Gastric Outlet Obstruction Palliation: A Novel Stent-Based Solution.
Gastric outlet obstruction (GOO) after esophagectomy is a morbid outcome and significantly hinders quality of life for end-stage esophageal cancer patients. In the pre-stent era, palliation consisted of chemotherapy, radiation, tumor ablation, or stricture dilation. In the current era, palliative stenting has emerged as an additional tool; however, migration and tumor ingrowth are ongoing challenges. To mitigate these challenges, we developed a novel, hybrid, stent-based approach for the palliative management of GOO. We present a patient with esophageal cancer diagnosed with recurrent, metastatic disease 1 year after esophagectomy. She developed dehydration and intractable emesis, which significantly interfered with her quality of life. For palliation, we dilated the stenosis and proceeded with our stent-based solution. Using a combined endoscopic and fluoroscopic approach, we placed a 12-mm silicone salivary bypass tube across the pylorus, where it kinked slightly because of local tumor biology. To bridge this defect and ensure luminal patency, we placed a nitinol tracheobronchial stent through the silicone stent. Clinically, the patient had immediate relief from her pre-operative symptoms and was discharged home on a liquid diet. In conclusion, GOO and malignant dysphagia after esophagectomy are significant challenges for patients with end-stage disease. Palliative stenting is a viable option, but migration and tumor ingrowth are common complications. The hybrid approach presented here provides a unique solution to these potential pitfalls. The flared silicone tube minimized the chance of migration and impaired tumor ingrowth. The nitinol stent aided with patency and overcame the challenges of the soft tube. This novel strategy achieved palliation, describing another endoscopic option in the treatment of malignant GOO.
Rueth
Natasha M
NM
Division of Thoracic and Foregut Surgery, Department of Surgery, University of Minnesota, Minneapolis, Minn., USA.
Andrade
Rafael S
RS
Groth
Shawn S
SS
Maddaus
Michael A
MA
D'Cunha
Jonathan
J
Ann Thorac Surg. 2009 Jun;87(6):1708-13; discussion 1713-4
19463583
Ann Thorac Surg. 2008 Jun;85(6):1968-72; discussion 1973
18498804
J Gastrointest Surg. 2007 Jan;11(1):107-13
17390196
Endoscopy. 2003 Jun;35(6):483-9
12783345
Dig Surg. 2002;19(3):160-4
12119515
Eur J Cardiothorac Surg. 2008 Jun;33(6):1105-11
18434178
Surg Oncol. 2007 Dec;16(4):259-65
17904357
Dis Esophagus. 2008;21(8):712-7
18847448
J Surg Oncol. 2007 Oct 1;96(5):389-96
17474082
Cardiovasc Intervent Radiol. 2010 Aug;33(4):772-9
19787398
Dis Esophagus. 2009;22(4):331-6
19473211
BMC Gastroenterol. 2009 Jun 17;9:45
19534803
Cochrane Database Syst Rev. 2009 Oct 07;(4):CD005048
19821338