GI Grand Rounds

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GI Grand Rounds

• Johanna Chan
• Gastroenterology Fellow
• Baylor College of Medicine
• 3/21/13

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No conflicts of interestNo financial disclosures
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HPI

• RFC hematemesis, melena
• 67yo East Asian F p/w 4-5 days of burning
  epigastric pain, black emesis, melena
• Presented to ER with dizziness, lightheadedness,
  fatigue
• No prior similar episodes, no NSAIDs, no EtOH, no
  known H. pylori, no risk factors for chronic
  liver disease
• No other associated symptoms, weight changes

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Past Medical History

• HTN
• Previously on medication, now diet controlled

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Medications

• None
• No OTC medications, including NSAIDs

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Other history

• Family history
• Mother and father died of old age
• Siblings alive and healthy
• No GI malignancy
• Social history
• Denies all EtOH
• Lifelong nonsmoker
• No IV drug use or other illicits
• Married, housewife

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Exam

• T 98.5, BP 121/62, HR 83, RR 12, O2 sat 99 RA
• 411, 100 lbs
• Gen NAD, AAOx4, conversational
• HEENT PERRL, EOMI, MMM, OP clear
• Neck supple, no LAD
• CV RRR 2/6 SEM RUSB
• Lungs CTAB
• Abd S/NT, NABS, slightly distended
• Ext WWP no c/c/e
• Rectal no blood, no stool in rectal vault

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Labs
136
23
101
7.9
368
6.9
131
25.9
0.6
4.1
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69 PMNs
MCV 91
Total protein 7.3 Albumin 3.8 Total bili 0.4 ALT
26 AST 29 Alk phos 90
INR 1.2 PTT 28
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Endoscopy
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Endoscopy
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Endoscopy
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Pathology

• Stomach antrum, biopsy
• Adenocarcinoma, signet ring cell type
• Focally invasive in muscular wall of stomach
• HER-2 negative

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Imaging

• Pyloric/antral mass (2.7 x 2.9 x 1.8cm)
• Distention of proximal stomach
• Nonspecific lymph nodes (largest 7mm) adjacent to
  lesser curve of stomach
• No significant pulmonary findings
• ? nonspecific liver hypodensities
• ? nodularity of omentum

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Clinical course

• No further hematemesis nor melena
• Unable to tolerate even clear liquid diet
• TPN initiated
• Tumor board discussion
• MRI liver to evaluate for metastases (negative)
• Diagnostic laparoscopy to evaluate for peritoneal
  disease (pending)
• Pending laparoscopy findings, further plans?

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Management of malignant gastric outlet obstruction
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Clinical questions

• What are methods for palliation of malignant
  gastric outlet obstruction?
• Open gastrojejunostomy
• Laparoscopic gastrojejunostomy
• Endoscopic stenting
• What is the role for gastrojejunostomy versus
  stent for palliation of malignant gastric outlet
  obstruction?

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Gastrojejunostomy

• Historical/traditional treatment for malignant
  gastric outlet obstruction
• 72 of patients with good functional outcome and
  relief of symptoms
• 13-55 morbidity

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Open versus laparoscopic GJ

• 3/1998 to 1/2000 78 GJ procedures (45 OGJ, 33
  LGJ)
• 68 patients had advanced gastric cancer
  undergoing palliative GJ (38 OGJ, 30 LGJ)
• 10 case matched controls (age, gender, ASA class,
  prior abdominal surgery)
• Assessed operating time, time to PO intake, use
  of pain medication, morbidity, mortality, WBC,
  ESR, IL-6, TNF alpha
• Laparoscopic GJ group had lower inflammatory
  markers, morbidity, earlier recovery of bowel
  function

Choi YB. Surg Endosc. 2002.16(11)1620-6.
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Open versus laparoscopic GJ

• 24 patients with inoperable neoplasm of distal
  stomach, duodenum, or biliary tract
• Malignant metastatic or locally advanced
  unresectable
• Randomized prospectively to undergo LGJ or OGJ,
  followed for 2 months
• Age, gender, ASA class, primary tumor location,
  and mean duration of surgery not significantly
  different
• LGJ significantly less blood loss and shorter
  time to PO intake compared with OGJ
• Post-op stay shorter with LGJ (not statistically
  significant, 11 vs. 12 days)

Navarra G et al. Surg Endosc 2006 20(12)1831-4.
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Stents
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Stents for malignant GOO

• 1st case report for self-expanding metallic stent
  for gastric outlet obstruction published in 1992
• Common complications include recurrence of GOO
  symptoms due to stent obstruction (food, tumor
  in-/overgrowth), stent migration, perforation,
  biliary obstruction
• Nitinol nickel-titanium shape-memory alloy,
  soft, flexible, smoother wire ends
• Uncovered versus covered

Boskoski I et al. Adv Ther 2010
27(10)691-703. Dormann A et al. Endoscopy.
200436543-550. Mauro MA et al. Radiology 2000
215659-69.
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Stents for malignant GOO

• Systematic review in 2004 on gt600 cases shows
  reported technical success rate 97, with
  clinical success 87
• Overall reported technical success rate 93-97,
  clinical success rate 84-93
• Stents with gt20mm diameter should permit passage
  of solid food

Dormann A et al. Endoscopy. 200436543-550. Van
Hooft JE et al. Gastrointest Endosc. 2009
69(6)1059-66.
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Stenting versus gastrojejunostomy

• Systematic review (10 studies between 1/1990 to
  5/2008) includes 2 RCTs
• 514 total patient outcomes (244 stents, 218 OGJ)
• 30 day follow up
• Endoscopic stenting more likely to result in
  earlier PO intake (7 days), shorter hospital stay
  (12 days)
• Comparable periprocedural complication rate
  (15-16)
• OGJ more major complications (AKI, MI, PNA)
• ES usually technical complications requiring
  repeat intervention

Ly J et al. Surg Endosc 2010 24(2)290-7.
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Stenting versus gastrojejunostomy

• Systematic review, 44 publications between 1/1996
  and 12/2005
• Includes same 2 RCTs (18 patients, 27 patients)
• No difference in early and late major
  complications (though high variability)
• More rapid food intake and relief of obstructive
  symptoms after stent
• Recurrent obstructive symptoms more common after
  stent (food obstruction, tumor in-/overgrowth)
• Stent may have more favorable short-term results
  GJ may be a better option in patients with longer
  survival

Jeurnink SM et al. BMC Gastroenterol. 2007 718.
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Stenting versus gastrojejunostomy

• SUSTENT multicenter randomized trial
• 21 centers in the Netherlands, 1/2006-5/2008
• 18 patients randomized to GJ, 21 patients to
  Enteral Wallflex stent
• Compared GOO scoring system, early and late major
  complications, minor complications, persistent
  obstructive symptoms (gt4 weeks), HRQoL, and costs

Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
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GOO Scoring System

• 0 no oral intake
• 1 liquids only
• 2 soft solids
• 3 almost complete diet
• 4 full diet

Adler DG, Baron TH. Am J Gastroenterol.
20029772-78.
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Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
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Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
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SUSTENT

• Stent placement more rapid PO intake, shorter
  hospital stay, lower costs
• GJ with longer follow-up (gt2 months) better food
  intake, fewer major complications, and fewer
  recurrent obstructive symptoms and
  re-interventions
• Recommend GJ as primary treatment if expected
  survival gt 2 months
• Recommend stent if expected survival lt 2 months

Jeurnink SM et al. Gastrointest Endosc 2010.
71(3)490-9.
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Take home points

• Several options for palliation of malignant
  gastric outlet obstruction
• Treatment decisions often complicated by poor
  nutritional status, advanced underlying disease
• Consider expected patient survival in management
  decisions

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References

• Boskoski I et al. Self-expandable metallic
  stents for malignant gastric outlet obstruction.
  Adv Ther 2010 27(10)691-703.
• Brimhall B and Adler DG. Enteral stents for
  malignant gastric outlet obstruction.
  Gastrointest Endosc Clin N Am. 2011 21(3)
  389-403.
• Canena JM et al. Oral intake throughout the
  patients lives after palliative metallic stent
  placement for malignant gastroduodenal
  obstruction a retrospective multicentre study.
  Eur J Gastroenterol Hepatol. 2012 24(7) 747-55.
• Choi YB. Laparoscopic gastrojejunostomy for
  palliation of gastric outlet obstruction in
  unresectable gastric cancer. Surg Endosc. 2002
  16(11)1620-6.
• Dormann A et al. Self-expanding metal stents for
  gastroduodenal malignancies systematic review
  of their clinical effectiveness. Endoscopy.
  200436543-550.
• Jeurnink SM et al. Stent versus
  gastrojejunostomy for the palliation of gastric
  outlet obstruction a systematic review. BMC
  Gastroenterol. 2007 718.

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References (cont)

• Jeurnink SM et al. Surgical gastrojejunostomy or
  endoscopic stent placement for the palliation of
  malignant gastric outlet obstruction (SUSTENT
  study) a multicenter randomized trial.
  Gastrointest Endosc 2010. 71(3)490-9. 
• Ly J et al. A systematic review of methods to
  palliate malignant gastric outlet obstruction.
  Surg Endosc 2010 24(2)290-7.
• Mauro MA et al. Advances in gastrointestinal
  intervention the treatment of gastroduodenal and
  colorectal obstructions with metallic stents.
  Radiology 2000 215659-69.
• Mehta S et al. Prospective randomized trial of
  laparoscopic gastrojejunostomy versus duodenal
  stenting for malignant gastric outlet
  obstruction. Surg Endosc. 2006 20(2)239-42.
• Mendelsohn RB et al. Carcinomatosis is not a
  contraindication to enteral stenting in selected
  patients with malignant gastric outlet
  obstruction. Gastrointest Endosc. 2011
  73(6)1135-40.
• Miller BH et al. An assessment of radiologically
  inserted transoral and transgastric
  gastroduodenal stents to treat malignant gastric
  outlet obstruction. Cardiovasc Intervent Radiol.
  2013 Mar 2 (epub ahead of print).

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References (cont).

• Navarra G et al. Palliative antecolic
  isoperistaltic gastrojejunostomy a randomized
  controlled trial comparing open and laparoscopic
  approaches. Surg Endosc 2006 20(12)1831-4.
• Roy A et al. Stenting versus gastrojejunostomy
  for management of malignant gastric outlet
  obstruction comparison of clinical outcomes and
  costs. Surg Endosc 2012 26(11)3114-9.
• Van Hooft JE, et al. Efficacy and safety of the
  new WallFlex enteral stent in palliative
  treatment of malignant gastric outlet obstruction
  (DUOFLEX study) a prospective multicenter study.
  Gastrointest Endosc. 2009 69(6)1059-66.

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Questions?