The American Gastroenterological Association published a clinical practice update expert review for managing malignant alimentary tract obstructions (MATOs) that includes 14 best practice advice statements, ranging from general principles to specific clinical choices.
“There are many options available for the management of MATOs, with the addition of new modalities as interventional endoscopy continues to evolve,” Osman Ahmed, MD, of the University of Toronto and colleagues wrote in Clinical Gastroenterology and Hepatology. “The important concept to understand for any physician managing MATOs is that there is no longer a ‘one-size-ﬁts-all’ approach that can be applied to all patients.”
First, the investigators called for an individualized, multidisciplinary approach that includes oncologists, surgeons, and endoscopists. They advised physicians to “take into account the characteristics of the obstruction, patient’s expectations, prognosis, expected subsequent therapies, and functional status.”
The remaining advice statements are organized by site of obstruction, with various management approaches based on candidacy for resection and other patient factors.
For patients with esophageal obstruction who are candidates for resection or chemoradiation, Dr. Ahmed and colleagues advised against routine use of self-expanding metal stents (SEMS) due to “high rates of stent migration, higher morbidity and mortality, and potentially lower R0 (microscopically negative margins) resection rates.”
If such patients are at risk of malnutrition, an enteral feeding tube may be considered, although patients should be counseled about associated procedural risks, such as abdominal wall tumor seeding.
Among patients with esophageal obstruction who are not candidates for resection, SEMS insertion or brachytherapy may be used separately or in combination, according to the investigators.
“Clinicians should not consider the use of laser therapy or photodynamic therapy because of the lack of evidence of better outcomes and superior alternatives,” the investigators noted.
If SEMS placement is elected, Dr. Ahmed and colleagues noted there remains ongoing debate. For this expert review, the authors advised using a fully covered stent, based on potentially higher risk for tumor ingrowth and reinterventions with uncovered SEMS.
Gastric outlet obstruction
According to the update, patients with gastric outlet obstruction who have good functional status and a life expectancy greater than 2 months should undergo surgical gastrojejunostomy, ideally via a laparoscopic approach instead of an open approach because of shorter hospital stays and less blood loss. If a sufficiently experienced endoscopist is available, an endoscopic ultrasound-guided gastrojejunostomy may be performed, although Dr. Ahmed and colleagues noted that no devices have been approved by the Food and Drug Administration for this technique.
For patients who are not candidates for gastrojejunostomy, enteral stent insertion should be considered; however, they should not be used in patients with severely impaired gastric motility or multiple luminal obstructions “because of limited benefit in these scenarios.” Instead, a venting gastrostomy may be elected.
For patients with malignant colonic obstruction, SEMS may be considered as a “bridge to surgery,” wrote Dr. Ahmed and colleagues, and in the case of proximal or right-sided malignant obstruction, as a bridge to surgery or a palliative measure, keeping in mind “the technical challenges of SEMS insertion in those areas.”
Finally, the expert panel suggested that SEMS may be appropriate for selective extracolonic malignancy if patients are not surgical candidates, noting that SEMS placement in this scenario “is more technically challenging, clinical success rates are more variable, and complications (including stent migration) are more frequent.”
The investigators concluded by advising clinicians to remain within the realm of their abilities when managing MATOs, and to refer when needed.
“[I]t is important for physicians to understand their limits and expertise and recognize when cases are best managed at experienced high-volume centers,” they wrote.
The clinical practice update expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board. Dr. Lee disclosed a relationship with Boston Scientific.