RonDom de Dom Stenting the GI Tract: When, How and Which Gastric Outlet Obstruction

1. RonDom de DomStenting the GI Tract:When, How and WhichGastric Outlet Obstruction Peter D. Siersema Dept. of Gastroenterolgy & Hepatology

2. Patient A • Male • 70-year-old • 2007: Pain radiating to back, fullness, weight loss (5 kg) • CT-scan: Pancreatic cancer

3. Patient A Which treatment do you advise: 1) (Palliative) surgery 2) Chemoradiation therapy 3) Radiation therapy 4) Palliation with stent

4. Treatment of pancreatic cancer >75%of the patients do not qualify for a resection, because of: • locally advanced disease (20%) • metastases (65%) • poor clinical condition (15%) • palliation

5. Palliation of pancreatic cancer Locally advanced + good clinical condition • Bypass • stent placement • enteral • common bile duct (CBD) • surgical • gastrojejunostomy • biliodigestive anastomosis • Chemo-radiation therapy (phase I-II studies)

6. Palliation of pancreatic cancer Metastases + poor clinical condition • Bypass • stent placement • enteral • common bile duct (CBD) • surgical • gastrojejunostomy • biliodigestive anastomosis • Pain relief • medication • EUS-guided celiac plexus neurolysis

7. Gastrojejunostomy

8. SUSTENT study - Conclusions Gastrojejunostomy • gave better long term relief of dysphagia • was associated with fewerrecurrent obstructions and reinterventions • was associated with longer hospital stay • resulted in more costs compared to stent placement

9. SUSTENT study - Food intake Days with GOOSS > 2 - GJJ: 72 days - Stent: 50 days (p=0.05) 6 weeks

10. SUSTENT study - Conclusions Gastrojejunostomy seems preferable to stent placement in relieving malignant dysphagia, however .…… • Does one palliative treatment fit all patients?

11. Patient A • Male • 70-year-old • COPD, IHD, DM • CT-scan: Pancreatic cancer (4 cm) + liver metastases

12. How to palliate malignant GOO? • Expected survival ≤6 weeks • Stent placement • Expected survival >6 weeks • Gastrojejunostomy Poor prognostic factors: • larger tumor size (>3 cm) • hepatic metastases • advanced age • male sex • comorbidity/performance status

13. Patient A • Male • 70-year-old • COPD, IHD, DM • CT-scan: Pancreatic cancer (4 cm) + liver metastases • Stent placement duodenum

14. Patient A Which stent do you advise: 1) Uncovered SEMS (e.g. Wallflex, Niti-S, Evolution) 2) Covered SEMS (e.g. Niti-S stent) 3) Either stent

15. How to place stents? • Use Large-caliber endoscope (forward-viewing) • Identifying the stricture • Direct vision • Using contrast media with catheter • Placing guidewire (flexible) • Placing stent under direct vision + fluoroscopy

16. Stent placement

17. Where to place proximal stent end with a stricture in first part of duodenum? • Proximal to pylorus • In duodenal bulb • Does not make a difference

18. Uncovered/Covered stent Uncovered stent • Tumor/tissue ingrowth • Food obstruction Covered stent • Stent migration • Cholangitis/Pancreatitis/Cholecystitis (??)

19. Patient A • Male, 70-year-old • Pancreatic cancer + liver metastases • Duodenal stent placement: • Wallflex (Boston Scientific) • Niti-S (Medicor) • Evolution (Cook)

20. Magnetic Anastomotic Device (MAD)

21. Patient A • Male, 70-year-old • Pancreatic cancer + liver metastases • Stent placement: • Wallflex (Boston Scientific) • Niti-S (Medicor) • Evolution (Cook) How to deal with obstructive jaundice?

22. Jaundice • 50% of patients prior to GOO • 20% of patients at same time of GOO • 30% of patients following GOO

23. Jaundice prior to GOO • Often already plastic stent in CBD • Change for metal CBD stent before duodenal stent placement • Alternatively: Remove plastic stent and perform biliodigestive anastomosis + GJJ

24. Surgical bypass vs. Biliary stent Smith et al. Lancet 1994

25. Surgical bypass vs. Biliary stent • Both are safe and effective palliative treatments for malignant CBD obstruction • Biliary stent placement is associated with good short term outcome • Surgical bypass is associated with better long termoutcome

26. Jaundice at same time of GOO • First place metal CBD stent and then duodenal stent • Preferably proximal or distal to papilla • Alternatively: Perform biliodigestive anastomosis + GJJ

27. Jaundice following GOO • If duodenal stent placed proximal or distal to papilla: CBD stent • If duodenal stent covers papilla: • Identify papilla through meshes

28. Jaundice following GOO • If duodenal stent placed proximal or distal to papilla: CBD stent • If duodenal stent covers papilla: • Identify papilla through meshes

29. Jaundice following GOO • If duodenal stent placed proximal or distal to papilla: CBD stent • If duodenal stent covers papilla: • Identify papilla through meshes • APC to identify papilla • EUS-guided approach

30. EUS-guided approach

31. Jaundice following GOO • If duodenal stent placed proximal or distal to papilla: CBD stent • If duodenal stent covers papilla: • Identify papilla through meshes • APC to identify to papilla • EUS-guided approach • Percutaneous transhepatic approach

32. Patient B • Female, 88-year-old • Poor performance status • Pancreatic cancer in tail (5 cm) + liver metastases • Distal duodenum obstruction

33. Patient B Which treatment do you advise: 1) GJJ 2) Chemoradiation 3) Radiation therapy 4) Stent placement

34. Stent placement distal duodenum Use of a therapeutic gastroscope may be difficult: • The length of the gastroscope is often too short (looping!) • When looping occurs, friction between the stent and channel of the endoscope may result • The ability to maintain the gastroscope in a stable position is reduced (angulated stricture) Solution: Colonoscope

35. Stent placement distal duodenum Advantages of using colonoscope: • Longer • Stiffer • Avoiding looping in the stomach and resulting in a more stable position close to a stricture

36. Stent placement distal duodenumResults Jeurnink et al. Surg Endosc 2008

37. Noteer alvast in uw agenda: RonDom de Dom III A day in the GI motility lab a practice-based course on upper GI motility tests 19 juni 2009