4751 Management of malignant duodenal strictures caused by pancreatic carcinoma with expandable stents.

Abstract

Pancreatic carcinoma is the second leading gastrointestinal cancer in the United States. Curative surgical procedures are rare at the time of initial Dx (< than 15%). Palliative endoscopic treatment options therefore take on a major role in pts with unresectable lesions. These include biliary and pancreatic endoscopic prosthesis for obstructed ducts as well as EUS-guided celiac plexus neurolysis for refractory abdominal pain. A less well known complication but equally important is treatment of high-grade duodenal strictures resulting in gastric outlet obstruction. AIM: To determine the effectiveness and complication rate of expandable metal stents in the treatment of malignant duodenal strictures. METHODS: Eleven pts, 8-W, 3-M, (age range 72-86, mean 76) underwent placement of enteral wall stents (Boston Scientific). All patients had unresectable pancreatic carcinomas involving the head of the pancreas. These pts were previously treated with biliary endoprosthesis (11) and pancreatic endoprosthesis (2). Time between biliary endoprosthesis and presentation of duodenal obstruction was 5 months to 13 months (mean 8.7 months). RESULTS: All pts underwent successful placement of expandable metal stents (size 20 mm diameter, Length 90 mm=4, 60 mm=7). None of the strictures were initially traversable with standard upper endoscope and required placement of an 0.35" guidewire beyond the stricture under fluoroscopic control to assist in deployment/positioning of the wall stent. Mean follow-up was 12.5 months (range 7-18 months). There were 2 complications related to wall stents, both perforations at the level of the proximal stent margin (1) and distal stent margin (1) presenting at 5 weeks and 12 weeks after deployment respectively. The perforations were felt to be directly related to the bare barbs at each end of the wall stent design. Both pts underwent successful surgical palliation. Survival, post duodenal wall stents, was 6.8 months (Range 4-13 months). Two pts are alive with good palliation of their duodenal obstruction. CONCLUSION: Expandable metallic stents are effective and provide a reasonably good palliative option for unresectable pancreatic carcinoma with duodenal strictures. The relative high rate of complication would require further modification in stent design.