Aim: To prospectively evaluate the use of SEMS as a primary intervention for relieving malignant gastric outlet obstruction in a resource limited environment in South Africa.Background: Gastro-duodenal obstruction secondary to advanced malignancy is often a difficult symptom to palliate. Surgical bypass can be inappropriate or contra-indicated due to advanced disease or co-morbidity. Primary stenting aims to rapidly restore enteral intake with minimal morbidity. SEMS enables patients with limited life expectancy to be independent of parenteral fluid administration and facilitates early discharge. SEMS are now internationally accepted as an alternative to surgery and can be a useful adjunct to management where expertise, operating time, limited hospital beds and other resource limitations exist. This is the first reported series using SEMS (performed by surgeons) for palliating malignant gastro-duodenal obstruction in Africa.
Method: Patients with clinical and endoscopically proven malignant gastro-duodenal obstruction and relative contra-indication to surgical bypass were eligible. A duodenoscope combined with fluoroscopic screening was used to place the SEMS under direct vision. Data was collected prospectively until death from November 2004 to November 2007.Results:42 patients, median age 64 years (range 39-84) had attempted SEMS placement. The obstruction was due to antral gastric carcinoma (n=17), pancreatic carcinoma (n=17), duodenal carcinoma (n=1), cholangiocarcinoma (n=3), gallbladder carcinoma (n=1) and other (n=3). Relative contraindications to surgery were locally advanced tumour (n=23), metastatic disease (n=12) and co-morbidity (n=7). The site of obstruction was gastric antrum (n= 17), bulb (n=11), second/third part (n=13) and third/fourth part (n=1) of the duodenum. There were four technical failures (9.5%). In the 38(90.5%) technically successful placements, 36 (94%) patients resumed oral intake (n=4 liquid, n=15 soft diet, n=17 full diet) and two failed (second obstruction distal to gastro-duodenal obstruction). 14 patients required additional biliary stenting. The median time from stent to discharge was two days (range 1-8). Median survival following SEMS was 41 days (range 4 - 194) with 10 patients still alive at a median of 26 days (range 14-321). One patient (gastric carcinoma) required a three unit blood transfusion following stent placement. There were no other immediate complications.
Conclusion: SEMS has a high technical success rate (90.5%) and is able to rapidly restore enteral intake in 94% of patients with malignant gastro-duodenal obstruction who are unsuitable for surgery in a resource-limited environment.