We read with interest the paper, “Stents and surgical interventions in the palliation
of gastric outlet obstruction: a systematic review” by Minata MK et al, which appeared
in Endoscopy International Open (2016; 4: E1158 – 1170) [1]. The Authors should be congratulated for an extensive and careful review.
In recent studies, we prospectively analyzed the clinical outcomes of 72 patients
[2]
[3] and we came to similar conclusions. We have abandoned the use of covered stents.
Distal migration of a covered stent can lead to serious consequences and a stent rarely
can be retrieved endoscopically [4].
Endoscopic stenting offers many advantages in comparison to surgery: shorter hospital
stay, faster return to oral intake, a less invasive procedure. However, life expectance
may be longer than 1 year in some patients with malignant gastric outlet obstruction,
particularly those with distal gastric cancer or gastric obstruction from metastatic
disease.
In this selected group of patients, food obstruction is common. The reason for it
in rare cases derives from tumor in-growth within the stent; in the majority of patients,
food obstruction is secondary to dismotility of the pyloric region. The dismotility
depends on many factors, including nerve infiltration by the tumor. Food obstruction
is not easily diagnosed. The stomach can enlarge significantly before vomiting occurs.
Stomach dilation can lead to nausea, discomfort, and dyspnea, symptoms that easily
can be attributed to the cancer itself.
For all these reasons, patients who have endoscopic stenting in this clinical setting
should have a very careful follow-up with repeated endoscopies and computed tomography
scan. This careful follow-up may not be well tolerated by a patient whose general
condition is slowly deteriorating or for his or her family.
Laparoscopic surgery can be performed with minimal discomfort for patients and it
should be seriously considered in patients whose conditions are generally acceptable.
Before such a procedure, the patient and family should be consulted and all positive
and negative aspects of the surgery should be thoroughly explained, leaving them to
choose the preferred treatment.
