Transcript Slide 1 - Baylor College of Medicine

GI Grand Rounds
Johanna Chan
Gastroenterology Fellow
Baylor College of Medicine
3/21/13
No conflicts of interest
No financial disclosures
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
Past Medical History
• HTN
• Previously on medication, now diet controlled
Medications
• None
• No OTC medications, including NSAIDs
Other history
• Family history
▫ Mother and father died “of old age”
▫ Siblings alive and healthy
▫ No GI malignancy
• Social history
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Denies all EtOH
Lifelong nonsmoker
No IV drug use or other illicits
Married, housewife
Exam
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T 98.5, BP 121/62, HR 83, RR 12, O2 sat 99% RA
4’11”, 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
Labs
136
101
23
131
4.1
26
0.6
6.9
7.9
25.9
69% PMNs
Total protein 7.3
Albumin 3.8
Total bili 0.4
ALT 26
AST 29
Alk phos 90
368
INR 1.2
PTT 28
MCV 91
Endoscopy
Endoscopy
Endoscopy
Pathology
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Stomach antrum, biopsy
Adenocarcinoma, signet ring cell type
Focally invasive in muscular wall of stomach
HER-2 negative
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
Clinical course
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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?
Management of malignant gastric
outlet obstruction
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?
Gastrojejunostomy
• Historical/traditional treatment for malignant
gastric outlet obstruction
• 72% of patients with good functional outcome
and relief of symptoms
• 13-55% morbidity
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.
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.
Stents
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. 2004;36:543-550.
Mauro MA et al. Radiology 2000; 215:659-69.
Stents for malignant GOO
• Systematic review in 2004 on >600 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 >20mm diameter should permit
passage of solid food
Dormann A et al. Endoscopy. 2004;36:543-550.
Van Hooft JE et al. Gastrointest Endosc. 2009 69(6):1059-66.
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.
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; 7:18.
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 (>4 weeks),
HRQoL, and costs
Jeurnink SM et al. Gastrointest Endosc 2010. 71(3):490-9.
GOO Scoring System
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0 = no oral intake
1 = liquids only
2 = soft solids
3 = almost complete diet
4 = full diet
Adler DG, Baron TH. Am J Gastroenterol. 2002;97:72-78.
Jeurnink SM et al. Gastrointest Endosc 2010. 71(3):490-9.
Jeurnink SM et al. Gastrointest Endosc 2010. 71(3):490-9.
SUSTENT
• Stent placement: more rapid PO intake, shorter
hospital stay, lower costs
• GJ with longer follow-up (>2 months): better
food intake, fewer major complications, and
fewer recurrent obstructive symptoms and reinterventions
• Recommend GJ as primary treatment if
expected survival > 2 months
• Recommend stent if expected survival < 2
months
Jeurnink SM et al. Gastrointest Endosc 2010. 71(3):490-9.
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
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):16206.
• Dormann A et al. Self-expanding metal stents for gastroduodenal
malignancies: systematic review of their clinical effectiveness. Endoscopy.
2004;36:543-550.
• Jeurnink SM et al. Stent versus gastrojejunostomy for the palliation of
gastric outlet obstruction: a systematic review. BMC Gastroenterol. 2007;
7:18.
References (con’t)
• 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; 215:659-69.
• 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).
References (con’t).
• 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.
Questions?