Palliative treatment for malignant gastrointestinal obstruction with peritoneal carcinomatosis: enteral stenting versus surgery

Abstract

Background and study aims Management of malignant gastrointestinal obstruction (MGIO) is more challenging in the presence of peritoneal carcinomatosis (PC). Outcomes data to guide the management of MGIO with PC are lacking. We aimed to compare the clinical outcomes and adverse events between endoscopic and surgical palliation and identify predictors of stent success in patients with MGIO with PC.

Patients and methods Consecutive inpatients with MGIO with PC between 2000 and 2018 who underwent palliative surgery or enteral stenting were included. Clinical success was defined as relief of obstructive symptoms.

Results Fifty-seven patients with enteral stenting and 40 with palliative surgery were compared. The two groups did not differ in rates of technical success, 30-day mortality, or recurrence. Clinical success from a single intervention (63.2 % versus 95 %), luminal patency duration (27 days vs. 145 days), and survival length (148 days vs. 336 days) favored palliative surgery (all P < 0.05) but the patients in the surgery group had a trend toward better Eastern Cooperative Oncology Group (ECOG) status. The rate of adverse events (AEs) (10.5 % vs. 50 %), the severity of AEs, and length of hospital stay (4.5 days vs. 9 days) favored enteral stenting (P < 0.05). The need for more than one stent was associated with a higher likelihood of stent failure.

Conclusions Our study suggests that enteral stenting is safer and associated with a shorter hospital stay than palliative surgery, although unlike other MGIOs, clinical success is lower in MGIO with PC. Identification of the right candidates and potential predictors of clinical success in ECOG-matched large-scale studies is needed to validate these results.

Publication History

Received: 17 February 2020

Accepted: 07 July 2020

Article published online:
07 October 2020

• References

• 1 Coccolini F, Gheza F, Lotti M. et al. Peritoneal carcinomatosis. World J Gastroenterol 2013; 19: 6979-6994
• 2 Lambert LA, Wiseman J. Palliative management of peritoneal metastases. Ann Surg Oncol 2018; 25: 2165-2171
• 3 Fagotti A, Gallotta V, Romano F. et al. Peritoneal carcinosis of ovarian origin. World J Gastrointest Oncol 2010; 2: 102-108
• 4 Segelman J, Granath F, Holm T. et al. Incidence, prevalence and risk factors for peritoneal carcinomatosis from colorectal cancer. Br J Surg 2012; 99: 699-705
• 5 Goodman MD, McPartland S, Detelich D. et al. Chemotherapy for intraperitoneal use: a review of hyperthermic intraperitoneal chemotherapy and early post-operative intraperitoneal chemotherapy. J Gastrointest Oncol 2016; 7: 45-57
• 6 Raptopoulos V, Gourtsoyiannis N. Peritoneal carcinomatosis. Eur Radiol 2001; 11: 2195-2206
• 7 Paul Olson TJ, Pinkerton C, Brasel KJ. et al. Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review. JAMA Surg 2014; 149: 383-392
• 8 Faraz S, Salem SB, Schattner M. et al. Predictors of clinical outcome of colonic stents in patients with malignant large-bowel obstruction because of extracolonic malignancy. Gastrointest Endosc 2018; 87: 1310-1317
• 9 Lee JE, Lee K, Hong YS. et al. Impact of Carcinomatosis on clinical outcomes after self-expandable metallic stent placement for malignant gastric outlet obstruction. PLoS One 2015; 10: e0140648
• 10 Park JJ, Rhee K, Yoon JY. et al. Impact of peritoneal carcinomatosis on clinical outcomes of patients receiving self-expandable metal stents for malignant colorectal obstruction. Endoscopy 2018; 50: 1163-1174
• 11 Rademacher C, Bechtler M, Schneider S. et al. Self-expanding metal stents for the palliation of malignant gastric outlet obstruction in patients with peritoneal carcinomatosis. World J Gastroenterol 2016; 22: 9554-9561
• 12 Abelson JS, Yeo HL, Mao J. et al. Long-term postprocedural outcomes of palliative emergency stenting vs stoma in malignant large-bowel obstruction. JAMA Surg 2017; 152: 429-435
• 13 Ahn HJ, Kim SW, Lee SW. et al. Long-term outcomes of palliation for unresectable colorectal cancer obstruction in patients with good performance status: endoscopic stent versus surgery. Surg Endosc 2016; 30: 4765-4775
• 14 Zheng B, Wang X, Ma B. et al. Endoscopic stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Dig Endosc 2012; 24: 71-78
• 15 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213
• 16 Roy A, Kim M, Christein J. et al. Stenting versus gastrojejunostomy for management of malignant gastric outlet obstruction: comparison of clinical outcomes and costs. Surg Endosc 2012; 26: 3114-3119
• 17 Jang S, Stevens T, Lopez R. et al. Superiority of gastrojejunostomy over endoscopic stenting for palliation of malignant gastric outlet obstruction. Clin Gastroenterol Hepatol 2019; 17: 1295-1302 e1291
• 18 Jeurnink SM, Polinder S, Steyerberg EW. et al. Cost comparison of gastrojejunostomy versus duodenal stent placement for malignant gastric outlet obstruction. J Gastroenterol 2010; 45: 537-543
• 19 No JH, Kim SW, Lim CH. et al. Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery. Gastrointest Endosc 2013; 78: 55-62
• 20 Park CH, Park JC, Kim EH. et al. Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy. Gastrointest Endosc 2015; 81: 321-332
• 21 Dabirian A, Yaghmaei F, Rassouli M. et al. Quality of life in ostomy patients: a qualitative study. Patient Prefer Adherence 2010; 5: 1-5
• 22 Smith DM, Loewenstein G, Rozin P. et al. Sensitivity to disgust, stigma, and adjustment to life with a colostomy. J Res Pers 2007; 41: 787-803