SEMS and Gastroenterostomy
SEMS and Gastroenterostomy
More than 20% of patients with gastric cancer have at presentation a stage IV disease.
 Advanced adenocarcinoma of the antro-pyloric region often determines a condition of gastric
 outlet obstruction syndrome (GOOS), which requires a rapid resolution for the severe
 consequences that will occur if the obstruction is not resolved. GOOS causes malnutrition,
 fluid and electrolyte imbalances that are difficult to control. Laparoscopic or open
 gastroenterostomy has been proposed as the treatment of choice in patients with advanced
 unresectable distal stomach tumor presenting with symptoms of GOOS. Noticeably, laparoscopic
 gastroenterostomy might be difficult to be performed in a hostile abdomen because of the
 involvement of the root of the mesentery, infiltration of the surrounding structures and
 peritoneal carcinosis. Furthermore, laparoscopic or open gastroenterostomy provides
 suboptimal palliation, because it is associated with postoperative complications ranging from
 15% to 50% related to a delayed gastric emptying and a protract postoperative hospital stay.
 These results negatively affect the quality of life (QoL), and therefore, the efficacy of
 gastroenterostomy for palliation has been questioned. In 1997, Kaminishi et al. introduced a
 technique of stomach-partitioning gastrojejunostomy (SPGJ), which divides the lower part of
 the stomach and connects the jejunum to the proximal part of the stomach while maintaining a
 tunnel that is 2 to 3 cm in diameter along the lesser curvature. This technique theoretically
 provides some benefits: endoscopic evaluation of the tumor response to adjuvant chemotherapy
 and the possibility of repeated endoscopic local treatment on the tumor, prevention of
 ingested food retention in the distal part of the stomach thus facilitating gastric emptying
 and improving patient's QoL. A current alternative to laparoscopic or open surgical approach
 to an advanced gastric tumor is the positioning of a self-expandable metal stent (SEMS) which
 offers many potential advantages: the avoidance of general anaesthesia for a laparoscopic or
 open approach, a shorter hospital stay and a minor patient postoperative discomfort.

 We want to perform a prospective longitudinal cohort trial, comparing the QoL of patients
 affected with stage IV antropyloric stomach cancer and symptoms of GOOS who underwent
 endoscopic placement of a SEMS or after open SPGJ.
Inclusion criteria are age less than 85 years, pre-treatment histological diagnosis of
 gastric adenocarcinoma, computed tomographic (CT), adjuvant-neoadjuvant chemotherapy
 regimen, symptoms of GOOS (symptoms of GOOS include: regular, frequent feeling of bloating
 or fullness; feeling full after eating less food; nausea and vomiting of undigested food,
 especially right after eating, abdominal pain) lumen reduction ranging between 70% and 99%
 at gastroscopy.

 Criteria for exclusion are a white blood cells count less than 4,000/L, a platelet count
 less than 70,000/L, patients with renal failure (i.e. albumin to creatinine ratio > 30
 mg/mmol and estimated glomerular filtration rate < 30-44 mL/min/1.73m2), patients with
 major alterations of liver function tests (i.e. total bilirubin > 25.6 μmol/L, AST > 5 U/L,
 ALT >5 U/L, PT-INR > 1.5).

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