What is the role of stent insertion in managing obstructive symptoms in patients with gastric cancer?

Role of Stent Insertion in Managing Obstructive Symptoms in Gastric Cancer

Endoscopic placement of self-expanding metal stents (SEMS) is a safe, effective, and minimally invasive palliative treatment for patients with luminal obstruction due to advanced gastric cancer, particularly for those with shorter life expectancy. 1

Patient Selection for Stent Placement vs. Surgical Bypass

The choice between stent placement and surgical intervention should be guided by the patient's prognosis:

• For patients with shorter life expectancy: SEMS placement is preferred due to:

  • Faster symptomatic relief 1
  • Shorter hospital stays 1
  • More rapid resumption of oral intake 1
  • Less invasive procedure 2

• For patients with longer life expectancy: Gastrojejunostomy may be preferable due to:

  • More durable long-term results 1
  • Lower rate of reintervention 1

Benefits of Stent Placement

• Technical success rates of approximately 98% 2
• Clinical success rates of approximately 84% 2
• Significant improvement in gastric outlet obstruction scoring system 2
• Median stent patency of 307 days in some studies 2
• Can be combined with chemotherapy for patients with good performance status 3, 4

Potential Complications and Management

• Tumor ingrowth/overgrowth:

  • More common with uncovered stents (16.6%) than covered stents (2.9%) 5
  • Can be managed with repeat endoscopic stent placement 6

• Stent migration:

  • More common with covered stents (17.1%) than uncovered stents (0%) 5
  • May require endoscopic repositioning or replacement 1

• Pain after stent placement:

  • Severe uncontrolled pain should be treated with immediate endoscopic removal of the stent 1, 7

Alternative Approaches for Obstruction Management

When stent placement is not feasible or unsuccessful:

• Surgical options:

  • Gastrojejunostomy for gastric outlet obstruction 1
  • Gastrectomy in select patients 1

• Non-surgical alternatives:

  • External beam radiation therapy 1
  • Balloon dilation 1
  • Percutaneous decompressive gastrostomy for symptom relief 1

• When obstruction cannot be alleviated:

  • Venting gastrostomy for gastric decompression 1
  • Feeding gastrostomy tubes (for EGJ/cardia obstruction) or jejunal feeding tubes (for mid/distal obstruction) 1
  • Drain ascites before venting gastrostomy tube placement to reduce infection risk 1

Comprehensive Approach to Symptom Management

Beyond addressing obstruction, management should include:

• Pain control:

  • External beam radiation therapy 1
  • Appropriate pain medications per NCCN Adult Cancer Pain guidelines 1

• Nausea and vomiting:

  • Follow NCCN Antiemesis guidelines 1
  • Endoscopic or fluoroscopic evaluation to determine if luminal enhancement is indicated 1

• Nutritional support:

  • Nutritional counseling 1
  • Appropriate feeding access if oral intake is inadequate 1

Integration with Other Treatment Modalities

• Stent placement can be safely combined with chemotherapy for patients with good performance status 3, 4
• No significant differences in survival, time to treatment failure, or response rates between surgery plus chemotherapy versus stenting plus chemotherapy 4
• A multidisciplinary approach involving endoscopists, surgeons, oncologists, and interventional radiologists is essential for optimal outcomes 6