‘Palliative alleviation of gastric outlet obstruction in terminal patients with advanced incurable cancers using self-expanding metallic stents. Can we predict outcome?’

Helene Würtz, MD, Søren I Abramsson, MD, Mohammad Abdul Ghani, MD, Lars S Jørgensen, MD, Poul B Thorsen, MD, PhD, Jan M Krzak, MD. Sygehus Lillebaelt, Kolding, Denmark

Introduction: Malignancies leading to gastric outlet obstruction (GOO) may be alleviated with endoscopically placed self-expanding metallic stents (SEMS). Is it possible to predict any difference in survival?

Objective: The primary objective of this study was to show that endoscopic placement of SEMS is a feasible option in alleviating gastric obstruction in patients with different types of advanced incurable malignancies. Secondary, the objective was to clarify whether overall survival was different in the groups identified.

Method: Over a 5-year period (January 2009 to September 2014), 43 patients with GOO, caused by different types of incurable advanced malignancies, underwent endoscopic placement of a SEMS. In this single-center study, charts from patients were reviewed retrospectively, and survival rates were compared. Three patients were excluded from this study. One patient was “outlier” with an uncertain pathology report, and two other patients as they are still alive today. There were no exclusions due to co-morbidity despite many of patients reached the end stage of the disease. Patients were divided into two groups; patients with incurable advanced pancreatic cancer (P-group) and patients with other incurable advanced gynecological and gastrointestinal cancers (A-group). Statistical analyses included T-tests for continuous variables distributed normally, and Mann-Whitney Ranksum tests for continuous variables not-normally distributed. Cox proportional hazard and Kaplan Meier plots were used for survival analyses

Results: Total number of patients in the study was 40; 16 patients in the P-group and 24 patients in the A-group. Median survival after stent placement was overall 54 days. Survival was higher in P-group with a median of 111 (IQR 34-159) days compared to A-group with a median of 45 (IQR 27-76). In the P-group, there were no technical failures, except one clinical failure. In the A-group there was 1 technical failure (duodenal rupture resulting in death), and 2 clinical failures. One patient needed a second stent placed for full alleviation of the stenosis in the first few days after stent placement, and two others needed second stent placement due to tumor ingrowth few months later. One patient was treated operatively with laparoscopic gastroenteroanastomosis two months later. Mean age in the whole study population was 69.9 and did not differ between the two groups. The AUC in our Kaplan-Meier plot shows a difference in post-operative survival favoring patients with pancreatic cancer. Comparing the two groups with survival analysis (Cox proportional hazard) shows a hazard rate ratio of 2.3 (95% CI 1.1-4.5). The software packages SPSS and STATA were used for the statistical analyses.

Conclusion: Alleviation of GOO with placement of SEMS in patients with advanced incurable cancers seems to be a successful choice of palliation. There seems to be a statistically significant higher survival in pancreatic cancer patients compared to other types of abdominal cancers.

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