Long-term outcome of palliative treatment with self-expanding metal stents for malignant obstructions of the GI tract.

BACKGROUND: Self-expanding metal stents (SEMS) are commonly used in the palliative treatment of malignant gastrointestinal (GI) obstructions with favorable short-term outcome. Data on long-term outcome are scarce, however. AIM: To evaluate long-term outcome after palliative stent treatment of malignant GI obstruction. METHOD: Between October 2006 and April 2008, nine Norwegian hospitals included patients treated with SEMS for malignant esophageal, gastroduodenal, biliary, and colonic obstructions. Patients were followed for at least 6 months with respect to stent patency, reinterventions, and readmissions. RESULTS: Stent placement was technically successful in 229 of 231 (99%) and clinically successful after 1 week in 220 of 229 (96%) patients. Long-term follow-up was available for 219 patients. Of those, 72 (33%) needed reinterventions. Stent occlusions or migrations (92%) were the most common reasons. Esophageal stents required reinterventions most frequently (41%), and had a significantly (p = 0.02) shorter patency (median 152 days) compared to other locations (gastroduodenal, 256 days; colon, 276 days; biliary, 460 days). Eighty percent of reinterventions were repeated endoscopic procedures that successfully restored patency. Readmissions were required for 156 (72%) patients. Progression of the underlying cancer was the most common reason, whereas 24% were readmitted due to stent complications. CONCLUSIONS: Long-term outcome after palliative treatment with SEMS for malignant GI and biliary obstruction shows that 70% had a patent stent until death, and that most reobstructions could be solved endoscopically. Hospital readmissions were mainly related to progression of the underlying cancer disease.

Patient-reported outcomes in palliative gastrointestinal stenting: a Norwegian multicenter study.

BACKGROUND: The clinical effect of stent treatment has been evaluated by mainly physicians; only a limited number of prospective studies have used patient-reported outcomes for this purpose. The aim of this work was to study the clinical effect of self-expanding metal stents in treatment of malignant gastrointestinal obstructions, as evaluated by patient-reported outcomes, and compare the rating of the treatment effect by patients and physicians. METHODS: Between November 2006 and April 2008, 273 patients treated with SEMS for malignant GI and biliary obstructions were recruited from nine Norwegian hospitals. Patients and physicians assessed symptoms independently at the time of treatment and after 2 weeks using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 questionnaire supplemented with specific questions related to obstruction. RESULTS: A total of 162 patients (99 males; median age = 72 years) completed both assessments and were included in the study. A significant improvement in the mean global health score was observed after 2 weeks (from 9 to 18 on a 0-100 scale, P < 0.03) for all stent locations. Both patients and physicians reported a significant reduction in all obstruction-related symptoms (>20 on the 0-100 scale, P < 0.006) after SEMS treatment. The physicians reported a larger mean improvement in symptoms than did the patients, mainly because they reported more severe symptoms before treatment. CONCLUSION: SEMS treatment is effective in relieving symptoms of malignant GI and biliary obstruction, as reported by patients and physicians. The physicians, however, reported a larger reduction in obstructive symptoms than did the patients. A prospective assessment of patient-reported outcomes is important in evaluating SEMS treatment.

[Profylactiv cholesystectomy after bile duct stones?]. / Profylaktisk kolecystektomi etter gallegangsstein?

BACKGROUND: Endoscopic sphincterotomy (EPT) is well established as a treatment of bile duct stones, often performed to reduce the frequency of complications. We wanted to evaluate the complication rates after preventive cholecystectomy compared with expectative follow up. MATERIAL AND METHODS: In this retrospective study we have registered the outcome for 63 patients treated with cholecystectomy and 298 patients followed up expectatively. Allocation to the groups was based on clinical evaluation without randomization, hence the groups are not similar, a fact which should be taken into consideration when results are evaluated. For both groups we have registered events due to biliary complications. RESULTS: The patients submitted to cholecystectomy were somewhat younger with higher comorbidity than the non-operated patients. In the expectative group, 27% had one or more late complications as opposed to 6.3% in the cholecystectomy group. There was no relative difference in mortality. INTERPRETATION: The study confirms that prophylactic cholecystectomy may actually contribute to a lower complication rate and is an option for treatment in low-risk patients. Prophylactic cholecystectomy cannot, however, be recommended as a routine procedure. The study is based on clinically selected patient groups and results must be interpreted with care.

The effect of Helicobacter pylori retreatment with ranitidine bismuth citrate, clarithromycin, and metronidazole depends on the first-line therapy.

BACKGROUND: Helicobacter pylori eradication rates seem to decrease. This study evaluates the effect of retreatment with ranitidine bismuth citrate (RBC) 400 mg B.I.D., clarithromycin (C) 500 mg B.I.D., and metronidazole (M) 500 mg every morning and 1,000 mg every evening for 14 days [RBC.C.M]. STUDY: Nine gastroenterologic units included patients with unsuccessful eradication of H. pylori in a preceding randomized trial. Previous treatment was either omeprazole (O) 20 mg, C 250 mg, and M 500 mg [O.C.M] or RBC 400 mg, tetracycline (T) 1,000 mg, and M 500 mg [RBC x T x M]; all drugs were given twice daily for 7 days. RESULTS: Twenty-six H. pylori-positive patients were included (nine males, 17 females; mean age, 54 years; range, 39-74 years). The eradication rates in the groups previously treated with O.C.M and RBC.T.M were three of nine (33%) (95% CI = 12-65) and 15 of 17 (88%) (95% CI = 66-97) respectively (p = 0.008). The corresponding results in a "per-protocol" analysis were three of eight (38%) (95% CI = 13-69) and 10 of 10 (100%) (95% CI = 72-100), respectively (p = 0.007). A side effect score was 21.8 compared with 8.3 in the previous study (p < 0.001). CONCLUSIONS: The effect of a retreatment regimen depends on the preceding treatment. The RBC x C x M regimen is effective in nonresponders to RBC x T x M, but it seems unsuitable after failure of the O x C x M regimen.