The recommended adult initial dosage of Megace ES (megestrol acetate) oral suspension is 625 mg/day (5 mL/day or one teaspoon daily). The equicaletn Megace dose it 800 mg and requires 20 ml. Megace ES 625 mg/5 mL and megestrol acetate oral suspension 800 mg/20 mL are bioequivalent in a fed state.
A bioavailability study directly comparing the rate and extent of absorption of Megace ES and megestrol acetate oral suspension revealed that the Cmax** level with the original formulation was 1,364 ng/mL in fed patients and 187 ng/mL in unfed patients. In contrast, the Cmax level with Megace ES was 1,517 ng/mL in fed patients and 1,041 ng/mL in unfed patients. Further, in unfed patients Megace ES achieved 5 times greater peak plasma levels than megestrol acetate oral suspension. Additionally, the study demonstrated that a lower volume of Megace ES achieved maximum blood concentration more rapidly than the currently available oral suspension products.

However, the two products were nto directly compared in regard to clinical effectiveness and it is not known if this pharmacokinetic advantages translate into any clinical advantage.

Jamie H. Von Roenn, MD; Donald Armstrong, MD; Donald P. Kotler, MD; David L. Cohn, MD; Nancy G. Klimas, MD; N. S. Tchekmedyian, MD; Lawrence Cone, MD; Patrick J. Brennan, MD; and Sigmund A. Weitzman, MD, Megestrol Acetate in Patients with AIDS-related Cachexia , Ann Intern Med. 15 September 1994;121(6):393-399

Michelle H. Oster, PhD, RD; Sheila R. Enders, BS; Steven J. Samuels, PhD; Lawrence A. Cone, MD; Thomas M. Hooton, MD; Henry P. Browder, PhD; and Neil M. Flynn, MD
Megestrol Acetate in Patients with AIDS and Cachexia Ann Intern Med. 15 September 1994;121(6):400-408

Food Effect Working Group of the Biopharmaceutics Coordinating Committee, Office of Pharmaceutical Science. Guidance for industry: food-effect bioavailability and fed bioequivalence studies. Food and Drug Administration, Center for Drug Evaluation and Research Web site. http://www.fda.gov/cder/guidance/5194fnl.pdf. Published December 2002

MegaceES, Prescribing Information, 2013

Food and Drug Administration, Center for Drug Evaluation and Research. Electronic Orange Book: Approved Drug Products With Therapeutic Equivalence Evaluations. 28th ed. Rockville, MD: Food and Drug Administration, Center for Drug Evaluation and Research; 2008.

For Lay version see here

Marinol for cachexia

Thalidmide for cachexia

Because of its expense (greater than $100/dose), for many years it was only used for patients undergoing cancer chemotherapy or after surgical procedures. As the cost dropped (now under a $1 a dose), it is came to be used in many hospital and outpatient settings. A growing area of use is empiric use in nursing homes. The drug is so effective, that some physicians consider using it as needed less morbid that performing a workup to determine the etiology of nausea in these patients.

This strategy needs more data to be considered well supported. Zofran is not a completely innocuous drug.  The U.S. Food and Drug Administration (FDA) recently informed healthcare professionals and the public that preliminary results from a recently completed clinical study suggest that a 32 mg single intravenous dose of ondansetron (Zofran, ondansetron hydrochloride, and generics) may affect the electrical activity of the heart (QT interval prolongation), which could pre-dispose patients to develop an abnormal and potentially fatal heart rhythm known as Torsades de Pointes. Consequenlty, GlaxoSmithKline (GSK) has announced changes to the Zofran drug label to remove the 32 mg single intravenous dose. While the 8 mg dose is presumably free of this complication, one remains uncomfortable about empiric use of Zofran in  any clinical situation and such a strategy needs to be validated with clinical trials.

Several other uses have been preliminarily explored. During the past decade ondansetron has been increasingly used in the United States for Nausea and Vomiting of Pregnancy (NVP), owing to the lack of a drug indicated by the FDA for this condition; some concern had been voiced about potential increased incidence of cleft palate in the offspring of mothers who took Zofran during pregnancy.  A 2006 double-blind, randomized controlled trial indicated that ondansetron may have value in the treatment of schizophrenia, as an adjunct to haloperidol. Another, albeit small, open-label trial had found ondansetron to be useful in treating antipsychotic-induced tardive dyskinesia in people with schizophrenia. Early studies have also examined ondansetron as a possible treatment for psychosis resulting from advanced Parkinson’s disease. Hewlett and others performed an open label study that suggested that it can decrease symptoms of OCD. Zofran appears to decrease the craving for alcohol, especially in early-onset alcoholics. Researchers at the Stanford University School of Medicine have demonstrated that ondansetron might be useful and effective for treating withdrawal symptoms of opioid addictions. Ondansetron has been useful in irritable bowel syndrome with diarrhea (IBS-D). Two small, placebo-controlled trials showed that ondansetron was found to be as effective as pethidine (meperidine, Demerol) to decrease post-anethsia shivering, when given prior to anesthesia.

In early January of 2012, the Food and Drug Administration approved the first generic versions of Zofran (Ondansetron) Tablets, Orally Disintegrating Tablets and Oral Solution which are indicated to prevent nausea and vomiting associated with surgery, radiotherapy and cancer chemotehrapy. This si a part of the FDA initiative to reduce drug costs by expediting approvals of generics. The indication is narrower than that of brand Zofran, which also includes  postoperative nausea.

Several alternatives exist for opioid induced nausea(OINV). , although currently there are no drugs specifically approved for opioid induced nausea. They include the less expensive compazine and metocopropamide and others. A recent guidelines says that  the drug of choice for preventing OINV is droperidol.

Several alternatives exist, although currently there are no drugs specifically approved for opioid induced nausea(OINV). They include the less expensive compazine and metocopropamide and others. A recent guideline says that  the drug of choice for preventing OINV is droperidol.
Gómez-Arnau JI, Aguilar JL, Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment. Rev Esp Anestesiol Reanim. 2010 Oct;57(8):508-24.

Lohitnavy M, Chaijittiprasert K, Polnok S, Lohitnavy O, Taytiwat P. Bioequivalence study of ondansetron tablet in healthy Thai male volunteers. J Med Assoc Thai. 2002 Jul;85(7):808-13.

Frank Porreca, and Michael H. Ossipov, Nausea and Vomiting Side Effects with Opioid Analgesics during Treatment of Chronic Pain: Mechanisms, Implications, and Management Options PAIN MEDICINE Volume 10 • Number 4 • 2009

Salvucci AA, Squire B, Burdick M, et al. Ondansetron is safe and effective for prehospital treatment of nausea and vomiting by paramedics. Prehosp Emerg Care 15(1): 34-8, Jan 2011.

Chu LF, Liang DY, Li X, Sahbaie P, Dʼarcy N, Liao G, Peltz G, David Clark J (February 2009). “From mouse to man: the 5-HT3 receptor modulates physical dependence on opioid narcotics”. Pharmacogenet. Genomics 19 (3): 193–205

Zofran, Prescribing Information, 2012

Zhang ZJ, Kang WH, Li Q, Wang XY, Yao SM, Ma AQ (2006). “Beneficial effects of ondansetron as an adjunct to haloperidol for chronic, treatment-resistant schizophrenia: a double-blind, randomized, placebo-controlled study”. Schizophrenia Research 88 (1–3): 102–10. Zullino DF, Eap CB, Voirol P (2001). “Ondansetron for tardive dyskinesia”. Am J Psychiatry 158 (4): 657–8. .

Sirota P, Mosheva T, Shabtay H, Giladi N, Korczyn AD (2000). “Use of the selective serotonin 3 receptor antagonist ondansetron in the treatment of neuroleptic-induced tardive dyskinesia”. Am J Psychiatry 157 (2): 287–9.

Zoldan J, Friedberg G, Livneh M, Melamed E (1995). “Psychosis in advanced Parkinson’s disease: treatment with ondansetron, a 5-HT3 receptor antagonist”. Neurology 45 (7): 1305–8.

Hewlett WA, Schmid SP, Salomon RM (2003). “Pilot trial of ondansetron in the treatment of 8 patients with obsessive compulsive disorder”. J Clin Psychiatry 64 (9): 1025–30.

Corrêa Filho JM, Baltieri DA. A pilot study of full-dose ondansetron to treat heavy-drinking men withdrawing from alcohol in Brazil. Addict Behav. 2013 Apr;38(4):2044–2051

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Insomnia of cancer patients can be a manifestation of chemotherapy, antiemetics or steroid drugs,  inadequately treated pain or anxiety and stress, and a workup for insomnia is reasonable to require.  Cognitive-behavioral therapy appears to be effective for the treatment of insomnia in the general population and also has been upgraded to “likely to be effective” in the Oncology Nursing Society Putting Evidence Into Practice weight of evidence category. It would be expected that many strategies used for non-cancer patients will also be useful for cancer patients. The most frequently used strategies are stimulus control, sleep restriction, relaxation therapies, paradoxical intention, sleep hygiene, and cognitive restructuring. Sleep medications can also be a useful adjunct.

Palesh OG, Roscoe JA, Mustian KM, et al.: Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol 28 (2): 292-8, 2010.

Savard J, Morin CM: Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 19 (3): 895-908, 2001.

Berger AM: Update on the state of the science: sleep-wake disturbances in adult patients with cancer. Oncol Nurs Forum 36 (4): E165-77, 2009

Otte JL, Carpenter JS.Theories, models, and frameworks related to sleep-wake disturbances in the context of cancer.
Cancer Nurs. 2009 Mar-Apr;32(2):90-104; quiz 105-6.

Michael J. Sateia et al, Clinical Practice Guideline for the Pharmacologic Treatment of
Chronic Insomnia in Adults: An American Academy of Sleep Medicine, Clinical Practice Guideline. Journal of Clinical Sleep Medicine, Vol. 13, No. 2, 2017

Amir Qaseem et al, Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians Free.  Ann Intern Med. 2016;165(2):125-133.

For Lay version see here

Aredia is not FDA indicated for osteoporosis and has no special advantage for this indication over zolendronate. Both pamidronate and zoledronic acid have been shown to reduce bone loss in men undergoing androgen deprivation therapy in prostate cancer. However, zoledronic acid has also been shown to increase bone mineral density in these patients and zoledronic acid has been shown in randomized controlled clinical studies to reduce the incidence of skeletal-related events in men undergoing androgen-deprivation therapy. In addition, zoledronic acid has been shown in clinical trials to reduce the incidence of skeletal events in men with osteoblastic bone metastases from prostate cancer. By contrast, a clinical study comparing pamidronate to placebo control in men with bone metastases due to prostate cancer found no significant differences in incidence of skeletal events between the two groups

Although there is evidence that pamidronate increases bone mass, there are no clinical trials demonstrating that intravenous pamidronate decreases fracture rate in postmenopausal osteoporosis or glucocorticoid-induced osteoporosis.

Zoledronic acid is avalable as Zometa and as Reclast for osteoporosis. Each formulation has its indications.

The United States Pharmacopeial Convention has concluded that zoledronic acid has an established role in prophylaxis of drug-induced osteopenia secondary to androgen-deprivation therapy in prostate cancer patients (USPDI, 2005). Although intravenous zoledronic acid injections have been shown in controlled clinical trials to increase bone density in women with osteoporosis, it has not been shown to decrease the incidence of fractures. As Solomon (2002) commented: “The suggestion that an intravenous dose of zoledronic acid once a year or even less often might effectively treat postmenopausal osteoporosis is encouraging. However, before this treatment can be recommended for routine use, studies are clearly needed to determine whether the risk of fractures is actually reduced and to determine whether long-term use of this medication is safe.” Zometa has been reported to cause jaw osteonecrosis and now a number of other oral biphosphonate alternatives are available.

However, subsequntly the FDA approved Reclast, a different preparation of zoledronic acid for once annual infusion for treatment of osteoporosis. New Phase III data presented for the first time demonstrated that the investigational treatment Reclast(R)^ (zoledronic acid) 5 mg was highly effective in reducing the incidence of bone fracture in women with postmenopausal osteoporosis across the most common fracture sites — hip, spine and non-spine^^ — with sustained effect over three years. Further data demonstrated that postmenopausal osteoporosis patients currently taking oral alendronate can be directly switched to Reclast and maintain beneficial bone effects for a full 12 months after a single dose. These studies were presented at the annual meeting of the American Society of Bone and Mineral Research (ASBMR) in Philadelphia.

In vivo animal studies suggest that exemestane may be more bone sparing than letrozole, owing to its androgenic structure. However, there are no human trials showing a differential effect of the individual AIs on bone.

Whereas Zometa is 4 mg and usually given once monthly for active cancer and biannually for osteoporosis, Reclast is a 5 mg dose and can be given even  when there is no cancer. The breast cancer literature supports twice annual Zometa for prevention of osteporosis for women placed on adjuvant arimidex. The details of one randomized trial were published as an early online report in the Journal of Clinical Oncology on December 11, 2006. Either formulation of Zometa is acceptable for osteoporosis, or as in this patient, osteopenia under active exemestane therapy as indicated and represents standard of care.

Reclast is indicated for treatment of osteoporosis in postmenopausal women. In postmenopausal women with osteoporosis, diagnosed by bone mineral density (BMD) or prevalent vertebral fracture, Reclast reduces the incidence of fractures (hip, vertebral and non-vertebral osteoporosis-related fractures). In patients at high risk of fracture, defined as a recent low-trauma hip fracture, Reclast reduces the incidence of new clinical fractures
Gnant MFX, Mlineritsch B, Luschin-Ebengreuth G et al. Zoledronic Acid Effectively Prevents Cancer Treatment-induced Bone Loss in Premenopausal Women Receiving Adjuvant Endocrine Therapy for Hormone-responsive Breast Cancer: A Report from the Austrian Breast and Colorectal Cancer Study Group. Journal of Clinical Oncology. Early online publication December 11, 2006.

Brufsky AM et al, Zoledronic acid effectively prevents aromatase inhibitor-associated bone loss in postmenopausal women with early breast cancer receiving adjuvant letrozole: Z-FAST study 36-month follow-up results.Clin Breast Cancer. 2009 May;9(2):77-85.

AU Safra T, Bernstein-Molho R, Greenberg J, Pelles-Avraham S, Stephansky I, Sarid D, Inbar MJ, Stemmer SM, Geffen DB The protective effect of zoledronic acid on bone loss in postmenopausal women with early breast cancer treated with sequential tamoxifen and letrozole: a prospective, randomized, phase II trial.
Oncology. 2011;81(5-6):298-305.

Black DM, et al. Effect of once-yearly infusion of Zoledronic Acid 5 mg on spine and hip fracture reduction in postmenopausal women with osteoporosis: the HORIZON pivotal fracture trial. Presented at 28th Annual meeting of the American Society for Bone and Mineral Research (ASBMR), 15-19 September 2006, Philadelphia, USA.

McClung M, et al. Single infusion of zoledronic acid 5 mg provides sustained benefits in BMD and biomarkers at 12 months in postmenopausal women with low bone mineral density and prior alendronate therapy. Presented at 28th Annual meeting of the American Society for Bone and Mineral Research (ASBMR), 15-19 September 2006, Philadelphia, USA.

Ward L, Tricco AC, Phuong P, et al. Bisphosphonate therapy for children and adolescents with secondary osteoporosis. Cochrane Database Syst Rev. 2007;(4):CD005324.
Julie R. Gralow, MD; J. Sybil Biermann, MD; Azeez Farooki, MD;
Monica N. Fornier, MD; Robert F. Gagel, MD; Rashmi Kumar, PhD;
Georgia Litsas, MSN, ANP-BC, AOCNP; Rana McKay, MD;
Donald A. Podoloff, MD; Sandy Srinivas, MD; and
Catherine H. Van Poznak, MDNCCN Task Force Report:
Bone Health in Cancer Care. JNCCNJournal of the National Comprehensive Cancer Network
Volume 11 Supplement 3,   August 2013

Dronabinol (Marinol) has been studied in both HIV and oncology patients, and is particularly useful for patients with both anorexia and nausea. Some patients respond best to round-the-clock (2.5-10 mg 3 times per day) dosing. Other patients do best with bedtime dosing, as some patients become “stoned”/sedated on daytime dronabinol. It is not a drug that substitutes for conventional anti-emetics given for chemotherapy and is, therefore, not a Part D Medicare drug.

There are phase III and phase II studies of this agent, although it is FDA approved only for nausea/vomiting. One recent clinical trial conducted by the North Central Cancer Treatment Group (NCCTG) evaluated both Marinol® and megestrol acetate oral suspension (which is FDA approved) for improving appetite and weight gain in late-stage cancer patients with anorexia. The study involved 469 late-stage cancer patients with an ongoing problem of anorexia and/or weight loss. Patients were divided into three groups: one group received Marinol®, another group received megestrol acetate, and a final group received both agents. Patients received a fixed dose of Marinol® in this trial of only 5 milligrams per day. The results indicated that improved appetite and weight gain were reported in 73% of patients taking megestrol acetate, 47% of patients taking Marinol® and 70% in the combination group. Side effects were comparable between the groups; however, 18% of men receiving megestrol acetate experienced impotence, compared with 14% in the combination group and only 4% in the Marinol® group.

Jatoi Am Windschitl H, Loprinzi C, et al. Dronabinol versus megestrol acetate versus combination therapy for cancer-associated anorexia: a North Central Cancer Treatment Group Study. Journal of Clinical Oncology. 2002;20:567-573.

Walsh D, Nelson KA, Mahmoud FA. Established and potential therapeutic applications of cannabinoids in oncology. Support Care Cancer. 2003;11(3):137-43.

Mantovani, G., Maccio, A., Madeddu, C., Serpe, R. and others. (2010). Randomized phase III clinical trial of five different arms of treatment in 332 patients with cancer cachexia. Oncologist. 15: 200-211.

Mechoulam R. Non-psychotropic plant cannabinoids: new therapeutic opportunities from an ancient herb. Trends Pharmacol Sci. 2009 Dec;30(12):609.

Prescribng Information, 2014

Wolters Kluwer Health, Inc. Dronabinol, Facts and Comparisons 4.0 [online]. Available at: www.factsandcomparisons.com.

There is controversy regarding the use of total parenteral nutrition (TPN) in individuals with metastatic malignancies. Studies show that patients with small bowel obstruction and metastatic malignancy may benefit from TPN as demonstrated by prolonged survival rate longer than 60 d. To provide or not to provide life-prolonging TPN in terminal situations becomes an ethical and moral question and it is a hotly debated issue in palliative care and ethics literature.

http://www.sign.ac.uk/guidelines/fulltext/75/section8.html

http://www.cks.library.nhs.uk/palliative_care_nausea_vomit/in_summary/malignant_bowel_obstruction

Vinaya Potluri, MD and Donna S. Zhukovsky, MD, FACP Recent Advances in Malignant Bowel Obstruction: An Interface of Old and New Current Pain and Headache Reports 2003, 7:270-278

J. R. Hardy (2000) Medical management of bowel obstruction British Journal of Surgery 87 (10), 1281–1283.

DUERKSEN Donald R. et al, Is There a role for TPN in terminally ill Patients with bowel obstruction? Nutrition (Nutrition) 2004, vol. 20, no9, pp. 760-763

Candidal infection is the most common fungal disease in transplant recipients. It is largely due to reactivation of endogenous fungi. Therefore, because most patients who develop candidal disease are colonized before bone marrow transplant, preventing exposure to Candida is not possible. Making the situation even more difficult, approximately 40% of transplant patients with invasive candidal infections have negative blood cultures, which makes the presence of the infection difficult to diagnose and emphasizes the importance of prevention.

Two controlled trials have demonstrated the efficacy of prophylactic fluconazole to prevent invasive systemic fungal infections. In these trials, fluconazole given at a dose of 400 mg/day IV or PO for approximately the first 3 months posttransplant reduced systemic fungal infections from a range of 16% to 18% to a range of 3% to 7%. On the basis of these trials, the IDSA recommends that fluconazole be administered until engraftment.

More recently, a concern for emerging flicanozole resistance raised new questions about the wisdom of this strategy; however, it remains recommended by guidelines and the CDC.

Goodman JL, Winston DJ, Greenfield RA, et al: A controlled trial of fluconazole to prevent fungal infections in patients undergoing bone marrow transplantation. N Engl J Med 1992 Mar 26; 326(13): 845-51

Dictar MO, Maiolo E, Alexander B, et al: Mycoses in the transplanted patient. Med Mycol 2000; 38 Suppl 1: 251-8

Recommendations and Reports
Guidelines for Preventing Opportunistic Infections Among Hematopoietic Stem Cell Transplant Recipients Recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation MMWR, October 20, 2000 / 49(RR10);1-128

The use of mesna and/or continuous bladder irrigation is rarely needed for doses <2 g/m 2. Cyclophosphamide (Cytoxan, Neosar) is associated with hemorrhagic cystitis in ~10% of patients being treated with standard doses. Incidence may increase to as high as 40% in patients receiving high-dose chemotherapy with bone marrow transplantation (BMT).

Korkmaz A, Oter S, Deveci S, Goksoy C, Bilgic H. Prevention of further cyclophosphamide induced hemorrhagic cystitis by hyperbaric oxygen and mesna in guinea pigs. J Urol 2001;166:1119-23.

AHFS Monograph – http://www.medscape.com/druginfo/monograph?cid=med&drugid=52888&drugname=Cytoxan+IV&monotype=monograph&secid=5

S Cesaro et al, Incidence and treatment of hemorrhagic cystitis in children given hematopoietic stem cell transplantation: a survey from the Italian association of pediatric hematology oncology-bone marrow transplantation group BMT November (1) 2003, Volume 32, Number 9, Pages 925-931

Watson NA, Notley RG. Urologic complications of cyclophos-phamide. Br J Urol 1973; 45: 609-612.

OXYCONTIN tablets should be taken at 12-hourly intervals. The dosage is dependent on the severity of the pain, and the patient’s previous history of analgesic requirements. Increasing severity of pain will require an increased dosage of OXYCONTIN tablets using the 5mg, 10mg, 20mg, 40mg or 80mg tablet strengths, either alone or in combination, to achieve pain relief. The correct dosage for any individual patient is that which controls the pain and is well tolerated, for a full 12 hours. There is no ceiling dose and so patients should be titrated to pain relief unless unmanageable adverse medicine reactions prevent this. The usual starting dose for opioid naïve patients or patients presenting with severe pain uncontrolled by weaker opioids is 10mg 12 hourly, or 5mg 12 hourly for patients with renal or hepatic impairment. The dose should then be carefully titrated, as frequently as once a day if necessary, to achieve pain relief. It is not uncommon for a patient to require higehr doses.

Riley J, Eisenberg E, Müller-Schwefe G, Drewes AM, Arendt-Nielsen L. Oxycodone: a review of its use in the management of pain.Curr Med Res Opin. 2008 Jan;24(1):175-92.

Oxycodone: Pharmacological profile and clinical data in chronic pain management minervamedica.it. Minerva Anestesiologica, 2005;71:451-60.

Management of cancer pain. In VT DeVita Jr et al., eds., Cancer: Principles and Practices of Oncology, 6th ed., pp. 2977–3011. Philadelphia: Lippincott Williams and Wilkins.

Pergolizzi J, Boger R, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an international expert panel with focus on the six clinically most often used World Health Organisation step III opioids (Buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone. Pain Pract 2008;8(4):287-313.

Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician 2010;13:401-35.

In well patients, surgery via gastroenterostomy is the traditional method for palliation of Gastric outlet obstruction (GOO) or duodenal obstruction. With unresectable cancer, the risks associated with surgical bypass and the possibility of postoperative delayed gastric emptying can outweigh the benefits. Conservative measures, such as nasoenteric tube feeding and venting gastrostomy, do little to relieve obstructive symptoms and do not allow patients the pleasure of oral food intake. Some patients develop recurrent malignant obstruction after palliative bypass. Endoscopic placement of SEMS can be a useful nonsurgical alternative for palliation of GOO. The first reported use of SEMS for malignant GOO was in the early 1990s. Nonrandomized prospective studies and retrospective studies have also compared surgical outcomes with endoscopic stent outcomes in GOO. In one study, the median time to oral fluid intake was up to 1 day after stenting, 4 days after laparoscopy, and 6 days after open surgery. In-hospital costs were lower for patients who underwent endoscopic stenting.

Mosler P et al. (2005) Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series. J Clin Gastroenterol 39: 124-128
Fiori E et al. (2004) Palliative management of malignant antro-pyloric strictures. Gastroenterostomy vs endoscopic stenting. A randomized prospective trial. Anticancer Res 24: 269-271
Johnsson E et al. (2004) Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation. World J Surg 28: 812-817