Malignant gastric outlet obstructions: treatment with self-expandable metallic stents

Abstract

Unresectable malignant gastric outlet obstruction (GOO) severely affects the quality of life, with complications that include nausea, vomiting, aspiration, pain, and malnutrition. Although palliative surgical procedures have been traditionally performed, they are associated with high morbidity and mortality rates. Placing self-expandable metallic stents is associated with higher clinical success rates, lower morbidity, shorter time from the procedure to starting oral intake, lower incidence of delayed gastric emptying, and a shorter hospital stay than palliative surgery. Fluoroscopic or endoscopic placement of either bare or covered self-expandable metallic stents is a safe, nonsurgical, palliative treatment option for unresectable malignant GOOs, with a high clinical success rate and a low rate of serious complications. Stent obstruction and migration are the most common complications, but most can be managed by interventional treatments. Although there have been substantial developments in stent design over the past decade, large prospective, randomized studies are required to determine the ideal stent for malignant GOOs.

Keywords: Endoscopy; Fluoroscopy; Malignant gastric outlet obstruction; Palliative treatment; Placement of a self-expandable metallic stent.

Fig. 1

A 48-year-old man with recurrent obstruction caused by distal tumor overgrowth. (A) Radiograph taken 2 months after stent placement showing tumor overgrowth (arrow) in the distal area of the stent. (B) Management of this complication by placement of a second stent (arrow) that overlapped the initial stent.

Fig. 2

A 57-year-old man with complete downward stent migration. (A) Radiograph taken immediately after stent placement showing the correct placement of the stent. (B) Radiograph taken 24 days after stent placement, showing complete downward stent migration (arrow). This patient had received chemotherapy after stent placement.

Fig. 3

A 77-year-old man with a biliary obstruction at 1 day after stent placement. (A) Axial computed-tomography image taken 1 day after stent placement showing bile-duct (arrow) dilatation. (B) Coronal computed-tomography image showing collision of the duodenal (arrow) and biliary (arrowhead) stents.