Expandable Metal Stents for the Palliation of Malignant Gastroduodenal Obstruction Rubeena Razzaq, Hans-Ulrich Laasch, Ruth England, Angie Marriott, Derrick Martin Department of Radiology, South Manchester University Hospital NHS Trust, Nell Lane, Withington, Manchester M20 2LR, UK Abstract Purpose: Gastric outlet obstruction is a debilitating compli- cation of upper gastrointestinal malignancy. We present our experience with insertion of self-expanding metal stents (SEMS). Methods: Twenty-eight patients were referred, stenting be- ing attempted in 23. Two patients had esophageal Wallstents inserted through a gastrostomy; 21 had an endoscopic ap- proach with enteral Wallstents. Results: One stent insertion failed, ten patients (45%) re- turned to a normal diet, ten patients (45%) managed semi- solid food and two patients (9%) had no significant improvement. No immediate complications were seen. One patient subsequently developed pancreatitis. Reintervention (4 stents, 1 jejunostomy, 1 gastrojejunostomy) was required in six of 22 patients (27%) for inadequate stent expansion (1), second stricture (2), stent migration (1), and tumor ingrowth (2). The mean survival was 95.4 days (SD 78.8 days, range 3–230 days). The mean follow-up time was 98.9 days (SD 86.7 days, range 3–309 days). Conclusions: SEMS are effective in palliating malignant gastric outlet obstruction. A combined endoscopic/fluoro- scopic approach allows the most complete assessment of the stricture and removes the need for gastrostomy insertion. Careful assessment of the gastrointestinal tract distal to the lesion is important. Key words: Endoscopy—Gastric outlet obstruction—Inter- ventional radiology—Metal stents Malignant gastric outlet obstruction is usually a complica- tion of advanced gastric, pancreatic, or duodenal carcinoma. It causes significant morbidity due to nausea, vomiting, and inability to eat and has a markedly debilitating effect on quality of life. Palliation of symptoms and relief of obstruc- tion, so that enteral feeding can continue satisfactorily, is the primary aim in these patients. Surgical bypass has a reported success rate in the region of 90%; however, it carries a relatively high complication rate of 25%–35% and a periop- erative mortality of up to 2% [1– 4]. In conjunction with high cost and a prolonged hospital stay this method of treatment is not always appropriate, particularly in patients in a poor state of health. Self-expanding metal stents (SEMS) have been used for some years in the palliation of symptoms from esophageal cancer and biliary tract obstruction [5]. More recently the introduction of enteral stents has made stent placement for gastric outlet obstruction possible. So far only limited data are available, but case reports in the literature and trials with small numbers of patients show promising results [6 –17]. The procedure is not appropriate in all cases, for example if there is acute angulation of small bowel loops or multiple sites of disease. We report our experience of using stents for palliation of gastric outlet obstruction and discuss the suit- ability of patients for palliation with currently available stents. Materials and Methods Between May 1996 and June 2000, 28 patients (15 male, 13 female) were referred for stent placement for malignant gastric outlet ob- struction. Mean age was 68.7 years (SD 12.5 years, range 33– 88 years). Initial presentation was either with symptoms of gastric outlet obstruction ( n = 15), obstructive jaundice ( n = 4), or both ( n = 9). The underlying diagnoses and the patients’ demographic details are shown in Table 1. ASA grading of patients or extent of disease precluded surgical bypass. Initially 10-cm, uncovered esophageal stents with a 22-mm diameter (Wallstent, Schneider, Boston Scientific, St. Albans, Herts, UK) were used. They are mounted on a delivery device 100 cm long, which is inadequate to reach the duodenum via the oral route. A 24 Fr percutaneous endoscopic gastrostomy tube (PEG 24; Wilson-Cook UK, Letchworth, UK) was sited the day prior to stent placement, and the procedure was performed under fluoroscopy through this. The duodenal lesion was outlined with nonionic contrast medium and crossed using a hydrophilic wire (Radiofocus, M-Terumo, Tokyo, Japan) and a Headhunter catheter (Cordis, Correspondence to: Dr. H.-U. Laasch, MRCP, FRCR; Tel.: +44 (0)161 291 3704. Fax: +44 (0)161 448 1688. e-mail: HU_Laasch@hotmail.com Cardio V ascular and Interventional Radiology © Springer-Verlag New York, Inc. 2001 Cardiovasc Intervent Radiol (2001) 24:313–318 Published Online: 6 September 2001 DOI: 10.1007/s00270-001-0031-9