significantly different between the two groups (OR,1.25; P = 0.50). The GJ group had a longer hospitalization, lower re-obstruction and lower reintervention. Moreover, GJ had a better survival than ES in the gastric cancer group (HR, 0.33; P = 0.009). However, no significant statistical difference was observed in the pancreatic cancer group (HR, 0.55; P = 0.159). CONCLUSIONS Both GJ and ES are safe and effective intervention modalities for malignant GOO. GJ had significantly improved survival in gastric cancer patients with GOO, while no significant difference was observed between the two groups in pancreatic cancer patients with GOO.
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Affiliation(s)
- Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Yizhou Chen
- Emergency Medical Center, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China.
| | - Jiayu Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Peidong Hu
- Schools of Medicine & Nursing Sciences, Huzhou University, Huzhou, Zhejiang, China.
| | - Ping Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
| | - Nannan Du
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Jingjie Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
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31
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Outcomes of patients with malignant duodenal obstruction after receiving self-expandable metallic stents: A single center experience. PLoS One 2022; 17:e0268920. [PMID: 35613143 PMCID: PMC9132295 DOI: 10.1371/journal.pone.0268920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/10/2022] [Indexed: 12/27/2022] Open
Abstract
Objectives
Self-expandable metallic stent (SEMS) placement is a safe and effective palliative treatment for malignant gastric outlet obstruction; however, the clinical outcomes of gastric and duodenal stenoses may differ. This study aimed to investigate the clinical efficacy of SEMS placement and the predictors of clinical outcomes, specifically in malignant duodenal obstruction (MDO).
Methods
Between September 2009 and March 2021, 79 patients with MDO who received SEMS placement in our hospital were retrospectively enrolled. Patients were divided into three groups according to the obstruction levels: above-papilla group (type 1), papilla involved group (type 2), and below-papilla group (type 3). The clinical outcomes and predictors of survival and restenosis were analyzed.
Results
The technical and clinical success rates were 97.5% and 80.5%, respectively. Among patients who had successful stent placement, stent restenosis occurred in 17 patients (22.1%). The overall median stent patency time was 103 days. The overall median survival time after stent placement was 116 days. There was no difference in the stent patency, or stent dysfunction and procedure-related adverse events among the three groups. A longer length of duodenal stenosis ≥ 4 cm was associated with poor prognosis (hazard ratio [HR] = 1.92, 95% confidence interval [CI] = 1.06–3.49, p = 0.032) and post-stent chemotherapy was associated with lower mortality (HR = 0.33; 95% CI = 0.17–0.63, p = 0.001).
Conclusion
SEMS is a safe and effective treatment for MDO. Chemotherapy after SEMS implantation improve the survival for these patients and a longer length of stenosis predicts higher mortality.
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32
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Mahmoud T, Storm AC, Law RJ, Jaruvongvanich V, Ghazi R, Abusaleh R, Vargas EJ, Bazerbachi F, Levy MJ, Truty MJ, Chandrasekhara V, Abu Dayyeh BK. Efficacy and safety of endoscopic ultrasound-guided gastrojejunostomy in patients with malignant gastric outlet obstruction and ascites. Endosc Int Open 2022; 10:E670-E678. [PMID: 35571468 PMCID: PMC9106441 DOI: 10.1055/a-1797-9318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 02/22/2022] [Indexed: 11/18/2022] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an endoscopic procedure for treating gastric outlet obstruction (GOO). Limited data exist regarding the safety and efficacy of EUS-GJ in patients with malignant GOO with ascites. Thus, we aimed to study the outcomes and safety of EUS-GJ in GOO patients with vs. without ascites. Patients and methods This is a retrospective cohort study of patients with malignant GOO who underwent successful EUS-GJ at a tertiary care academic center. Primary outcomes included the efficacy and safety of EUS-GJ. Secondary outcomes included 30-day readmission, reintervention, and survival utilizing Kaplan-Meier analysis. Results A total of 55 patients (mean age of 67.0 ± 11.3 years, 40.0 % female) who underwent EUS-GJ, of whom 24 had ascites (small in 22, large in 2) were included. Clinical success was achieved in 91.7 % and 93.5 % ( P = 1.00) of patients with and without ascites, respectively. A higher rate of adverse events (AEs) was noted in patients with ascites but this was not statistically significant (37.5 % vs. 19.4 %, P = 0.13). Four patients in the ascites group (16.6 %) developed clinical evidence of peritonitis or sepsis post-EUS-GJ. Eight patients with ascites developed worsening ascites within a month of EUS-GJ. In contrast, only one patient without ascites developed evidence of new ascites. The median survival of patients was not significantly different between the two groups (patients with ascites: 129 days vs. patients without ascites: 180 days, ( P = 0.12). Conclusions The efficacy EUS-GJ in the presence of ascites is promising; however, the safety profile remains concerning given the high rate of AEs, specifically peritonitis and sepsis.
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Affiliation(s)
- Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Ryan J. Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Rami Abusaleh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J. Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Fateh Bazerbachi
- Interventional Endoscopy Program, CentraCare Digestive Center, St. Cloud Hospital, St. Cloud, Minnesota, United States
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Mark J. Truty
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Thomas J, Abraham K, Osilli D, Mukherjee S. Adult Distal Duodenal Obstruction: A Diagnostic and Therapeutic Challenge. Cureus 2022; 14:e24095. [PMID: 35573532 PMCID: PMC9100483 DOI: 10.7759/cureus.24095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Distal duodenal obstruction (DDO) can be succinctly defined as features of gastric outlet obstruction with bilious vomiting and radiological or endoscopic evidence of post-bulbar obstruction. Obstructions of the third (D3) and fourth (D4) parts of the duodenum are rare and present significant diagnostic and surgical challenges, particularly when the cause is malignant. In the following three case reports, we discuss three distinct aetiologies of this rare syndrome and highlight important considerations surrounding the early investigation and management of these individuals. The first patient is a 60-year-old lady with primary duodenal adenocarcinoma resulting in malignant stricture at D4. She underwent segmental resection of the D4 tumour with a duodeno-jejunal anastomosis. The second patient is a 17-year-old boy with superior mesenteric artery (SMA) syndrome, who was treated conservatively. The last patient is a 71-year-old lady with a caecal carcinoma invading the retroperitoneal structures and D3. The patient underwent a palliative laparoscopic gastro-jejunostomy. Although infrequently encountered in clinical practice, the individual burden of a missed or late diagnosis of DDO, malignant or otherwise, can be disastrous. This case series illustrates the varied presentation of DDO and discusses current principles of investigation and management.
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Affiliation(s)
- Joel Thomas
- Radiology, Barking, Havering and Redbridge University Hospitals National Health Service (NHS) Trust, Romford, GBR
| | - Karen Abraham
- General Surgery, Barking, Havering and Redbridge University Hospitals National Health Service (NHS) Trust, Romford, GBR
| | - Dixon Osilli
- General Surgery, Barking, Havering and Redbridge University Hospitals National Health Service (NHS) Trust, Romford, GBR
| | - Samrat Mukherjee
- General Surgery, Barking, Havering and Redbridge University Hospitals National Health Service (NHS) Trust, Romford, GBR
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Palliation in Gallbladder Cancer: The Role of Gastrointestinal Endoscopy. Cancers (Basel) 2022; 14:cancers14071686. [PMID: 35406458 PMCID: PMC8997124 DOI: 10.3390/cancers14071686] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/23/2022] [Accepted: 03/24/2022] [Indexed: 12/24/2022] Open
Abstract
Gallbladder cancer is a rare malignancy burdened by poor prognosis with an estimated 5-year survival of 5% to 13% due to late presentation, early infiltration of surrounding tissues, and lack of successful treatments. The only curative approach is surgery; however, more than 50% of cases are unresectable at the time of diagnosis. Endoscopy represents, together with surgery and chemotherapy, an available palliative option in advanced gallbladder cancers not eligible for curative treatments. Cholangitis, jaundice, gastric outlet obstruction, and pain are common complications of advanced gallbladder cancer that may need endoscopic management in order to improve the overall survival and the patients’ quality of life. Endoscopic biliary drainage is frequently performed to manage cholangitis and jaundice. ERCP is generally the preferred technique allowing the placement of a plastic stent or a self-expandable metal stent depending on the singular clinical case. EUS-guided biliary drainage is an available alternative for patients not amenable to ERCP drainage (e.g., altered anatomy). Gastric outlet obstruction is another rare complication of gallbladder malignancy growing in contact with the duodenal wall and causing its compression. Endoscopy is a less invasive alternative to surgery, offering different options such as an intraluminal self-expandable metal stent or EUS-guided gastroenteroanastomosis. Abdominal pain associated with cancer progression is generally managed with medical treatments; however, for incoercible pain, EUS-guided celiac plexus neurolysis has been described as an effective and safe treatment. Locoregional treatments, such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and intraluminal brachytherapy (IBT), have been described in the control of disease progression; however, their role in daily clinical practice has not been established yet. The aim of this study is to perform a review of the literature in order to assess the role of endoscopy and the available techniques in the palliative therapy of advanced gallbladder malignancy.
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Abstract
Importance Surgery plays a critical role in the management of all stages of gastric cancer. Observations For patients with early gastric cancer and low risk of lymph node metastasis, endoscopic therapy or surgery alone is potentially curative. Novel techniques, such as sentinel lymph node biopsy, may allow for greater use of stomach-sparing procedures that could improve quality of life without compromising oncologic outcomes; however, experience with these techniques is rare outside of East Asia, and studies of long-term outcomes are still ongoing. Patients with later-stage localized gastric cancer benefit from more extensive lymphadenectomy and multimodality therapy, as they are at risk for nodal and distant metastases. There have been recent advances in chemotherapy that have led to improved survival, but the optimal sequencing of multimodality therapy is still being investigated. Better systemic therapy may also increase the role of surgery for patients with oligometastatic disease. There are ongoing studies examining the efficacy of peritoneal-directed therapies in both patients with low-volume peritoneal disease and patients at high risk of peritoneal recurrence. Conclusions and Relevance The management of gastric cancer continues to evolve. Surgeons should be aware of novel surgical approaches currently under investigation as well as how surgery fits into the contemporary multidisciplinary approach to this disease.
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Affiliation(s)
- George Z Li
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jiping Wang
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Hashmi SSH, Trusty RK, Mora MCF, Abushahin A, Winters H. A Unique Case of Invasive Adenocarcinoma of the Body and Tail of the Pancreas Presenting as Gastric Outlet Obstruction. Cureus 2022; 14:e23154. [PMID: 35433144 PMCID: PMC9007278 DOI: 10.7759/cureus.23154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
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Ajani JA, D'Amico TA, Bentrem DJ, Chao J, Cooke D, Corvera C, Das P, Enzinger PC, Enzler T, Fanta P, Farjah F, Gerdes H, Gibson MK, Hochwald S, Hofstetter WL, Ilson DH, Keswani RN, Kim S, Kleinberg LR, Klempner SJ, Lacy J, Ly QP, Matkowskyj KA, McNamara M, Mulcahy MF, Outlaw D, Park H, Perry KA, Pimiento J, Poultsides GA, Reznik S, Roses RE, Strong VE, Su S, Wang HL, Wiesner G, Willett CG, Yakoub D, Yoon H, McMillian N, Pluchino LA. Gastric Cancer, Version 2.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:167-192. [PMID: 35130500 DOI: 10.6004/jnccn.2022.0008] [Citation(s) in RCA: 775] [Impact Index Per Article: 258.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastric cancer is the third leading cause of cancer-related deaths worldwide. Over 95% of gastric cancers are adenocarcinomas, which are typically classified based on anatomic location and histologic type. Gastric cancer generally carries a poor prognosis because it is often diagnosed at an advanced stage. Systemic therapy can provide palliation, improved survival, and enhanced quality of life in patients with locally advanced or metastatic disease. The implementation of biomarker testing, especially analysis of HER2 status, microsatellite instability (MSI) status, and the expression of programmed death-ligand 1 (PD-L1), has had a significant impact on clinical practice and patient care. Targeted therapies including trastuzumab, nivolumab, and pembrolizumab have produced encouraging results in clinical trials for the treatment of patients with locally advanced or metastatic disease. Palliative management, which may include systemic therapy, chemoradiation, and/or best supportive care, is recommended for all patients with unresectable or metastatic cancer. Multidisciplinary team management is essential for all patients with localized gastric cancer. This selection from the NCCN Guidelines for Gastric Cancer focuses on the management of unresectable locally advanced, recurrent, or metastatic disease.
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Affiliation(s)
| | | | - David J Bentrem
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | - Prajnan Das
- The University of Texas MD Anderson Cancer Center
| | - Peter C Enzinger
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | | | | | - Farhood Farjah
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | | | | | | | | | - Rajesh N Keswani
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Samuel J Klempner
- Dana-Farber/Brigham and Women's Cancer Center
- Massachusetts General Hospital Cancer Center
| | - Jill Lacy
- Yale Cancer Center/Smilow Cancer Hospital
| | | | | | - Michael McNamara
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Mary F Mulcahy
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | - Haeseong Park
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | - Kyle A Perry
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Scott Reznik
- UT Southwestern Simmons Comprehensive Cancer Center
| | - Robert E Roses
- Abramson Cancer Center at the University of Pennsylvania
| | | | | | | | | | | | - Danny Yakoub
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
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Azemoto N, Ueno M, Yanagimoto H, Mizuno N, Kawamoto Y, Maruki Y, Watanabe K, Suzuki R, Kaneko J, Hisada Y, Sato H, Kobayashi S, Miyata H, Furukawa M, Mizukami T, Miwa H, Ohno Y, Tsuji K, Tsujimoto A, Nagano H, Okuyama H, Asagi A, Okano N, Ishii H, Morizane C, Ikeda M, Furuse J. Endoscopic duodenal stent placement versus gastrojejunostomy for unresectable pancreatic cancer patients with duodenal stenosis before introduction of initial chemotherapy (GASPACHO study): a multicenter retrospective study. Jpn J Clin Oncol 2022; 52:134-142. [PMID: 34969090 DOI: 10.1093/jjco/hyab194] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/26/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endoscopic duodenal stent placement is an alternative technique to gastrojejunostomy for gastric outlet obstruction due to pancreatic cancer. We compared the efficacy of endoscopic duodenal stent placement with that of gastrojejunostomy for treating patients with pancreatic cancer who are candidates for intensive combination chemotherapies as the first line of treatment. METHODS This retrospective observational study included 100 patients from 18 institutions in Japan. Inclusion criteria were as follows: (1) cytologically or histologically confirmed adenocarcinoma of the pancreas, (2) good performance status, (3) gastric outlet obstruction scoring system score of 0-1 and (4) no history of treatment for pancreatic cancer. RESULTS There was no significant difference in the background characteristics of patients in the endoscopic duodenal stent placement (n = 57) and gastrojejunostomy (n = 43) groups. The median overall survival in the endoscopic duodenal stent placement and gastrojejunostomy groups was 5.9 and 6.0 months, respectively. Clinical success was achieved in 93 cases; the median time to food intake resumption was significantly shorter in the endoscopic duodenal stent placement group (median: 3 days, n = 54) than in the gastrojejunostomy group (median: 5 days, n = 43). Chemotherapy was introduced in 63% of the patients in both groups after endoscopic duodenal stent placement or gastrojejunostomy. Chemotherapy was started earlier in the endoscopic duodenal stent placement group (median: 14 days) than in the gastrojejunostomy (median: 32 days) group. CONCLUSIONS Endoscopic duodenal stent placement showed similar or better clinical outcomes than gastrojejunostomy. Thus, it might be a promising option in patients with good performance status.
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Affiliation(s)
- Nobuaki Azemoto
- Center of Liver-Biliary-Pancreatic Diseases, Matsuyama Red Cross Hospital, Matsuyama, Japan
- Department of Gastroenterology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Makoto Ueno
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Hiroaki Yanagimoto
- Department of Surgery, Division of Hepato-Biliary-Pancreatic Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuyuki Kawamoto
- Division of Cancer Center, Hokkaido University Hospital, Sapporo, Japan
| | - Yuta Maruki
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuo Watanabe
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Junichi Kaneko
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yuya Hisada
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroki Sato
- Division of Metabolism and Biosystemic Science, Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Satoshi Kobayashi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, Yokohama, Japan
| | - Hideki Miyata
- Gastroenterology Center, Ehime Prefecture Central Hospital, Matsuyama, Japan
| | - Masayuki Furukawa
- Department of Hepato-Biliary-Pancreatology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Takuro Mizukami
- Department of Clinical Oncology, St Marianna University School of Medicine, Kawasaki, Japan
| | - Haruo Miwa
- Department of Gastroenterology, Yokohama City University Medical Center, Yokohama, Japan
| | - Yoshinori Ohno
- Department of Gastroenterology, Uwajima Municipal Hospital, Uwajima, Japan
| | - Kunihiro Tsuji
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Akiko Tsujimoto
- Division of Gastroenterology, Chiba Cancer Center, Chiba, Japan
| | - Hiroaki Nagano
- Department of Gastroenterological, Breast and Endocrine Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Hiroyuki Okuyama
- Department of Clinical Oncology, Kagawa University Hospital, Miki, Japan
| | - Akinori Asagi
- Department of Gastroenterology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Naohiro Okano
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Hiroshi Ishii
- Division of Gastroenterology, Chiba Cancer Center, Chiba, Japan
| | - Chigusa Morizane
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Masafumi Ikeda
- Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East, Kashiwa, Japan
| | - Junji Furuse
- Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan
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Chamely EA, Hoang B, Jafri NS, Felinski MM, Bajwa KS, Walker PA, Barge J, Wilson EB, Cen P, Shah SK. Palliative Endoscopic Salvage of a Functionally Obstructed Gastrojejunostomy - Report of Technique. CRSLS : MIS CASE REPORTS FROM SLS 2022; 9:e2021.00094. [PMID: 36016812 PMCID: PMC9387390 DOI: 10.4293/crsls.2021.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Gastric outlet obstruction secondary to foregut gastrointestinal malignancies can be managed with a variety of medical, endoscopic, and surgical options. Laparoscopic gastrojejunostomy is an option for those patients who are able to tolerate an operation as a long-term palliative option. This operation may be associated with some significant postoperative technical and nontechnical complications, including delayed gastric emptying. This paper describes an incision-less, endoscopic option that we propose can be used to salvage a functionally obstructed gastrojejunostomy. CASE DESCRIPTION A 57-year old male patient had a history of pancreatic adenocarcinoma causing gastric outlet obstruction and underwent a previously created surgical gastrojejunostomy at an outside hospital. His procedure was complicated by anastomotic leak and essentially persistent obstructive symptoms secondary to delayed gastric emptying. Though his anastomosis was demonstrably patent, these symptoms were thought to be secondary to a functional obstruction at the gastrojejunostomy. After repeated workups and many failed attempts to treat these symptoms, he ultimately underwent endoscopic placement of an uncovered colonic stent into the efferent limb of his gastrojejunostomy. This allowed for preferential drainage of gastric contents down the efferent limb, and improvement of his delayed gastric emptying. CONCLUSIONS In a select group of patients with advanced foregut malignancy, and with high re-operative risks, salvage endoscopic stenting may be useful in the palliation of symptoms from a functionally obstructed gastrojejunostomy.
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Affiliation(s)
- Elias A Chamely
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan Hoang
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Nadim S Jafri
- Michael E DeBakey Institute of Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX
| | - Melissa M Felinski
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Kulvinder S Bajwa
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Peter A Walker
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Erik B Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Putao Cen
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
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Kamposioras K, Geraghty J, Appleyard J, Dawod M, Papadimitriou K, Lamarca A, Anthoney A. Pancreaticobiliary Malignancies in the Emergency Room: Management of Acute Complications and Oncological Emergencies. J Gastrointest Cancer 2021; 53:1050-1065. [PMID: 34648136 PMCID: PMC9630225 DOI: 10.1007/s12029-021-00718-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
Background Management of pancreaticobiliary (PB) malignancies remains a clinical challenge. In this review, we focus on the management of oncological emergencies in PB malignancies and the potential complication of associated therapeutic interventions. Methods Biobliographic review of current evidence on the management of oncological emergencies, their potential complications, as well as synthesis of recommendations was performed. The pathogenesis, frequency, related symptoms as well as appropriate investigations are presented. Results The oncologic emergencies in PB patients were summarised in six categories: (1) hematological (including febrile neutropaenia, thrombocytopenia, coagulopathies), (2) gastrointestinal (gastric outlet and biliary obstruction, gastrointestinal bleeding), (3) thromboembolic events, (4) ascites, (5) metabolic disorders and (6) neurologic complications. The pathogenesis, frequency, related symptoms as well as appropriate investigations are also presented. Conclusion Patients with PB malignancies are at increased risk of a wide variation of medical emergencies. Clinical knowledge, early recognition and collaboration with the relevant specialties are critical to manage these complications effectively, tailoring overall management around the actual prognosis and individuals’ expectations.
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Affiliation(s)
| | - Joe Geraghty
- Department of Gastroenterology, Manchester Royal Infirmary, Manchester, UK
| | | | - Mohammed Dawod
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK
| | | | - Angela Lamarca
- The Christie NHS Foundation Trust, Manchester, Greater Manchester, UK.,Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alan Anthoney
- Leeds Institute of Medical Research, St James' Institute of Oncology, St James' University Hospital, University of Leeds, Leeds, LS9 7TF, UK.
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Ovalle-Hernández AF, Vargas-Rubio RD. Experience in the management of neoplastic gastric outlet obstruction in patients at the Hospital Universitario San Ignacio in Bogotá, Colombia. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2021; 87:35-43. [PMID: 34656501 DOI: 10.1016/j.rgmxen.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 09/28/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Malignant gastric outlet obstruction is a condition that alters patient quality of life, conditioning progressive malnutrition. However, self-expanding metal stents (SEMSs) and surgical gastrojejunostomy (SGJ) are palliative options in patients with unresectable disease. AIM To characterize patients diagnosed with malignant gastric outlet obstruction requiring SEMS placement or SGJ. MATERIALS AND METHODS Sequential non-probability convenience sampling was conducted and included 68 patients, 40 of whom had SEMS placement and 28 of whom underwent SGJ. RESULTS Patients sought medical consultations for the symptoms of vomiting, abdominal pain, weight loss, and upper gastrointestinal bleeding. Ninety-five percent of the patients in the SEMS group and 64.3% in the SGJ group presented with metastasis. Technical and clinical success, patency duration, and number of patients with no complications were greater in the SGJ group. Mean survival in days was 88 (SD ± 21) in the SEMS group versus 501 (SD ± 122) in the SGJ group. The log-rank test detected a statistically significant difference between subgroups (p = 0.00). CONCLUSION SGJ has greater technical and clinical success rates but SEMS placement continues to be utilized in distal gastric cancer, especially in cases in which surgery is not an option.
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Affiliation(s)
- A F Ovalle-Hernández
- Unidad de Gastroenterología, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá D.C., Colombia.
| | - R D Vargas-Rubio
- Unidad de Gastroenterología, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogotá D.C., Colombia
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Porter RJ, McKinlay AW, Metcalfe EL. Endoscopically placed venting gastrostomy can be a safe and effective palliative intervention in benign and malignant gastrointestinal obstruction. Frontline Gastroenterol 2021; 13:309-315. [PMID: 35722598 PMCID: PMC9186026 DOI: 10.1136/flgastro-2021-101930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/05/2021] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Chronic gastrointestinal obstruction can precipitate a constellation of symptoms including nausea, vomiting, abdominal distension and pain that negatively impact on health-related quality of life. Decompression via venting gastrostomy can offer symptomatic relief but safety and efficacy data are sparse. This study characterises the diverse venting percutaneous endoscopic gastrostomy (vPEG) cohort at our tertiary referral centre and defines the safety and efficacy of this procedure. METHODS Patients undergoing vPEG between May 2012 and June 2020 were identified from a prospectively maintained database and demographic, procedure-related and mortality data were extracted. Retrospective analysis of case notes provided data on patient symptoms. Last follow-up was May 2021. RESULTS 27 patients (median age 63, range 18-90 years) underwent vPEG insertion. The majority of vPEGs were for patients with obstruction secondary to locally advanced or metastatic malignancy (n=21/27, 77.8%). Six procedures were performed for benign disease (n=6/27, 22.2%). No patients developed the recognised serious complications of bleeding, perforation or peritonitis from vPEG insertion. Symptoms of nausea (p=0.006), vomiting (p<0.001), abdominal distension (p<0.001) and abdominal pain (p=0.002) were improved following vPEG. Pain beyond the expected postprocedural discomfort was associated with a lower number of days survived postprocedure (p=0.026). CONCLUSION vPEG can be a safe and efficacious palliative intervention for benign and malignant chronic gastrointestinal obstruction. Severe postprocedural pain should be promptly investigated to exclude a potential complication. A defined clinical strategy for assessing and managing these patients would facilitate wider recognition of the benefits of vPEG and improve the safety profile in centres with more limited experience.
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Affiliation(s)
- Ross J Porter
- Department of Digestive Disorders, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK,Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
| | - Alastair W McKinlay
- Department of Digestive Disorders, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | - Emma L Metcalfe
- Department of Digestive Disorders, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
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Ahmed O, Lee JH, Thompson CC, Faulx A. AGA Clinical Practice Update on the Optimal Management of the Malignant Alimentary Tract Obstruction: Expert Review. Clin Gastroenterol Hepatol 2021; 19:1780-1788. [PMID: 33813072 DOI: 10.1016/j.cgh.2021.03.046] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/22/2021] [Accepted: 03/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The purpose of this expert review is to describe the current methodologies available to manage malignant alimentary tract obstructions as well the evidence behind the various methods (including their efficacy and safety), indications, and appropriate timing of interventions. METHODS This is not a formal systematic review but is based on a review of the literature to provide best practice advice statements. No formal rating of the quality of evidence or strength of recommendation is carried out. BEST PRACTICE ADVICE 1: For all patients with alimentary tract obstruction, the decision about specific interventions should be made in a multidisciplinary setting including oncologists, surgeons, and endoscopists and take into account the characteristics of the obstruction, patient's expectations, prognosis, expected subsequent therapies, and functional status. BEST PRACTICE ADVICE 2: For patients who present with esophageal obstruction from esophageal cancer and who are potential candidates for resection or chemoradiation, clinicians should not routinely insert a self-expanding metal stent (SEMS) without multidisciplinary review because of high rates of stent migration, higher morbidity and mortality, and potentially lower R0 (microscopically negative margins) resection rates. BEST PRACTICE ADVICE 3: For patients who present with esophageal obstruction from esophageal cancer who are potential candidates for resection and who have concerns of malnutrition, clinicians may consider the use of enteral feeding tubes (via nasogastric or percutaneous route). Clinicians should be aware of the potential risk of abdominal wall tumor seeding as well as making subsequent gastric conduit formation difficult with percutaneous endoscopic gastrostomy placement. BEST PRACTICE ADVICE 4: For patients who present with esophageal obstruction from esophageal cancer who are not candidates for resection, clinicians should consider either SEMS insertion or brachytherapy as sole therapy or in combination. Clinicians should not consider the use of laser therapy or photodynamic therapy because of the lack of evidence of better outcomes and superior alternatives. BEST PRACTICE ADVICE 5: For patients with malignant esophageal obstruction who are undergoing SEMS placement, clinicians should use a fully covered or partially covered SEMS and not an uncovered SEMS, with consideration of a stent-anchoring/fixation method. BEST PRACTICE ADVICE 6: For patients with gastric outlet obstruction who have a life expectancy greater than 2 months, have good functional status, and who are surgically fit, surgical gastrojejunostomy should be considered. BEST PRACTICE ADVICE 7: For patients with gastric outlet obstruction who are undergoing surgical gastrojejunostomy, a laparoscopic approach is favored over an open approach because of lower blood loss and shorter hospital stay. BEST PRACTICE ADVICE 8: For patients with gastric outlet obstruction who are not candidates for gastrojejunostomy (surgical or endoscopic ultrasound-guided), clinicians should consider the insertion of an enteral stent. BEST PRACTICE ADVICE 9: Enteral stents should not be used in patients with multiple luminal obstructions or severely impaired gastric motility because of the limited benefit in these scenarios. Clinicians can consider placement of a venting gastrostomy in these patients. BEST PRACTICE ADVICE 10: Depending on the experience of the endoscopist, endoscopic ultrasound-guided gastrojejunostomy is an acceptable alternative to surgical gastrojejunostomy and enteral stent placement. Clinicians should be aware that there are currently no dedicated Food and Drug Administration-approved devices for endoscopic ultrasound-guided gastrojejunostomy. BEST PRACTICE ADVICE 11: For patients with malignant colonic obstruction who are candidates for resection, insertion of SEMS is a reasonable choice as a "bridge to surgery" to allow for one-stage, elective resection. BEST PRACTICE ADVICE 12: For patients with malignant colonic obstruction who are not candidates for resection, either SEMS placement or a diverting colostomy are reasonable choices depending on the patient's goals and functional status. BEST PRACTICE ADVICE 13: SEMS is a reasonable option for patients with proximal (or right-sided) malignant obstructions, both as a "bridge to surgery" and in the palliative setting. BEST PRACTICE ADVICE 14: SEMS placement is a reasonable alternative for patients with extracolonic malignancy who are not candidates for surgery, although their placement is more technically challenging, clinical success rates are more variable, and complications (including stent migration) are more frequent.
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Affiliation(s)
- Osman Ahmed
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey H Lee
- Department of Gastroenterology, M. D. Anderson Cancer Center, Houston, Texas.
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ashley Faulx
- Department of Medicine, Case Western Reserve University, and University Hospitals, Cleveland Medical Center, Cleveland, Ohio
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Laparoscopic versus EUS-guided gastroenterostomy for gastric outlet obstruction: an international multicenter propensity score-matched comparison (with video). Gastrointest Endosc 2021; 94:526-536.e2. [PMID: 33852900 DOI: 10.1016/j.gie.2021.04.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 04/03/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic GE (L-GE) are scarce. Our aim was to perform a propensity score-matched comparison between EUS-GE and L-GE. METHODS An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of .1 was applied, also considering underlying disease and oncologic staging. RESULTS Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE-treated patients (94.6%) versus 100% in the L-GE group (P = .493). Clinical success, defined as eating without vomiting or GOO Scoring System ≥2, was achieved in 97.1% and 89.2%, respectively (P = .358). Median time to oral intake (1 [interquartile range {IQR}, .3-1.0] vs 3 [IQR, 1.0-5.0] days, P < .001) and median hospital stay (4 [IQR, 2-8] vs 8 [IQR, 5.5-20] days, P < .001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P = .007) and severe (.0% vs 16.2%, P = .025) adverse events were identified more frequently in the L-GE group. CONCLUSIONS For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable.
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Havre RF, Dai C, Roug S, Novovic S, Schmidt PN, Feldager E, Karstensen JG, Pham KDC. EUS-guided gastroenterostomy with a lumen apposing self-expandable metallic stent relieves gastric outlet obstruction - a Scandinavian case series. Scand J Gastroenterol 2021; 56:972-977. [PMID: 34236273 DOI: 10.1080/00365521.2021.1925338] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND EUS-guided gastroenterostomy (EUS-GE) with lumen-apposing metallic stents (LAMS) in patients with gastric outlet obstruction (GOO) has proven to be an alternative to luminal stenting in the duodenum and surgical gastroenterostomy. In severely ill patients, the method can provide improved quality of life (QoL) and symptom relief by restoration of the luminal passage of fluid and nutrients to the small intestine. AIM To assess the technical and clinical success and safety of EUS-GE. MATERIAL AND METHODS A dual center retrospective case series of 33 consecutive patients with GOO due to malignant (n = 28) or non-malignant conditions (n = 5). The patients were treated with EUS-GE using cautery enhanced LAMS. Procedures were performed guided by EUS and fluoroscopy in general anesthesia or conscious sedation. RESULTS Technical success was achieved in all patients. The median procedure time was 71 min and the median hospital stay was three days. Thirty (91%) patients were able to resume oral nutrition after the procedure. Ten patients (30%) experienced adverse events (AEs), including migration of the stent, bleeding, and infection. Four patients had fatal AEs (12%). All stent-related AEs were handled endoscopically. Five patients (15%) needed re-intervention. The median survival time for patients with malignant obstruction was 8.5 weeks (0.5-76), and 13 patients with obstructing malignancies lived 12 weeks or longer. CONCLUSION EUS-GE is a minimally invasive and efficient method for restoration of the gastrointestinal passage and may improve palliative care for patients with GOO. The method has potential hazards and should only be offered in expert centers that regularly perform the procedure.
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Affiliation(s)
- R F Havre
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - C Dai
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - S Roug
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - S Novovic
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - P N Schmidt
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - E Feldager
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - J G Karstensen
- Gastro Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - K D C Pham
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Abstract
Surgery is an essential component of curative-intent treatment strategies for gastric cancer. However, the care of each patient with gastric cancer must be individualized based on patient and tumor characteristics. It is important that all physicians who will be caring for patient with gastric cancer understand the current best practices of surgical management to provide patients with the highest quality of care. This article aims to provide this information while acknowledging areas of surgical management that are still controversial.
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Affiliation(s)
- Ian Solsky
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue Block Building #112, New York, NY 10461, USA
| | - Haejin In
- Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, 1300 Morris Park Avenue Block Building #112, New York, NY 10461, USA; Department of Surgery, Albert Einstein College of Medicine, New York, NY, USA; Department of Epidemiology and Population Health, Albert Einstein College of Medicine, New York, NY, USA.
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Arnstadt B, Allescher HD. [Palliative endoscopy]. Chirurg 2021; 93:310-322. [PMID: 34137905 DOI: 10.1007/s00104-021-01426-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/07/2022]
Abstract
Endoscopy is the leading method in the diagnostics of gastrointestinal malignancies. With the increasing incidences of various tumor entities, a palliative treatment situation is already present in many patients despite an increasing number of screening strategies. Palliative endoscopy can make an essential contribution to alleviation of tumor-related symptoms, such as dysphagia, malnutrition, cholestasis, ileus and pain. Various approaches can be offered to safeguard the nutrition, e.g. percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ), for maintenance of the gastrointestinal passage (stents) and secretion drainage or to drain congested hollow organs. Furthermore, in cases of inaccessibility or impassability of stenoses due to tumors, endosonographically assisted punctures offer the possibility to guarantee new drainage options or continuities by stent placement. In all interventions possible contraindications and complications must be taken into account.
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Affiliation(s)
- Benno Arnstadt
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland.
| | - Hans-Dieter Allescher
- Gastroenterologie, Hepatologie, Stoffwechsel, Nephrologie, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Deutschland
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Klose J, Rieder S, Ronellenfitsch U. Surgical and interventional treatment options in unresectable gastrointestinal cancer. SURGERY IN PRACTICE AND SCIENCE 2021. [DOI: 10.1016/j.sipas.2021.100037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Kobayashi S, Ueno M, Nagashima S, Sano Y, Kawano K, Fukushima T, Asama H, Tezuka S, Morimoto M. Association between time to stent dysfunction and the anti-tumour effect of systemic chemotherapy following stent placement in patients with pancreaticobiliary cancers and malignant gastric outlet obstruction: a retrospective cohort study. BMC Cancer 2021; 21:576. [PMID: 34011301 PMCID: PMC8136227 DOI: 10.1186/s12885-021-08336-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background Malignant gastric outlet obstruction (MGOO) occasionally occurs due to pancreaticobiliary cancer. Endoscopic duodenal stenting (DS) is a common treatment for MGOO. However, it has been reported that DS does not have sufficient patency time for it to be used in patients who have a potentially increased lifespan. Nowadays, systemic chemotherapy for pancreaticobiliary cancer has developed, and its anti-tumour effect would make time to stent dysfunction longer. Therefore, we retrospectively evaluated the association between objective response to systemic chemotherapy, followed by DS and time to stent dysfunction in patients with advanced pancreaticobiliary cancer. Methods This retrospective study included 109 patients with advanced pancreaticobiliary cancer who received systemic chemotherapy after DS. Patients who showed complete or partial response were defined as responders. The rest were defined as non-responders. Time to stent dysfunction was compared between responders and non-responders using the landmark analysis at 2 months after DS. Death without recurrence of MGOO was considered as a competing risk for time to stent dysfunction. Results Combination and monotherapy regimens were adopted for 46 and 63 patients, respectively. Median progression-free survival and overall survival were 3.2 months (95% confidence interval [CI], 2.4–4.0) and 6.0 months (95% CI, 4.6–7.3). Objective response was observed in 21 patients (19.3%). Median time to stent dysfunction was 12.5 months (95% CI, 8.4–16.5) in the entire cohort. In 89 patients, responders had a lower cumulative incidence of stent dysfunction than non-responders: 9.5 and 19.1% at 6 months, and 19.0 and 27.9% at 1-year, respectively. There was difference of time to stent dysfunction between responders and non-responders among patients who received combination regimen as the first-line treatment with p-value of 0.009: cumulative incidence was 0 and 42.9% at 6 months, and 9.3 and 57.1% at 1-year, respectively. Conclusions Longer time to stent dysfunction is expected when systemic chemotherapy following DS suppresses tumour progression; DS is slated to be a standard treatment for MGOO even in patients with pancreaticobiliary cancer and a long lifespan. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-08336-z.
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Affiliation(s)
- Satoshi Kobayashi
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan.
| | - Makoto Ueno
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Shuhei Nagashima
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Yusuke Sano
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Kuniyuki Kawano
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Taito Fukushima
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Shun Tezuka
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
| | - Manabu Morimoto
- Department of Gastroenterology, Hepatobiliary and Pancreatic Medical Oncology Division, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama City, 241-0815, Japan
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Heo YC, Han DK, Kim MT. Therapeutic effect of local photothermal heating of gold nanoparticle-coated self-expandable metallic stents for suppressing granulation tissue formation in the mouse colon. PLoS One 2021; 16:e0249530. [PMID: 33798254 PMCID: PMC8018628 DOI: 10.1371/journal.pone.0249530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/21/2021] [Indexed: 01/10/2023] Open
Abstract
PURPOSE To investigate the therapeutic effect of local photothermal (PT) heating on suppression of stent-induced granulation tissue formation in mouse colon. MATERIALS AND METHODS A gold nanoparticle (GNP)-coated self-expandable metallic stent (SEMS) was prepared using a two-step synthesis process for local PT heating under near-infrared laser irradiation. Twenty-four mice were randomly divided into two groups of 12 and subjected to SEMS placement in the colon. Group A received a GNP-coated SEMS without local heating and Group B received a GNP-coated SEMS and underwent local heating at 55°C after SEMS placement. The therapeutic effect of local heating was assessed by comparing the histopathological, immunohistochemical, and endoscopic results. RESULTS Four mice were excluded because of stent migration (n = 3, group B) or death (n = 1, group A). Stent-induced granulation tissue-related variables were significantly lower in group B than in group A (p < 0.001). In vivo endoscopic images, 4 weeks after stent placement, showed granulation tissue formation over the wire mesh in group A and relatively good patency of the stented colon with no definite irregularities in group B. There was more vascular endothelial growth factor (VEGF) positivity in group A than in group B. CONCLUSION Local PT heating suppresses granulation tissue formation after stent placement in mouse colon.
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Affiliation(s)
- Yeong-Cheol Heo
- Department of Radiological Science, College of Health Science, Eulji University, Seongnam, South Korea
| | - Dong-Kyoon Han
- Department of Radiological Science, College of Health Science, Eulji University, Seongnam, South Korea
| | - Min Tae Kim
- Department of Radiologic Technology, Cheju Halla University, Jeju-si, Jeju-do, South Korea
- Biomedical Engineering Research Center, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
- * E-mail:
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