Comparison of Duodenal Stenting vs Transpyloric and Duodenal Stenting for Malignant Obstruction

Not Applicable

Completed

Brief Summary: Malignant duodenal obstruction in patients not fit for surgery is treated by placing enteral stents during endoscopy. These patients may also have poor gastric motility. Hence bridging the pyloric opening with the stent along with the duodenal obstruction may deliver better symptomatic improvement. Both approaches are commonly clinically practiced but no formal comparative studies have been done to compare which one is better.

Detailed Description: Enteral self-expanding metal stents are routinely used to palliate malignant gastric outlet obstruction (pancreas cancer, duodenal cancer, gastric cancer and metastasis) in patients not fit for surgical bypass. The technical success in placing these stents approaches \~100% and many of these procedures can be performed in an outpatient setting. However the functional success (patient's ability to eat) is much lower than the technical success. One of the major reasons for this discrepancy is these patients are on narcotics, which are known to be associated with poor gastric motility. At the discretion of the gastroenterologist, FDA approved enteral stents are placed either completely within the duodenum bridging the obstruction or placed across the pyloric opening besides bridging the duodenal obstruction. The significance of this study is to determine if trans-pyloric extension of an intra-duodenal stent facilitates better gastric emptying compared to an intra-duodenal stent without trans-pyloric extension.

Recruitment & Eligibility

Inclusion Criteria

1 - Confirmed diagnosis of cancer

Evidence of a single small bowel obstruction
Considered palliative (can be on narcotics, chemotherapy, and/or radiation therapy)
Not a surgical candidate
>18 years of age
Able to give consent
Eligible for endoscopy (medically fit)
Able to traverse past obstruction with a guidewire

Exclusion Criteria

1 - <18 years of age

Arm && Interventions

Group	Intervention	Description
Enteral stenting intraduodenal	Enteral stenting	Enteral stent (Wallflex enteral stent) will be placed in the duodenum with the entire stent lying within the duodenum bridging the obstruction.
Enteral stenting transpyloric	Enteral stenting	Enteral stent (Wallflex enteral stent) will be placed in the duodenum with the stent bridging the obstruction and the pyloric opening with proximal end of the stent lying within the stomach

Primary Outcome Measures

Name	Time	Method
Number of Participants With Any Change (2 Point Increase or Decrease) in Symptoms From Baseline	Baseline (before stent) and follow-up (after stent) at 48 hrs (including gastric emptying study) and then symptom follow up at each clinic/telephone visit up to 6 months.	Symptoms of nausea, regurgitation, bloating, fullness, belching, pain, and vomiting were recorded at baseline and then on follow-up after stent placement on a visual analog scale with 0 being no symptoms and 10 being severe symptoms. The visual analog scale used was: 0 No symptom to 10 Severe symptom: Drop by 2 points or more from baseline score after intervention was recorded as "Better" and increase in over 2 points from baseline after intervention was recorded as symptom getting "Worse". A -1 to +1 shift from baseline was considered as "Unchanged". Gastric emptying was objectively assessed at 48 hours after stent placement with no baseline testing. Over all quality of life change after stent placement over baseline was a subjective response from the patient as being "Satisfied", "Neutral", "Dissatisfied." Re-interventions and adverse events if any were recorded.

Secondary Outcome Measures

Name	Time	Method
Gastric Emptying	48 hours after stent placement	Gastric emptying study test
Technical Success: Stent Placed in the Desired Position as Per Randomization	Day of stent deployment	Successful placement of the stent across the duodenal obstruction with or without trans-pyloric extension as per randomization will determined immediately during endoscopic procedure by endoscopic visualization.
Complications	Up to 6 months after stent deployment	Stent related complications