Self-expandable duodenal metal stent placement for the palliation of gastric outlet obstruction over the past 20 years

Abstract

Introduction: Duodenal stent placement is a palliative option for management of malignant gastric outlet obstruction (GOO). In the last 20 years, management of gastrointestinal cancers has considerably changed. It is unknown if these changes have affected clinical outcome of duodenal stent placement. Methods: Retrospective cohort study conducted in a tertiary referral center. Patients who underwent duodenal stent placement for GOO-symptoms due to a malignant stricture were included. Primary outcome was GOO-symptom free survival. Secondary outcomes included stent-related adverse event rates. Potential explanatory parameters such as period of stent placement (1998-2009 vs 2010-2019), prior treatments, peritoneal deposits, and stricture length were evaluated using multivariable Cox regression analysis. Results: A total of 147 patients (62% male; median age 64 years) were included. After a median of 28 days after stent placement, 82 patients (57%) had recurrent GOO-symptoms. GOO-symptom free survival was significantly lower in 2010-2019 (P<0.01). Time period was the only independent predictor for reduced GOO-symptom free survival (HR 1.76, P<0.01). Stent-related adverse event rates increased over time (1998-2009: 31% vs 2010-2019: 37%). Prior treatment with chemotherapy and/or radiotherapy was significantly associated with an increased risk of adverse events (OR 2.53, P=0.02). Conclusions: Clinical outcome of duodenal stent placement did not improve over time. The decreased GOO-symptom free survival and increased adverse event rate in more recent years are probably related to the chemo- and/or radiotherapy treatment provided prior to duodenal stent placement.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

“…From these results, it appears that the use of newer stents and more experience do not provide a significant benefit in improving outcomes. In a recent single-facility study by Reijm et al comparing the results of two time periods (1998–2009 vs. 2010–2019) ( 35 ), the technical success rate was better in more recent years (1998–2009 vs. 2010–2019; 94 vs. 100%, P = 0.04). However, clinical outcome did not improve over time.…”

“…As stated above, Reijms' study ( 35 ) showed that prior treatment with chemotherapy and/or radiotherapy was the only independent risk factor for AEs, and patients with a history of prior treatment experienced more AEs than those without (47 vs. 27%) ( 35 ). However, the reason for the discrepancy in AE incidence has not been alluded to in this study.…”

“…However, clinical outcome did not improve over time. A decreased GOO-symptom free survival and increased adverse event rate were noted in more recent years, which is probably due to an increased number of patients being treated with prior chemo- and/or radiation therapy in recent period ( 35 ). The authors also stated that another reason for the shorter symptom-free survival in stent-treated patients was that duodenal stent placement had been primarily recommended for patients with a shorter life expectancy, according to the results of the SUSTENT study in the early 2010s ( 36 ).…”

“…However, the reason for the discrepancy in AE incidence has not been alluded to in this study. The authors proposed that special attention be paid while informing patients who have received prior chemotherapy and/or radiotherapy to explain the benefits and potential risks of duodenal stent placement ( 35 ).…”

“…Although many researchers have reported chemotherapy prolongs the patency of gastroduodenal stent, such patients are often not indicated for chemotherapy. According to a study on ES over the past 20 years by Reijm et al ( 35 ), only 12% of patients underwent concurrent chemotherapy, although 33% received prior chemotherapy and/or radiotherapy. However, there are some cases in which PS improves after stent placement by alleviating obstructive symptoms and resuming oral intake.…”