Malignant Strictures

Proximal and unresectable malignant strictures, in turn, have usually been treated with surgical bypass or, occasionally, palliative resection (Table 85-4). The latter has been associated with morbidity of 20 to 40% and mortality rates ranging from 0 to 20% (Nassif et al, 2003). As a consequence, self-expandable metal stents (SEMS) have been used with increased frequency, particularly in patients with late stage gastric outlet obstruction in the setting of pancreaticobiliary malignancy (Wong et al, 2002; Adler and Baron, 2002; Nassif et al, 2003; Mosler et al, 2004). Although many esophageal prostheses have been used (Z stent, Wilson-Cook, Inc., Winston-Salem, NC; Ultraflex, Microvasive, Inc., Natick, MA; and EsophaCoil, Medtronics, Inc., Eden Prairie, MN), most US series have used the only TTS prosthesis currently released by the Food and Drug Administration, the Enteral Wallstent (Microvasive, Inc., Natick, MA) (Figure 85-2). The latter prosthesis, ranging between 6 to 9 cm in length and 18 to 22 mm in diameter, is released after stricture delineation

TABLE 85-4. Treatment Modalities for Malignant Intestinal and Colonic Stenoses

Upper intestinal tract Surgery Resection Bypass Endoscopic Rx

Dilatation/enteric stent placement ± Diverting PEG/feeding PEJ Mid-distal SB/Colon Surgery Endoscopic Rx

Dilatation - balloon versus Savary-type SEMS

Palliative Rx Preoperatively

PEG = percutaneous endoscopic gastrostomy; PEJ = percutaneous endoscopic jejunostomy; SB = small bowel; SEMS = self-expandable metal stent.

by contrast injection through the stenosis or submucosal injection of contrast proximally and distally at the margins of the tumor (Figure 85-3).

Technical success rates for stent placement approximate 90 to 95%, although a second stent is needed in up to one-third of placements (Mosler et al, 2004). Functional success rates allowing intake of soft foods or full liquids, in turn, have been reported to be 80 to 90% (Nassif et al, 2003) and complications include both short term (bleeding, perforation, and malplacement) as well as long term (erosion/perforation, migration, bleeding, and obstruction). Most series

1bmmx60mm wallstent >

FIGURE 85-2. Enteral Wallstent delivery system

FIGURE 85-3. C-loop Wallstents in patient with primary pancreatic malignancy (A to F). Note incomplete distal prosthesis expansion (B) treated with second prosthesis (D,E, and F). Continued on next page.

FIGURE 85-3 Continued. C-loop Wallstents in patient with primary pancreatic malignancy (A to F). Note incomplete distal prosthesis expansion (B) treated with second prosthesis (D,E, and F).

cited earlier report a survival approximating only 2 to 4 months after SEMS insertion for upper gastrointestinal (GI) malignancies, and, at the time of this writing, there have been no randomized studies comparing upper GI tract stenting to palliative surgery. There have, however, been large single center series, and a recent multicenter trial by Nassif and colleagues (2003) reported 63 patients in whom stent placement was attempted. Successful in 60 (95%), there was no procedure-related mortality, but 30% of the patients developed complications including 13 stent obstructions, 4 migrations, and 2 duodenal perforations. Median survival was 7 weeks.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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