Surg Endosc (2011) 25:1505–1513 DOI 10.1007/s00464-010-1426-y
Self-expandable metallic stent placement for malignant obstruction in patients with locally recurrent gastric cancer Jaihwan Kim • Il Ju Choi • Chan Gyoo Kim • Jong Yeul Lee • Soo-Jeong Cho • Sook Ryun Park Jun Ho Lee • Keun Won Ryu • Young-Woo Kim • Young-Iee Park
•
Received: 27 January 2010 / Accepted: 27 September 2010 / Published online: 26 October 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Background Self-expandable metallic stents (SEMSs) provide effective palliation for inoperable malignant gastric outlet obstruction (GOO). The objective of this study was to evaluate the effectiveness of SEMSs in patients with recurrent gastric cancer after radical gastrectomy. Methods We retrospectively analyzed data from patients with gastric cancer who underwent endoscopic SEMS placement. The patients had obstructive symptoms due to recurrent gastric cancer after curative-intent subtotal or total gastrectomies. Technical and clinical success rates of stent placement were evaluated and clinical outcomes were compared according to operation types. Results A total of 15 patients underwent total gastrectomies with esophagojejunostomies and Roux-en-Y reconstructions, 8 underwent subtotal gastrectomies with Billroth I reconstructions, and 12 underwent subtotal gastrectomies with Billroth II reconstructions. Four patients in the Billroth II group received stents in afferent and efferent loops, so a total of 39 stents were placed. Technical success was achieved with 92% (36/39) of stents, and clinical success occurred with 90% (35/39) of stents, with no significant differences among surgery groups or between stent types (covered vs. uncovered). The GOO score (preprocedure: 0.45 ± 0.62) increased by 1 week (2.06 ± 0.51,
I. J. Choi (&) C. G. Kim J. Y. Lee S.-J. Cho S. R. Park J. H. Lee K. W. Ryu Y.-W. Kim Y.-I. Park Center for Gastric Cancer, Research Institute and Hospital, National Cancer Center, 111 Jungbalsan-ro, Ilsandong-gu, Goyang, Gyeonggi 410-769, Korea e-mail:
[email protected] J. Kim Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
p \ 0.001) and was maintained up to 1 month (1.71 ± 1.15, p \ 0.001 compared with initial score). Complications occurred with 17 of 39 stents (44%) and included 2 perforations, 3 migrations, and 12 restenoses. Median stent patency duration was 10.7 weeks and median survival was 21.3 weeks; these did not significantly differ by surgery group (p = 0.25 and 0.93, respectively) or stent type (covered vs. uncovered, p = 0.51 and 0.96, respectively). Conclusion Endoscopic SEMS placement for obstruction due to recurrent cancer after total or subtotal gastrectomy is feasible and provides effective short-term palliation, independent of the type of surgical procedure or stent (covered vs. uncovered) used. Keywords Stent Gastric outlet obstruction Gastric cancer Recurrence Gastrectomy
Many patients who undergo radical gastrectomy for advanced gastric cancer eventually experience relapses [1, 2]. When obstructive symptoms due to local recurrences develop, not only is the patient’s life threatened if proper nutrition cannot be supplied, but also the quality of life rapidly decreases for the short expected lifetime. Because surgical treatment to relieve obstruction symptoms in patients with recurrent gastric cancer is usually difficult or impossible due to concurrent extra-anastomotic metastases [1] or surgery-related mortality and morbidity [3], a less invasive method is necessary. The self-expandable metallic stent (SEMS) has recently become a primary treatment modality for malignant gastric outlet obstruction (GOO) in inoperable patients because of its noninvasive placement and ease of application [4, 5]. However, only a few reports on the placement of SEMSs in recurrent cases after curative surgery have been published
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[6–8]. In this study we evaluated clinical outcomes after endoscopic SEMS placement in patients with recurrent gastric cancer and obstructive symptoms after previous radical gastrectomies.
Materials and methods Patients We reviewed the medical records (paper charts and electronic orders) of patients who were treated from March 2003 to November 2008 at the National Cancer Center, Korea, and identified those who met the following inclusion criteria: (1) previous radical gastrectomy for documented gastric adenocarcinoma, by either total gastrectomy with esophagojejunostomy and Roux-en-Y reconstruction (referred to as the total gastrectomy group), subtotal gastrectomy with Billroth I reconstruction (the Billroth I group), or subtotal gastrectomy with Billroth II reconstruction (the Billroth II group); (2) documentation by esophagogastroduodenoscopy of recurrent malignant obstruction at the esophagojejunal or gastrojejunal anastomosis or the jejunum; and (3) obstruction defined by symptoms that resulted in decreased oral intake (early satiety, nausea, and/or vomiting). Patients were excluded if the gastrectomy was performed for other indications such as benign gastric ulcer or other malignancies, including esophageal or pancreatic cancer. Anastomotic or remnant stomach recurrences were evaluated by endoscopy, and extra-anastomotic recurrences by computed tomography (CT). Before SEMS insertion, informed consent for treatment was obtained from all patients. The initial cancer staging was determined by the 6th edition of the International Union Against Cancer (UICC)/American Joint Committee on Cancer (AJCC) TNM classification system [9]. Data regarding obstructive symptom recurrence were obtained through regular follow-up or telephone surveys until death. The dates of death were obtained through the national death registry or telephone survey. The local ethics committee of the National Cancer Center approved this retrospective study. Characteristics of SEMSs SEMSs from three commercial manufacturers were used in this study, including CHOOSTENTTM esophageal or HANAROSTENTTM esophageal (covered) (M. I. Tech, Seoul, Korea), Niti-S esophageal or pyloric/duodenal stents (covered or uncovered) (Taewoong, Seoul, Korea), and WALLSTENT colonic and duodenal Endoprosthesis or WallFlexTM duodenal stents (uncovered) (Boston Scientific, Natick, MA, USA). A total of 39 stents were inserted,
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with a median diameter of 20 mm (range = 18–22 mm) and median length of 90 mm (range = 60–120 mm). Stent placement Gastric lavage was performed before stent insertion when abundant food material was noted in the remnant stomach. Patients were consciously sedated with intravenous midazolam (0.06 mg/kg) and meperidine (25 or 50 mg). All endoscopic procedures were performed under fluoroscopic assistance. The endoscopes used in this study were the GIF-H260 or the GIF-2T240 (Olympus Optical Co. Ltd, Tokyo, Japan). The Jagwire guidewire (Boston Scientific) and Tandem XL catheter (Boston Scientific) were used. Before stent insertion, stenosis was evaluated using CT, endoscopy, and fluoroscopic evaluations. The choice between the covered stent and the uncovered stent was made based on the endoscopist’s experience and preference. The length of the stent was selected based on the estimated stricture length, with at least 20-mm tumor-free margins on each end. If it was difficult to evaluate the length of the stricture by direct endoscopic visualization due to tight stenosis, water-soluble contrast dye was used under fluoroscopic guidance. A guidewire was inserted across the stenotic portion through the working channel of the scope (GIF-2T240, Olympus) under fluoroscopic guidance, and the SEMS was advanced over the guidewire. The stent was gradually deployed after proper placement of the undeployed stent across the stenotic portion. Stent patency was evaluated immediately after placement with fluoroscopy using contrast dye. Clinical outcomes and definition of success, failure, and patency duration The GOO scoring system proposed by Adler and Baron [10] was used to evaluate the severity of the obstructive symptoms. Symptoms compatible with GOO were defined as early satiety, nausea, and vomiting. The scoring system assigns points depending on the patient’s level of oral intake (no oral intake, 0; liquids only, 1; soft solids, 2; lowresidue or full diet, 3). The GOO score was assessed before stent insertion and 1 week and 1 month afterwards. Technical success was defined as adequate placement of the stent across the stenosis confirmed by a combination of endoscopy and fluoroscopy. Clinical success was defined as the relief of obstructive symptoms or an improved GOO score on the third day after stent insertion. In addition, appropriate expansion of the stent was confirmed by endoscopy and a plain abdominal radiograph on the third day. Failure of stent patency was defined as loss of stent patency due to migration or tumor ingrowth or overgrowth. Patency duration was defined as the period between stent
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placement and failure of stent patency. If the stent remained patent until the patient’s death, the patient was censored at the time of death.
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anastomoses, a total of 39 stents (14 covered and 25 uncovered) were placed (Table 2). Deployment of two stents at the afferent and efferent anastomotic obstructions in a patient in the Billroth II group is shown in Fig. 1.
Follow-up Outcomes of stents If stent insertion was technically successful without any immediate complications, the patient was allowed to drink clear liquids on the day of the procedure. If the patient was able to tolerate this and obstructive symptom(s) did not recur, the diet was advanced gradually to a low-residue diet in 2 days. Patients who were successfully treated were discharged from the hospital and regularly followed for assessment of recurrent obstructive symptoms and complications. When patients attended outpatient visits, their diet level was assessed, and if obstructive symptoms recurred, endoscopic evaluation of patency was performed. For patients who were unable to attend follow-up, we obtained information on diet and obstructive symptoms by telephone survey. Statistics Age, surgery to stent interval, follow-up, and survival are presented as median values (range). Technical and clinical successes among the three groups were compared by Pearson’s v2 test; changes in GOO score before and 1 week and 1 month after stent placement were evaluated by Wilcoxon signed-rank test. GOO score among the three groups in patients who experienced clinical success were compared by the Kruskal–Wallis test. Rates of complications (i.e., migration or restenosis) with covered versus uncovered stents were evaluated by Fisher’s exact test. Stent patency and survival duration were assessed by Kaplan–Meier methods and compared by the log-rank test. Two-sided p values less than 0.05 were considered significant. All statistical analyses were performed using the SPSS for Windows (Statistical Product and Services Solutions, version 12.0, SPSS Inc., Chicago, IL, USA).
Results Baseline characteristics of patients Thirty-five patients were included in the study, and their clinical parameters are presented in Table 1. Results of CT revealed 23 extra-anastomotic recurrences (66%). Most concurrent recurrences were distant metastases, and all patients with regional lymph node metastases also had peritoneal seeding or distant metastases (Table 1). Because four patients in the Billroth II group simultaneously received two stents at the afferent and efferent loop
Technical and clinical successes by type of surgery are presented in Table 3. Technical success was achieved in 13 of 14 covered stents (93%) and in 23 of 25 uncovered stents (92%, p [ 0.99), and clinical success occurred in 12 of 14 covered stents (86%) and in 23 of 25 uncovered stents (92%, p = 0.61). In the 31 patients with clinical success, the GOO score improved significantly in all three groups 1 week after stent insertion compared with before stent insertion. The scores did not significantly deteriorate at 1 month (Table 3). Obstructive symptoms recurred in 19 patients (54%) overall, including 9 of 15 patients (60%) in the total gastrectomy group, 2 of 8 patients (25%) in the Billroth I group, and 8 of 12 patients (67%) in the Billroth II group. Patency duration (Table 3; Fig. 2A) and survival did not differ significantly among the three groups. Two patients died within 4 weeks, and one patient who had undergone subtotal gastrectomy with Billroth I reconstruction 8 years before stent insertion has been alive for more than 3.5 years after stent insertion (Table 1; Fig. 2B). The patency duration did not differ between covered and uncovered stents (Table 4; Fig. 3). Complications Complications occurred with 17 of 39 stents (44%); 6 of these occurred with covered stents (6/14; 43%) and 11 with uncovered stents (11/25; 44%) (Table 3). Two perforations (5%) occurred within 1 week of insertion. A microperforation immediately after uncovered stent insertion was detected in one patient who had a previous total gastrectomy. The patient was initially treated with antibiotics and parenteral nutrition without surgical intervention for several reasons, such as uncertainty of the perforation site on CT scan, stable condition, and advanced disease status with rectal shelf metastases and peritoneal seeding. Although the patient’s general condition improved briefly, she died of sepsis due to uncontrolled intraperitoneal infection 46 days after the procedure. The other patient with a perforation was in the Billroth II group, received an uncovered stent, and underwent surgical repair immediately after the procedure. The patient, however, was unable to tolerate oral intake because of poor postoperative condition and died 54 days after the procedure. Late complications beyond 1 week after stent insertion included migration and restenosis due to tumor overgrowth or ingrowth. Migration
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Table 1 Patient characteristics Total gastrectomy group (n = 15)
Billroth I group (n = 8)
Billroth II group (n = 12)
Total (n = 35)
Sex Male
11 (73%)
10 (83%)
26 (74%)
53 (35–70)
65 (56–76)
61 (30–79)
62 (30–79)
WD or MD adenocarcinoma
3 (20%)
3 (37.5%)
2 (17%)
8 (23%)
PD adenocarcinoma
9 (60%)
4 (50%)
8 (67%)
21 (60%)
3 (20%)
1 (12.5%)
2 (17%)
6 (17%)
I
1 (7%)
5 (62.5%)
2 (17%)
8 (23%)
II
2 (13%)
1 (12.5%)
1 (8%)
III
6 (40%)
1 (12.5%)
5 (42%)
12 (34%)
6 (40%)
1 (12.5%)
4 (33%)
11 (31.5%)
4 (50%)
8 (67%)
23 (66%)
1 (12.5%)
1 (8%)
10 (29%)
Age (years)
5 (63%)
Histology
Signet ring cell carcinoma Preoperative cancer stage
IV Chemotherapy before stent
11 (73%)
Balloon dilation before stent
8 (53%)
4 (11.5%)
Concurrent extra-anastomotic site of recurrence Regional lymph node
1 (7%)
4 (50%)
1 (8%)
6 (17%)
Peritoneal seeding
4 (27%)
3 (37.5%)
4 (33%)
11 (31.5%)
Distant metastasis Interval from surgery to stent (months) Survival (weeks)
7 (47%)
6 (75%)
8 (67%)
21 (60%)
15 (2–83)
34 (8–97)
16 (9–73)
19 (2–97)
22.0 (5.7–41.4)
1-month mortality
13.1 (1.4–190.7)
0 (0%)
1 (12.5%)
13.6 (7.7–61.6) 1 (8%)
21.3 (1.4–190.7) 2 (6%)
Data are presented as number (percent) or median (range) Total gastrectomy group refers to patients after total gastrectomy with esophagojejunostomy and Roux-en-Y reconstruction; Billroth I group refers to patients after subtotal gastrectomy with Billroth I reconstruction; Billroth II group refers to patients after subtotal gastrectomy with Billroth II reconstruction WD Well-differentiated, MD moderately differentiated, PD poorly differentiated
Table 2 Stent type and location of SEMS Total gastrectomy group (n = 15)
Billroth I group (n = 8)
Billroth II group (n = 16)
Total (n = 39)
Stent type Covered
9 (60%)
2 (25%)
3 (19%)
14 (36%)
Uncovered
6 (40%)
6 (75%)
13 (81%)
25 (64%)
1 (7%)
0 (0%)
1 (6%)
2 (5%)
Afferent loop
0 (0%)
0 (0%)
6 (38%)
6(15%)
Efferent loop
11 (73%)
8 (100%)
9 (56%)
28 (72%)
0 (0%)
0 (0%)
3(8%)
Location Esophagus or GEJ
Jejunum
3 (20%)
Data are presented as number (percent) Total gastrectomy group refers to patients after total gastrectomy with esophagojejunostomy and Roux-en-Y reconstruction; Billroth I group refers to patients after subtotal gastrectomy with Billroth I reconstruction; Billroth II group refers to patients after subtotal gastrectomy with Billroth II reconstruction GEJ Gastroesophageal junction
occurred in three patients, two with covered stents (2/14; 14%) and one with an uncovered stent (1/25; 4%) (p = 0.29) (Table 4). A proximally migrating stent was
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successfully removed by upper endoscopy. A stent that partially migrated in the distal direction was endoscopically repositioned in one patient. However, a chest X-ray
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Fig. 1 Malignant gastrojejunal anastomotic obstruction A before SEMS insertion, showing the guidewire inserted into the afferent loop; B after the placement of a covered SEMS into the afferent loop; and C after the simultaneous insertion of an uncovered SEMS into the efferent loop. D A plain abdominal radiograph showing appropriate expansion of both SEMSs on the third day after stent insertion
after this endoscopic repositioning revealed a pneumoperitoneum that necessitated surgical management. Another patient had no definite obstructive symptoms but had stent migration that was detected incidentally on the CT scan 3 months after stent insertion. Initially nothing was done, but then obstructive symptoms began 2 months after this CT and a second stent was successfully inserted. Restenosis occurred in 12 patients due to tumor overgrowth in 5 and tumor ingrowth in 7; among these restenotic lesions, 4 occurred with covered stents (4/14; 29%) and 8 with uncovered stents (8/25; 32%) (p [ 0.99). Among the 12 patients with restenosis, additional stents were inserted in 10 and only supportive care was provided to the other 2 patients.
Discussion SEMS insertion has become widely accepted for malignant GOO because it allows for a shorter procedure time and prompt restoration of oral intake when compared with surgical gastroenterostomy [11]. However, only a few
published reports have addressed stent placement for recurrent malignant obstruction after surgery [7, 8, 12]. Although stent insertion is considered more difficult in recurrent rather than primary malignant GOO, because of altered anatomy, the overall technical success of stent insertion was 92%, and clinical success was 90% in our study. These figures are comparable to those achieved with inoperable esophagogastric junction or cardia gastric cancer (95–100%) [13, 14], or with malignant gastroduodenal obstruction (87–97%) [15]. Our results suggest that endoscopic SEMS insertion is effective even with obstruction due to recurrent gastric cancer. The endoscopic technique may have advantages over the fluoroscopic method for the following reasons: anatomic alteration after gastric surgery, a relatively short delivery system with the fluoroscopic method [16], and the large working channel of the endoscope that facilitates advancement of the stent through tortuous anatomy and a distended stomach [4]. In one study where stent insertion was performed primarily under fluoroscopic guidance, two cases were reported in which stent insertions were possible with the endoscopic method after failed attempts with
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Table 3 Outcomes of SEMS placement and GOO score before and after stent placement Total gastrectomy group (n = 15)
Billroth I group (n = 8)
Billroth II group (n = 16)
Total (n = 39)
p value*
Technical success
13 (87%)
8 (100%)
15 (94%)
36 (92%)
0.500
Clinical success
12 (80%)
8 (100%)
15 (94%)
35 (90%)
0.254
Before stent
0.42 ± 0.52 (n = 12)
0.50 ± 0.00 (n = 8)
0.45 ± 0.69 (n = 11)
0.45 ± 0.62 (n = 31)
0.995
1 week after stent
2.00 ± 0.00 (n = 12)
2.38 ± 0.52 (n = 8)
1.91 ± 0.70 (n = 11)
2.06 ± 0.51 (n = 31)
0.127
1 month after stent
1.73 ± 1.19 (n = 11)
2.00 ± 1.27 (n = 6)
1.55 ± 1.13 (n = 11)
1.71 ± 1.15 (n = 28)
0.646
pà (before vs. 1 week) pà (before vs. 1 month)
0.004 0.032
0.010 0.066
0.003 0.019
\0.001 \0.001
GOO score (mean ± SD)
pà (1 week vs. 1 month) Complications, total Migration
0.335
0.480
0.317
0.125
8 (53%)
2 (25%)
7 (44%)
17 (44%)
2 (13%)
1 (12.5%)
0 (0%)
3 (8%)
Overgrowth
2 (13%)
0 (0%)
3 (19%)
5 (13%)
Ingrowth
3 (20%)
1 (12.5%)
3 (19%)
7 (18%)
Perforation
1 (7%)
0 (0%)
1 (6%)
2 (5%)
10.7 (0.4–38.3)
24.7 (1.4–190.7)
9.7 (3.3–45.0)
10.7 (0.4–190.7)
Median stent patency duration (weeks)
Data are presented as number (percent), mean ± SD, or median (range) Total gastrectomy group refers to patients after total gastrectomy with esophagojejunostomy and Roux-en-Y reconstruction; Billroth I group refers to patients after subtotal gastrectomy with Billroth I reconstruction; Billroth II group refers to patients after subtotal gastrectomy with Billroth II reconstruction * Two-sided p values obtained from Pearson’s v2 test for technical and clinical successes
p values obtained from Kruskal–Wallis test for GOO scores among patients in the three groups with clinically successful procedures
à
p values obtained from Wilcoxon signed-rank test for change in GOO score
fluoroscopy [8]. In addition, simultaneous stent insertion into the afferent and efferent loops or coaxial double-stent insertion was possible [6]. Moreover, removal of proximally migrated stents or repositioning of malpositioned stents can be performed by the endoscopic method. In contrast, others have reported that endoscopic insertion is associated with difficulty due to friction between the long delivery system of the stent and the working channel of the endoscope when it is in an angulated position [17]. The technical and clinical successes in our study were similar to those of fluoroscopic stent studies, which reported technical success at 94–100% and clinical success at 90–96% [7, 8, 12]. Although we did not directly compare endoscopic stent insertion with the fluoroscopic method, our data suggest that the endoscopic approach is comparable to the fluoroscopic method. The GOO score improved immediately after stent insertion, increased by 1 week, and was maintained up to 1 month in this study. This result is in agreement with the results of studies of primary malignant GOO in which the mean dysphagia score improved considerably by day 7, and the improvement was maintained up to day 30 [13, 18]. When considering improved quality of life and performance score after stent placement [19, 20], it might allow the chance for additional chemotherapy.
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Early complications of stent placement are perforation, bleeding, and aspiration pneumonia. In our study, the two early complications (5%) were both perforations, and no other critical events such as bleeding or aspiration pneumonia occurred. Some studies with small numbers of patients reported no critical or major complications [6, 12, 21], but other studies reported complications of 1–10%, including perforation, aspiration pneumonia, bleeding, and cholangitis [8, 22, 23]. The early complication rate of 5% in our study is comparable to those in previous reports. All of the late complications occurred more than 1 month after stent insertion, and these were migration or restenosis due to tumor overgrowth or ingrowth, comparable to the results of previous studies [13, 17, 24]. Complications may be affected by stent location. In recurrent gastric cancer, complications of stent insertion with esophagojejunal anastomotic obstruction occurred at 44% in one study [12] and 15% with gastrojejunal anastomotic obstruction in another study [8]. Those results suggested that complications of stent insertion with esophagojejunal anastomosis seemed to be higher than with gastrojejunal anastomosis. In our study, complications in the total gastrectomy group and the subtotal gastrectomy group (Billroth I and II) occurred at similar levels. The high level of complications in this study might be due to
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Fig. 2 A Kaplan–Meier plots for cumulative stent patency according to the types of operation. B Kaplan–Meier plots for overall survival of patients according to the types of operation. Cumulative stent patency and patient survival did not differ among the three types of operations. STGBI Subtotal gastrectomy with Billroth I reconstruction, STGBII subtotal gastrectomy with Billroth II reconstruction, TG total gastrectomy with esophagojejunostomy and Roux-en-Y reconstruction
Fig. 3 A Kaplan–Meier plots for cumulative stent patency according to the types of stent (covered vs. uncovered). B Kaplan–Meier plots for overall survival of patients according to the types of stent. Cumulative stent patency and patient survival did not differ between the types of stent
Table 4 Outcomes of SEMS placement according to the stent type Covered stent (n = 14)
Uncovered stent (n = 25)
p Value [0.99*
Technical success
13 (93%)
23 (92%)
Clinical success
12 (86%)
23 (92%)
0.609*
Before stent
0.36 ± 0.50
0.56 ± 0.71
0.544
1 week after stent
1.64 ± 0.84
1.92 ± 0.81
0.339
1 month after stent
0.173
GOO score (mean ± SD)
1.17 ± 1.27 (n = 12)
1.78 ± 1.17 (n = 23)
à
0.001
\0.001
à
p (before vs. 1 month)
0.026
\0.001
pà (1 week vs. 1 month)
0.459
0.328
6 (43%)
11 (44%)
Migration Overgrowth
2 (14%) 2 (14%)
1 (4%) 3 (12%)
0.289§ [0.99§
Ingrowth
2 (14%)
5 (20%)
[0.99§
Perforation
0 (0%)
2 (8%)
0.528§
10.7 (0.4–45.0)
11.4 (1.4–190.7)
0.515}
p (before vs. 1 week)
Complications, total
Stent patency (median, range) (weeks)
0.945*
Data are presented as number (percent), mean ± SD, or median (range) * Two-sided p values obtained from Pearson’s v2 test
Two-sided p values obtained from the Mann–Whitney U test
à
p values obtained from Wilcoxon signed-rank test for change in GOO score
§
Two-sided p values obtained from Fisher’s exact test
}
p values obtained from log-rank test
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relatively long survival (median = 21.3 weeks), similar to results of a previous study in which complications occurred in 44% of patients with a median survival of 112 days [25]. Nineteen patients (54%) experienced recurrence of obstructive symptoms, and the median stent patency duration was 10.7 weeks. This is shorter than the results of two previous studies of stent placement after gastrectomy in which the duration of patency ranged from 140 to 180 days [8, 12]. Median survival in our study was 21.3 weeks, similar to previous reports of survival from 110 to 150 days [6, 8]. In addition, survival did not differ significantly among the three groups. Considering the short life expectancy after tumor recurrence, stent insertion is a reasonable option for relieving obstructive symptoms irrespective of gastrectomy type or reconstruction method. A small retrospective study (n = 20) showed that the median patency duration did not differ between covered and uncovered stents (56 vs. 37 days, respectively, p = 0.7) [26]. Our data showed a similar result: the median patency duration did not differ between the covered and uncovered stents (10.7 and 11.4 weeks, respectively, p = 0.515). A large-scale prospective study is needed to determine which type of stent would be preferred. Our study showed that SEMS insertion for recurrent malignant obstruction after gastrectomy due to gastric cancer was effective and safe. However, this study had certain limitations. First, it was a single-center nonrandomized retrospective study and therefore may be vulnerable to selection bias. Second, the postoperative reconstruction methods were heterogeneous. Third, our results might not be generalizable to patients with esophageal or pancreatic cancer because we included only patients with gastric cancer. Lastly, various types of SEMSs were used, including covered or uncovered stents. In conclusion, endoscopic SEMSs can offer feasible and effective short-term palliation to patients who have obstructive symptoms due to local recurrences after radical gastrectomy. Acknowledgment This work was supported by grant 0910090 from the National Cancer Center, Korea. Disclosures Drs. Jaihwan Kim, Il Ju Choi, Chan Gyoo Kim, Jong Yeul Lee, Soo-Jeong Cho, Sook Ryun Park, Jun Ho Lee, Keun Won Ryu, Young-Woo Kim, and Young-Iee Park have no conflicts of interest or financial ties to disclose.
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