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Self-expandable Metal Stents in Palliation of Malignant Gastrointestinal Obstruction: Review of the Current Literature Data and 5-Year Experience at Harbor-UCLA Medical Center
from Medscape General Medicine™ Posted 01/10/2003.
Sofiya Gukovsky-Reicher, MD
Richard M. Lin, MD
Shahid Sial, MD
Benedict Garrett, MD
Dennis Wu, MD
Tonny Lee, MD
Hanson Lee, MD
Tracy Arnell, MD
Michael J. Stamos, MD
Viktor E. Eysselein, MD
Abstract and Introduction
Abstract
Management of malignant gastrointestinal obstruction presents a significant challenge. Most patients are in a profoundly decompensated state due to underlying malignancy and are not ideal candidates for invasive surgical procedures. In recent years, self-expandable metal stents (SEMS) have emerged as an effective and safe, less invasive alternative for the treatment of malignant intestinal obstruction. Here we report a retrospective analysis of 59 SEMS placed for gastroduodenal and colorectal obstruction in 48 patients at Harbor-UCLA Medical Center during the last 5 years, as well as review the literature published on SEMS placement. Technical and clinical success rates were approximately 92% and 80%, respectively. The majority of patients tolerated oral food intake by 36 hours after SEMS. There were no major complications of perforation, bleeding, or death. Thirteen patients had obstructive symptom recurrence, which in most cases was successfully managed with additional endoscopic interventions.
Our data confirm SEMS efficacy in palliation of malignant intestinal obstruction with lower rates of major complications than previously reported.
Introduction
Colorectal and gastroduodenal cancers make up a significant proportion of gastrointestinal malignancies. Indeed, colorectal cancer alone ranks as the second leading cause of cancer-related death rates in the United States, affecting 135,000 people annually. Intestinal obstruction is a common presentation of colorectal cancer, and is often seen in nongastrointestinal cancers invading or metastasizing to the gastrointestinal tract. In some series, up to one third of colorectal cancer patients presented with obstructive symptoms. Management of intestinal obstruction is challenging because the patients are often acutely ill and debilitated from underlying malignancy. Severe vomiting leading to electrolyte imbalance, sepsis, ischemia, and impending perforation are the well-known features of intestinal obstruction. Associated morbidity and mortality are high. Not surprisingly, acute colonic obstruction is considered a surgical emergency.
A number of surgical and nonsurgical modalities are available for treatment of malignant intestinal obstruction. Unfortunately, surgery is not a viable option for most patients with gastroduodenal malignancies: 40% of gastric cancer patients and 95% of pancreatic cancer patients with duodenal involvement are not candidates for curative resection. Surgical palliation can be achieved through gastroenterostomy or gastrojejunostomy. However, such surgical procedures carry a high morbidity rate in advanced cancer patients. Gastroduodenal obstruction in nonsurgical candidates is typically treated with nasogastric intubation or 2-valve gastrojejunostomy tube, allowing for decompression and feeding. Other gastroduodenal palliative techniques, such as endoluminal irradiation, laser ablation, and chemical injection, have somewhat limited application in management of large exophytic tumors. None of the above-mentioned modalities allow for adequate oral food intake, and all are associated with
significant patient discomfort.
Acute colorectal obstruction is traditionally approached with segmental colectomy and diverting colostomy. Colostomy reversal is accomplished at a later time (2-step Hartmann's procedure). However, up to 25% of patients never undergo colostomy closure, and colostomy reversal itself carries a 7% mortality rate. Emergent colectomy is associated with a mortality and morbidity rate of 23% and 55%, respectively. Lack of adequate bowel preparation and complications associated with emergent surgery are most likely responsible for such high mortality rates. In comparison, the mortality rate after elective colectomy is less than 5%.
During the last decade, SEMS have been increasingly used in the management of malignant intestinal obstruction. In several series, successful resumption of oral intake and relief of obstructive symptoms have been achieved in 80% to 90% of patients after SEMS placement for gastroduodenal malignant obstruction. SEMS were also shown to be more cost-effective compared with standard gastrojejunostomy, with lower procedure-related costs and shorter hospital stays. In colorectal malignant obstruction, SEMS play a crucial role in relieving acute obstruction, thus avoiding emergent surgery and allowing for proper patient preparation and staging prior to definitive surgical procedure. SEMS can also be used in palliation of colorectal obstruction in nonsurgical candidates, with reported symptomatic relief in more than 90% of the patients. Additional applications for SEMS have emerged in the management of colovesicular/coloenteral fistula and benign intestinal obstruction. However, SEMS placement is associated with a number of potential complications, including reobstruction, stent migration, and perforation.
Here we review the recent literature data and present our experience with 59 gastroduodenal and colorectal SEMS placed from 1997 to 2002 at the Harbor-UCLA Medical Center.
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