Year: 2013
Type: dissertation
Study design: Observational Study
Abstract: Gastric outlet obstruction (GOO) is a preterminal event in incurable malignancies of the gastrointestinal tract. Pancreatic cancer and gastric cancer are the most common causes for GOO. Colorectal cancer (CRC) is the most common etiology for colorectal obstruction (CRO). Other causes for CRO include extracolonic malignancies (ECM) and benign causes. Traditional treatment of GOO and CRO is surgery, but it carries a high rate of complications. Self-expanding metal stents (SEMS) have become an alternative for surgery in GOO and CRO. The aim of this work was to evaluate the results of endoscopic stenting (ES) in GOO and CRO. The study material consisted of 323 patients with GOO or CRO treated at Meilahti Hospital between January 1998 and December 2010. In study I, 104 patients with incurable GOO were included in the analysis. The study II population consisted of 97 patients with advanced gastric cancer and GOO, and of these 50 underwent ES, 26 palliative resection (PR), and 21 gastrojejunostomy (GJ). In study III, 21 patients with benign CRO were included in the analysis. The study IV population comprised 101 patients with malignant CRO, and of these 11 were stented as a bridge to surgery. In study IV, 66 underwent palliative stenting due to CRC and 24 due to ECM. In study I, a median GOOSS (gastric outlet scoring system) improved significantly from 0 to 2 after stenting, and 73% of the patients managed with one stenting procedure until death. In study II, ES resulted in a more rapid improvement in oral intake and a shorter hospital stay than GJ or PR. Complication rates were similar between the groups. In the PR group, symptom-free and overall survivals were longest. In multivariate survival analysis, independent prognostic factors were age, BMI, pre-procedure GOOSS, PR as treatment modality, and chemotherapy. In study III, 63% of anastomotic strictures (AS) were resolved with SEMS. Of diverticular strictures (DS), 30% were resolved with SEMS. Complication rate was 43%. Of the complications, 67% occurred for patients with DS or Crohn`s disease strictures. In study IV, a primary anastomosis rate in elective operations was 90% in the bridge to surgery group. In palliative stenting, clinical success rates were significantly lower for patients with ECM than for patients with CRC (63% vs. 94%, p<0.001). Between palliation groups, complication, operation, and stoma rates were similar. SEMS provides good palliation for patients with incurable GOO. In advanced gastric cancer and GOO, SEMS is a treatment of choice for patients unfit for surgery. PR seems to provide survival benefit, and should be considered as a treatment option for patients fit for surgery. In benign CRO, SEMS is a good treatment option in AS for selected patients. In DS and Crohn`s disease strictures, a high rate of complications limit the utility of SEMS. In malignant CRO, SEMS can be used as a bridge to surgery and as palliation. A higher clinical failure rate is associated with palliative stenting for ECM than for CRC.
Source: Työväentutkimus Vuosikirja
Author: Ilona Keränen
Language: English
Topic: Esophageal and GI Pathology
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W2154959938