Palliation of malignant gastric outlet and duodenal obstruction using expandable metallic stents

Introduction: The application of expandable stents, commonly used for biliary and esophageal strictures is gaining acceptance in the treatment of gastric outlet obstruction. We report here our experience with 18 patients with malignant gastric outlet and duodenal obstruction treated with expandable stents. Methods: There were 10 men and 8 women with the average age of 63 years (range 35-71). The primary malignancy was pancreatic cancer in 4, gastric cancer in 4, primary duodenal cancer in 3, cholangiocarcinoma in 2 and bile duct sarcoma, adenocarcinoma of unknown origin, lymphoma, metastatic colon cancer and leiomyosarcoma in 1 patient each. The location of the obstruction was in the antrum/pylorus in 3, first and second portion of the duodenum in 12, third portion of the duodenum in 2 and gastro-jejunal anastomotic recurrence in 1 patient. All patients had a contrast UGI study prior to stent placement. All patient with pancreatic cancer and cholangiocarcinoma had biliary Wallstents placed prior to duodenal stenting. One patient with leiomyosarcoma had a plastic biliary stent. Ballon dilation of the stricture was performed in 4 patients. The endoscope could successfully be advanced through the stricture in 6/18 patients. In the other 12 patients a standard biliary cannula was advanced through and contrast injected to define the length and course of the stricture. Dedicated enteral Wallstents (Schneider) were used in 13, biliary Wallstents in 4 and Ultraflex (Microvasive) in 1 patient. Results: Stent placement was successful in 16 patients (89%). The only two failures were in the patients with strictures in the third portion of the duodenum. A positive clinical response with resolution of obstuctive symptoms was seen in 14 patients (78%) with successful stent placement. One patient failed to respond after unsuspected obstructive lesions in the proximal jejunum were diagnosed after opening the duodenal stricture with the Wallstent. The only complication was distal migration of the stent in one patient who had balloon dilation of the stricture. Surgery was required in the 2 patients who failed to respond to stenting of the strictures and in 1 patient with stent migration. The average survival after stent placement was 8.2 weeks (range 3-13). There were no procedure related mortality. Conclusions: Expandable metallic stents are safe and effective in providing non-surgical palliation in malignant gastric outlet and duodenal obstruction.

Duke Scholars

Author James Abbruzzese Medicine, Medical Oncology