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Patients with Obstructing Gastric Cancer Present Difficult Challenges
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Q: What Options Exist for Patients With Gastric Outlet Obstruction From Gastric Cancer?
A: The patient with obstructing gastric cancer can be a difficult challenge for the practicing gastroenterologist. This article will review the medical, endoscopic, and surgical options for relieving obstruction.
Differential Diagnosis of Malignant Obstruction
The differential diagnosis for malignant gastric outlet obstruction includes primary gastric malignancies (adenocarcinoma, lymphomas, gastrointestinal stromal tumors, and carcinoid) and perigastric or periampullary malignancies (pancreatic, duodenal, or ampullary adenocarcinoma, cholangiocarcinoma, extragastric lymphomas, and perigastric metastases) as well as several benign conditions. For the purposes of this discussion, we will focus on gastric outlet obstruction from gastric adenocarcinoma.
Gastric cancer is still the world’s second leading cause of cancer mortality, second only to lung cancer, although 15% to 20% of pancreatic cancer patients will develop gastric outlet obstruction during the course of their treatment. Endoscopic biopsy and complete radiographic characterization by computed tomography scan is vital in identifying the cause of obstruction and, in the case of malignant obstruction, in providing for adequate staging of the underlying cancer.
No matter the cause, clinical presentation usually involves vomiting, nausea, malnutrition, dehydration, and associated electrolyte abnormalities. Malignant gastric outlet obstruction can go unrecognized until severe malnutrition has already been established. This is often seen in patients receiving chemoradiation in whom nausea and vomiting are attributed to these therapies instead of the actual underlying mechanical obstruction. Two important items in a patient’s clinical history that should trigger your suspicion for malignant obstruction are vomiting undigested food and nonbilious emesis.
Surgical Options
Surgical options for the patient with gastric outlet obstruction include both resection and bypass. All patients with resectable disease whose overall health would permit a major operation should undergo resection. Management of these patients should be reviewed in a multidisciplinary fashion in concert with the medical and radiation oncologists, as most patients will require either neoadjuvant treatment or adjuvant chemoradiotherapy. Resection with a distal or total gastrectomy depends upon tumor size and location. Distal lesions are amenable to subtotal gastrectomy with either Billroth II gastrojejunostomy or Roux-en-Y reconstruction. For distal gastrectomy, a 5-cm margin of grossly normal stomach is required to ensure negative microscopic margins. Total gastrectomy with Roux-en-Y esophagojejunostomy is required for bulky tumors that involve the body and fundus of the stomach. In patients with metastatic disease and gastric outlet obstruction, a palliative distal gastrectomy can be performed if technically feasible, if patient comorbidities are favorable, and if a limited extent of metastatic disease is present. A total gastrectomy for palliation should be discouraged because of excessive morbidity.
Figure 1. Intraoperative photo of a newly created surgical gastrojejunostomy showing the anastomosis between the small bowel and the stomach.
Image: Singleton A, Glasgow RE
If not resectable, the goal of palliative surgery in the obstructed patient with gastric cancer is maximal relief of obstructive symptoms with minimal morbidity. Options include endoscopic, percutaneous, or surgical tube gastrostomy for decompression and surgical jejunostomy for enteral access. Open and laparoscopic gastrojejunostomy bypass is technically simple and can be done with low morbidity (Figure 1). Occasionally, surgical, radiographic, or endoscopic treatment of concomitant biliary obstruction is necessary. These modalities are best applied to patients with a greater than 6-month anticipated survival and no peritoneal disease, hepatic metastasis, ascites, diffuse nodal metastases, or proximal gastric outlet obstruction. The laparoscopic approach is now commonplace with decreased blood loss, decreased time to solid food intake, and decreased complications but no difference in length of stay when compared to open gastrojejunostomy. Complications related to gastrojejunostomy include bleeding, infection, damage to associated structures, and the more procedure-specific risks of anastomotic leak, efferent or afferent loop obstruction, marginal ulcer, and anastomotic stricture.
Endoscopic Options
Nonsurgical options for management of gastric outlet obstruction from gastric cancer include balloon dilation, percutaneous endoscopic gastrostomy tubes with jejunal extensions for feeding, and enteral stenting (ES). Balloon dilation is technically simple and inexpensive but has uniformly short-lived efficacy. Dilation may serve to facilitate other more lasting options. Gastrostomy tubes may be placed endoscopically or via interventional radiology.
Palliative stenting of the gastroduodenal region has gained widespread acceptance. Stenting has the advantage of preserving normal oral nutrition. The stents currently used are metal expandable mesh (Figure 2). The goal of endoscopic stenting is to restore and maintain patency, re-establishing continuity between the stomach and duodenum. The stents pass through the operating channel of a therapeutic endoscope and are used with fluoroscopic guidance for precise localization of obstruction and dimensional information about the obstruction, which is crucial to stent length selection and placement.
Reported clinical success rates of endoscopic stenting range from 79% to 91% depending on the outcome measures used. The most common of these are improvement in obstructive symptoms (nausea/vomiting), resumption of a solid or soft diet, or change in the gastric outlet obstruction scoring system score developed by Adler and Baron. Complications of ES have been categorized as immediate, early, or late. Immediate complications occur within 24 hours and include bleeding and perforation. Early complications occur up to 2 to 4 weeks after stent placement. Early complications include stent positioning problems, perforation, bleeding, and aspiration. Late complications include reobstruction, stent migration, bleeding, and a single reported case of aortoenteric fistula from stent erosion. Uncovered metal stents have been compared to covered stents with results showing an increased incidence of tumor overgrowth into uncovered stents and a stent migration rate of 21% to 26% in covered stents, requiring an increased rate of re-intervention. In our patient, the presence of what appears to be profound gastric tumor involvement may reduce the chances of a good clinical outcome as there is likely to be little to no gastric motility even after stenting, and the patient may only be able to take liquids.
Figure 2. (A) Endoscopic image of the pylorus in a patient with malignant gastric outlet obstruction due to gastric cancer. The distal stomach has been completely infiltrated with malignant tissue, the pylorus is stenosed, and there is no functional peristalsis in the stomach. (B) Fluoroscopic image of the same patient following placement of a stent across the pylorus into the pylorus and proximal duodenum.
Reprinted with permission from Douglas G. Adler, MD, FACG, AGAF, FASGE
Endoscopy Vs. Surgery
A recent comprehensive review of 13 studies comparing surgical and endoscopic modalities was published, including a total of 514 patients. Patients undergoing ES were more likely to ever tolerate an oral diet (soft or solid), have a shorter mean time to oral intake (7 days), and have a shorter length of stay. Of note, there were no differences in survival or 30-day mortality between the ES and surgical groups. Open gastrojejunostomy patients were found to have more “major” complications, including respiratory tract infections, myocardial infarction, acute renal failure, and wound infection, but better long-term patency. Only 3 studies in this review looked at laparoscopic gastrojejunostomy (LGJ) compared with ES. Average length of stay was shorter for the ES group. LGJ patients had more complications and longer mean time to tolerate a diet. Average patient survival was improved in the LGJ group compared to the ES patients. Most studies conclude that long-term patency is superior with bypass over stenting with fewer secondary interventions to maintain patency, supporting the recommendation that patients with a longer life expectancy be considered for surgical gastrojejunostomy.
Radiation and Chemotherapy
Radiation therapy has been shown to improve symptoms associated with gastric cancer, including dysphagia/obstruction, bleeding, and pain in patients not fit for other palliative modalities. In a recent review, 81% (13 of 16) of patients were shown to have obstructive/dysphagia symptoms controlled by radiation therapy for a median time of 81% of remaining life. While effective in palliating malignant obstruction, radiotherapy will take at least 2 to 3 weeks to achieve peak benefits, which may be too long for some patients facing profound failure to thrive.
The addition of chemotherapy to ES for gastric outlet obstruction from gastric cancer has been shown to improve long-term patency. Chemotherapy, along with radiation therapy, is commonly prescribed to gastric cancer patients in either a neoadjuvant setting, adjuvant setting, or for palliation of bleeding and gastric outlet obstruction. According to the National Comprehensive Cancer Network guidelines, response rates to these therapies may range from 10% to 20%, and a variety of agents are available.
Excerpted from:
Rubin DT, Friedman S, Farraye FA. Curbside Consultation in IBD: 49 Clinical Questions, Second Edition (pp 45-49). ©2015 SLACK Incorporated.
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