Maetani Iruru
Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.
Ann Palliat Med. 2014 Apr;3(2):54-64. doi: 10.3978/j.issn.2224-5820.2014.04.01.
Malignant gastric outlet obstruction (GOO) often has a markedly adverse impact on the quality of life (QOL) of patients. Procedures in affected patients should aim to reduce obstructive symptoms and enable oral ingestion. Surgical gastrojejunostomy (GJJ) has been performed as a conventional palliative procedure. Enteral stenting has been increasingly used as an alternative to surgical palliation because of its lower invasiveness. Enteral stents used for GOO are made of a metal alloy mesh in a cylindrical shape, and are termed self-expandable metallic stent (SEMS). Of the two placement techniques, over-the-wire (OTW) and through-the-scope (TTS) deployment, TTS is easier and is now more frequently used. In general, the technical success rate is extremely high, at nearly 100%, and the clinical success rate is about 90%, but complications after placement can occur, most frequently late-developing stent dysfunction due to stent obstruction and migration. Biliary obstruction can occur concurrently with GOO, or before or after GOO, particularly in patients with pancreaticobiliary malignancies. Considering accessibility to the bile duct, biliary stenting should generally be conducted prior to enteral stenting. Transhepatic or transmural biliary stenting may be required if transpapillary stenting is not possible. Because enteral stenting is more commonly associated with late-developing stent dysfunction, it is better suited than GJJ for patients with a short life expectancy and poorer performance score. Chemotherapy may be beneficial in reducing the risk of stent obstruction, despite the possible risk of migration, particularly in patients with GOO due to gastric cancer. Many enteral stents with different structures are now commercially available, but the association between the design and mechanical properties of a stent and clinical outcomes is still poorly understood. Further, no consensus on the benefits of covered SEMS has yet been obtained. Further study to verify which types of SEMS are most suited for GOO is warranted.
恶性胃出口梗阻（GOO）通常会对患者的生活质量（QOL）产生明显的不利影响。针对受影响患者的治疗方法应旨在减轻梗阻症状并恢复经口摄入。外科胃空肠吻合术（GJJ）一直是传统的姑息性手术。由于侵入性较低，肠道支架置入术越来越多地被用作手术姑息治疗的替代方法。用于GOO的肠道支架由金属合金网制成，呈圆柱形，被称为自膨式金属支架（SEMS）。在两种放置技术中，即导丝置入（OTW）和经内镜置入（TTS），TTS更简便，目前使用更频繁。一般来说，技术成功率极高，接近100%，临床成功率约为90%，但放置后可能会出现并发症，最常见的是由于支架阻塞和移位导致的晚期支架功能障碍。胆管梗阻可能与GOO同时发生，或在GOO之前或之后出现，特别是在胰胆管恶性肿瘤患者中。考虑到胆管的可及性，胆管支架置入术通常应在肠道支架置入术之前进行。如果无法进行经乳头胆管支架置入术，则可能需要行经肝或经壁胆管支架置入术。由于肠道支架置入术更常与晚期支架功能障碍相关，因此对于预期寿命短和体能状态评分较差的患者，它比GJJ更适用。化疗可能有助于降低支架阻塞的风险，尽管存在移位的可能风险，特别是对于因胃癌导致GOO的患者。现在市面上有许多结构不同的肠道支架，但支架的设计和力学性能与临床结果之间的关系仍知之甚少。此外，对于覆膜SEMS的益处尚未达成共识。有必要进行进一步研究以验证哪种类型的SEMS最适合GOO。
