Enteral Stents in the Gastric Outlet and Duodenum

Objectives

Self-expanding stents are designed to provide quick relief of enteric obstruction. The first attempts at stenting gastroduodenal obstructions were made in the early 1990 s, using esophageal stents, sometimes through a gastrostomy [1] [2], until the introduction of dedicated systems. The technique is based on the intuitive assumption that regaining enteral patency by a relatively noninvasive procedure is superior to other methods. Alternatives consist of bypass surgery or continuous external drainage. Many patients are unfit for gastroenterostomy, and drainage via nasogastric tube or venting gastrostomy does little to improve a patient’s already poor quality of life. The effects extend beyond vomiting, dehydration and inadequate calorie intake: nausea and regurgitation of foul stomach content are a constant reminder of the underlying cancer, and patients are excluded from social interactions associated with eating and drinking.

A patient with only a few precious weeks to live should spend the shortest time possible undergoing palliative treatment that only relieves symptoms (Latin palliare, to mask, to cloak). Cost-benefit analyses have shown the effectiveness of the procedure [3] [4]. The first trials comparing stenting with open bypass surgery, as well as with the newer alternative of laparoscopic gastroenterostomy, are beginning to provide a scientific basis for the rationale of palliative stenting [5] [6].

References

• 1 Razzaq R, Laasch H U, England R. et al . Expandable metal stents for the palliation of malignant gastroduodenal obstruction.  Cardiovasc Intervent Radiol. 2001;  24 313-318
• 2 Kozarek R A, Ball T J, Patterson D J. Metallic self-expanding stent application in the upper gastrointestinal tract: caveats and concerns.  Gastrointest Endosc. 1992;  38 1-6
• 3 Maosheng D, Ohtsuka T, Ohuchida J. et al . Surgical bypass versus metallic stent for unresectable pancreatic cancer.  J Hepatobiliary Pancreat Surg. 2001;  8 367-373
• 4 Yim H B, Jacobson B C, Saltzman J R. et al . Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction.  Gastrointest Endosc. 2001;  53 329-232
• 5 Maetani I, Tada T, Ukita T. et al . Comparison of duodenal stent placement with surgical gastrojejunostomy for palliation in patients with duodenal obstructions caused by pancreaticobiliary malignancies.  Endoscopy. 2004;  36 73-78
• 6 Mittal A, Windsor J, Woodfield J. et al . Matched study of three methods for palliation of malignant pyloroduodenal obstruction.  Br J Surg. 2004;  91 205-209
• 7  . Royal College of Radiologists .Safe sedation, analgesia and anaesthesia within the radiology department. London; Royal College of Radiologists 2003: Available online www.rcr.ac.uk/pubtop.asp?PublicationID = 186
• 8  . British Society of Gastroenterology .Guidelines on safety and sedation for endoscopic procedures. London; British Society of Gastroenterology 2003: Available online http://www.bsg.org.uk/clinical_prac/guidelines/sedation.htm
• 9 Bell J K, Laasch H U, Wilbraham L. et al . Bispectral index monitoring for conscious sedation in intervention: better, safer, faster.  Clin Radiol: In press. ; 
• 10 Owen A, Laasch H-U, Marriott A. et al . Oesophageal stent follow-up: routine contrast swallow does not add to the management [abstract].  Cardiovasc Intervent Radiol. 2003;  26 197