Matched study of three methods for palliation of malignant pyloroduodenal obstruction

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis

BACKGROUND

Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed.

RESULTS

After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to  - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001).

CONCLUSION

ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

Comparison of gastrojejunostomy to endoscopic stenting for gastric outlet obstruction: An updated Systematic Review and Meta-analysis

BACKGROUND

This study aimed to determine the optimal intervention modality for malignant GOO by comparing clinical outcomes after Gastrojejunostomy and endoscopic stenting.

METHODS

Two authors independently searched Web of Science, PubMed, Embase, and the Cochrane Library for articles before February 2021 to compare the clinical outcomes of GOO patients undergoing GJ or ES.

RESULTS

This meta-analysis included 31 articles with 2444 GOO patients. Although the GJ group outperformed the ES group in technical success (OR,3.79; P = 0.003), clinical success was not significantly different between the two groups (OR,1.25; P = 0.50). The GJ group had a longer hospitalization, lower re-obstruction and lower reintervention. Moreover, GJ had a better survival than ES in the gastric cancer group (HR, 0.33; P = 0.009). However, no significant statistical difference was observed in the pancreatic cancer group (HR, 0.55; P = 0.159).

CONCLUSIONS

Both GJ and ES are safe and effective intervention modalities for malignant GOO. GJ had significantly improved survival in gastric cancer patients with GOO, while no significant difference was observed between the two groups in pancreatic cancer patients with GOO.

Recent Updates in Gastrointestinal Stent Placement from the Esophagus to the Colon: A Radiological Perspective

Fluoroscopic-guided stent placement has become an advantageous treatment option for diverse gastrointestinal disorders. In addition to palliative stent placement in patients with inoperable cancers, stenting has gradually expanded to other conditions, including as a bridge to surgery, as well as in patients' benign lesions and anastomotic strictures or leaks. This narrative review describes the indications, efficacy and safety of stent placement from the esophagus to the colon, including current recommendations, recent updates, and novel stents.

Palliative gastrojejunostomy in unresectable cancer and gastric outlet obstruction: a retrospective cohort study

INTRODUCTION

Palliative gastrojejunostomy is a surgical technique that allows restoration of oral intake among patients with gastric outlet obstruction (GOO) caused by unresectable neoplasms. Research suggests standard treatment for malignant GOO should be laparoscopic gastrojejunostomy (LGJ). This study presents the clinical outcomes of palliative gastrojejunostomy and compares results from LGJ and open gastrojejunostomy (OGJ) at our centre.

METHODS

We performed a retrospective analysis on patients who underwent palliative gastrojejunostomy for GOO caused by unresectable neoplasms between 2008 and 2018. We included demographic variables, time to recover intestinal transit, time to recover oral intake, hospital stay, complications and global survival.

RESULTS

A total of 39 patients underwent palliative gastrojejunostomy (20 OGJ, 19 LGJ). Patients in the LGJ group recovered oral intake and intestinal transit faster than those in the OGJ group (3 vs 5 days, p<0.05). There were no statistically significant differences in median operating time, hospital stay or postoperative complications between the two groups. No intraoperative complications occurred. The estimated global survival was 178 days, with no significant difference between the groups.

CONCLUSIONS

Palliative LGJ allows earlier restoration of oral intake and does not increase morbidity or mortality. Palliative LGJ should be considered the standard treatment for these patients.

Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy using double balloon occlusion methods: a clinical retrospective study in 36 patients with malignant gastric outlet obstruction

Background and study aims  Gastric outlet obstruction (GOO) is common in the late stage of many malignant tumors of the digestive system. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is commonly used for palliative treatment of malignant GOO. The objective of this study was to investigate the safety, efficacy, and prognosis of EUS-GE in treatment of malignant GOO in Chinese patients. Patients and methods  This was a retrospective, single-center study with 36 consecutive patients with malignant GOO who were treated with EUS-GE. The main outcome measures were technical success rate, clinical success rate, incidence of adverse events (AEs), and median survival time. Results  A total of 36 patients with malignant GOO underwent double-balloon-assisted EUS-GE between March 2017 and June 2019 in our hospital. GOO occurred mainly in elderly men (mean age 69.0 years, M:F 0.89). The most common etiology of GOO was pancreatic cancer (41.7 %). The most common obstruction site was the second part of the duodenum (63.9 %). The technical success rate was 100 % (36/36). The clinical success rate was 94.4 % (34/36). Median time for the total procedure was 52 minutes (range 34 - 156 min). Median time for determination of puncture site was 20 minutes (range 15 - 28 min). Median time between puncture and successful delivery of the stent was 38 minutes (range 19 - 128 min). The GOOSS score was 0.2 before EUS-GE. The GOO Scoring System (GOOSS) score was 2.2 at 15 days after the EUS-GE ( P  = 0.001). The GOOSS score was still higher than 2 during a median follow-up period of 89 days. AEs were observed in nine patients (25.0 %) and 13 total AEs occurred. One patient died as a result of delayed stent migration and bleeding. Mean length of hospital stay was 5.8 ± 4.7 days. The median survival period was 103 days. The rate of GOO recurrence was 2.7 % (1/36). Conclusion  EUS-GE was associated with increased safety and efficacy for treatment of malignant GOO in Chinese Mainland.

Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction

INTRODUCTION AND OBJECTIVES

Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement.

MATERIAL AND METHODS

A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction.

RESULTS

The study included 43 patients, technical success was 97.7% (n=42), and clinical success was 88.3% (n=38). SEMS dysfunction presented in 30.2% (n=13) of the patients, occurring in<6 months after placement in 53.8% (n=7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p=0.02) and the use of uncovered SEMS (p=0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months).

CONCLUSIONS

SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors.

Natural history and cost analysis of surgical bypass versus endoscopic stenting for the palliative management of malignant gastric outlet obstruction

BACKGROUND

Malignant gastric outlet obstruction (GOO) is managed with palliative surgical bypass or endoscopic stenting. Limited data exist on differences in cost and outcomes.

METHODS

Patients with malignant GOO undergoing palliative gastrojejunostomy (GJ) or endoscopic stent (ES) were identified between 2012 and 2015 using the MarketScan® Database. Median costs (payments) for the index procedure and 90-day readmissions and re-intervention were calculated. Frequency of treatment failure-defined as repeat surgery, stenting, or gastrostomy tube-was measured.

RESULTS

A total of 327 patients were included: 193 underwent GJ and 134 underwent ES. Compared to GJ, stenting resulted in lower total median payments for the index hospitalization and procedure-related 90-day readmissions ($18,500 ES vs. $37,200 GJ, p = 0.032). For patients treated with ES, 25 (19%) required a re-intervention for treatment-failure, compared to 18 (9%) patients who underwent GJ (p = 0.010). On multivariable analysis, stenting remained significantly associated with need for secondary re-intervention compared to GJ (HR for ES 2.0 [1.1-3.8], p 0.028).

CONCLUSION

In patients with malignant GOO, endoscopic stenting results in significant 90-day cost saving, however was associated with twice the rate of secondary intervention. The decision for surgical bypass versus endoscopic stenting should consider patient prognosis, anticipated cost, and likelihood of needing re-intervention.

Palliative surgical bypass is superior to palliative endoscopic stenting in patients with malignant gastric outlet obstruction: systematic review and meta-analysis

BACKGROUND

Gastrojejunostomy (GJ) and self-expanding metal stents (SEMS) are the two most common palliative treatment options for patients with malignant gastric outlet obstruction (GOO). Randomised trials and retrospective studies have shown discrepant results, so that there is still a controversy regarding the optimal treatment of GOO.

METHODS

Medline, Web of Science and Cochrane Library were systematically searched for studies comparing GJ to SEMS in patients with malignant GOO. Primary outcomes were survival and postoperative mortality. Secondary outcomes were frequency of re-interventions, major complications, time to oral intake and length of hospital stay.

RESULTS

Twenty-seven studies, with a total of 2.354 patients, 1.306 (55.5%) patients in the SEMS and 1.048 (44.5%) patients in the GJ group, were considered suitable for inclusion. GJ was associated with significantly longer survival than SEMS (mean difference 43 days, CI 12.00, 73.70, p = 0.006). Postoperative mortality (OR 0.55, CI 0.27, 1.16, p = 0.12) and major complications (OR 0.73, CI 0.5, 1.06, p = 0.10) were similar in both groups. The frequency of re-interventions, however, was almost three times higher in the SEMS group (OR 2.95, CI: 1.70, 5.14, p < 0.001), whereas the mean time to oral intake and length of hospital stay were shorter in the SEMS group (mean differences - 5 days, CI - 6.75, - 3.05 days, p < 0.001 and - 10 days, CI - 11.6, - 7.9 days, p < 0.001, respectively).

CONCLUSIONS

Patients with malignant GOO and acceptable performance status should be primarily considered for a palliative GJ rather than SEMS.

Complications After Endoscopic Stenting for Malignant Gastric Outlet Obstruction: A Cohort Study

BACKGROUND

Gastric stenting has become a common place in clinical practice. The aim of our study was to evaluate the factors influencing the clinical outcome in patients who received endoscopic stenting for malignant gastric outlet obstruction (GOO).

MATERIALS AND METHODS

We prospectively evaluated the clinical course of 87 patients who presented to our attention with malignant GOO.

RESULTS

There was neither mortality nor major morbidity after endoscopic stenting. Survival was reduced (average, 2 mo) in patients with an obstruction due to no resectable pancreatic cancer. In patients with primary no resectable pyloric adenocarcinoma, the crude survival was >1 year. Almost half of the patients required a new endoscopy. Food obstruction was common after 6 months from stent placement, limiting the quality of life of the patients.

CONCLUSIONS

Endoscopic stenting represents a valid treatment in patients with symptoms of GOO from metastatic cancer. Patients with metastatic pyloric adenocarcinoma and normal liver function tests have survival rates longer than 1 year. In this selected group of patients, laparoscopic surgical gastrojejunostomy can be a valid alternative to avoid a close and exhausting follow-up, with the possibility of a better quality of life (res Registry 808).

Palliative therapy in pancreatic cancer-palliative surgery

Pancreatic cancer is a highly lethal disease with a dismal prognosis. It will probably become the second leading cause of cancer-related death within the next decade in Western countries. Over 80% of patients undergo palliative treatment for unresectable pancreatic cancer due to locally advanced disease or metastases. Those patients often develop gastric outlet obstruction (GOO), obstructive jaundice and pain during the course of their disease. Symptoms such as vomiting, anorexia, pruritus and jaundice will impact the quality of life (QOL) and could delay the administration of the chemotherapy. Palliative therapy in pancreatic cancer aims to relieve the symptoms durably and to improve the QOL. Palliative surgery was traditionally considered as a gold standard with the "double by-pass" including biliary-digestive and gastro-jejunal anastomosis. However, since the development of endoscopic stenting and minimally invasive surgery, the choice of the best modalities remains debated. While there is still a place for surgical gastrojejunostomy (GJ) in case of duodenal or GOO, endoscopic biliary stenting during endoscopic retrograde cholangiopancreatography (ERCP) is now accepted as the gold standard in case of obstructive jaundice. In pain management, endoscopic ultrasound guided or percutaneous celiac plexus neurolysis is recommended. The selection of the best technique should consider the effectiveness and the morbidity of the treatment, the performance status of the patient and the disease stage. While endoscopic stenting is associated with earlier recovery and shorter length of stay, recurrence of symptoms and reintervention are less frequent after palliative surgery. Finally, controversy exists on whether to perform prophylactic palliative surgery in the absence of symptoms when unresectable disease is discovered during surgical exploration.

Closed Loop Duodenal Obstruction Secondary to Pancreatic Carcinoma: A Case Report

BACKGROUND

Patients with pancreatic adenocarcinoma may develop into duodenal obstruction during the course of their disease. The diagnosis of obstruction can be generally achieved by means of imaging technologies.

Case and Outcome

We reported a rare case of pancreatic tumor with duodenal obstruction accompanied by obstructive symptoms, which was finally confirmed by laparotomy. A 68-year-old man was admitted to our department with a 3-day medical history of upper abdominal pain, nausea and vomiting. The diagnosis of duodenal obstruction was established by means of various imagings including computed tomography (CT) scan, gastroscopy and upper gastrointestinal imaging. Upper gastrointestinal imaging and magnetic resonance imaging (MRI) showed extrinsic tumor mass was noted at the second and third portion of the duodenum accompanied by duodenal obstruction and dilatation, respectively. Laparotomy confirmed a tumor mass arising from the head and uncinate process of pancreas, which had invaded the second and third portions of the duodenum and caused closed loop obstruction. A pancreaticoduodenectomy (Whipple procedure) was performed followed by therapeutic trade-off according to intraoperative exploration. Postoperative histopathology revealed pancreatic tumor only infiltrated duodenal wall, while resection margins of pancreas, common bile duct and duodenum were all negative. The patient was cured and discharged home 12 days after surgery.

CONCLUSION

The present case indicated radical operation in our study appeared to be the first choice treatment for patients with malignant duodenal obstruction.

Current role of palliative interventions in advanced pancreatic cancer

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of self-expanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

De-novo Gastrointestinal Anastomosis with Lumen Apposing Metal Stent

Gastric outlet obstruction, afferent or efferent limb obstruction, and biliary obstruction among patients with altered anatomy often require surgical intervention which is associated with significant morbidity and mortality. Endoscopic dilation for benign etiologies requires multiple sessions, whereas self-expandable metal stents used for malignant etiologies often fail due to tumor in-growth. Lumen apposing metal stents, placed endoscopically with the intent of creating a de-novo gastrointestinal anastomosis bypassing the site of obstruction, can potentially achieve similar efficacy, with a much lower complication rate. In our study cohort (n=79), the composite technical success rate and clinical success rate was 91.1% (72/79) and 97.2% (70/72), respectively. Five different techniques were used: 43% (34/79) underwent the balloon-assisted method, 27.9% (22/79) underwent endoscopic ultrasound-guided balloon occluded gastro-jejunostomy bypass, 20.3% (16/79) underwent the direct technique, 6.3% (5/79) underwent the hybrid rendezvous technique, and 2.5% (2/79) underwent natural orifice transluminal endoscopic surgery (NOTES)-assisted procedure. All techniques required an echoendoscope except NOTES. In all, 53.2% (42/79) had non-cautery enhanced Axios stent, 44.3% (35/79) had hot Axios stent, and 2.5% (2/79) had Niti-S spaxus stent. Symptom-recurrence was seen in 2.8%, and 6.3% had a complication (bleeding, abdominal pain or peritonitis). All procedures were performed by experts at centers of excellence with adequate surgical back up.

Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer

BACKGROUND

Malignant gastric outlet obstruction (GOO) often develops in patients with advanced pancreatic cancer (APC). It is not clear whether endoscopic duodenal stenting (DS) or surgical gastrojejunostomy (GJJ) is preferable as palliative treatment.

AIMS

To compare the efficacy and safety of GJJ and DS for GOO with APC.

METHODS

Consecutive 99 patients who underwent DS or GJJ for GOO with APC were evaluated. We compared the technical and clinical success rates, the incidence of adverse event (AE), the time to start chemotherapy and discharge and survival durations between DS and GJJ. Prognostic factors for overall survival (OS) were investigated on the multivariate analysis.

RESULTS

GOO was managed with GJJ in 35 and DS in 64. The technical and clinical success rates were comparable. DS was associated with shorter time to start oral intake and earlier chemotherapy start and discharge. No difference was seen in the early and late AE rates. Multivariate analyses of prognostic factors for OS showed that performance status ≧2, administration of chemotherapy, and presence of obstructive jaundice to be significant factors. There were no significant differences in survival durations between the groups, regardless of the PS.

CONCLUSIONS

There were no significant differences in the technical and clinical success and AE rates and survival duration between DS and GJJ in management of GOO by APC. DS may be a preferable option over GJJ given that it will lead to an earlier return to oral intake, a shortened length of hospital stay, and finally an earlier referral for chemotherapy.

Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction

BACKGROUND

Malignant gastric outlet obstruction is the clinical and pathological consequence of cancerous disease causing a mechanical obstruction to gastric emptying. It usually occurs when malignancy is at an advanced stage; therefore, people have a limited life expectancy. It is of paramount importance to restore oral intake to improve quality of life for the person in a manner that has a minimal risk of complications and a short recovery period.

OBJECTIVES

To assess the benefits and harms of endoscopic stent placement versus surgical palliation for people with symptomatic malignant gastric outlet obstruction.

SEARCH METHODS

In May 2018 we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and Ovid CINAHL. We screened reference lists from included studies and review articles.

SELECTION CRITERIA

We included randomised controlled trials comparing stent placement with surgical palliation for people with gastric outlet obstruction secondary to malignant disease.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes, mean difference (MD) or standardised mean difference (SMD) with 95% CI for continuous outcomes and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where meaningful. We assessed the quality of evidence using GRADE criteria.

MAIN RESULTS

We identified three randomised controlled trials with 84 participants. Forty-one participants underwent surgical palliation and 43 participants underwent duodenal stent placement. There may have been little or no difference in the technical success of the procedure (RR 0.98, 95% CI 0.88 to 1.09; low-quality evidence), or whether the time to resumption of oral intake was quicker for participants who had undergone duodenal stent placement (MD -3.07 days, 95% CI -4.76 to -1.39; low-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved all-cause mortality and median survival postintervention.The time to recurrence of obstructive symptoms may have increased slightly following duodenal stenting (RR 5.08, 95% CI 0.96 to 26.74; moderate-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved serious and minor adverse events. The heterogeneity for adverse events was moderately high (serious adverse events: Chi² = 1.71; minor adverse events: Chi² = 3.08), reflecting the differences in definitions used and therefore, may have impacted the outcomes. The need for reintervention may have increased following duodenal stenting (RR 4.71, 95% CI 1.36 to 16.30; very low-quality evidence).The length of hospital stay may have been shorter (by approximately 4 to 10 days) following stenting (MD -6.70 days, 95% CI -9.41 to -3.98; moderate-quality evidence).

AUTHORS' CONCLUSIONS

The use of duodenal stent placement in malignant gastric outlet obstruction has the benefits of a quicker resumption of oral intake and a reduced inpatient hospital stay; however, this is balanced by an increase in the recurrence of symptoms and the need for further intervention.It is impossible to draw further conclusions on these and the other measured outcomes, primarily due to the low number of eligible studies and small number of participants which resulted in low-quality evidence. It was not possible to analyse the impact on quality of life each intervention had for these participants.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreatic-biliary cancer are biliary obstruction, pain and gastric outlet obstruction (GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decision-making must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation of the patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques

BACKGROUND

EUS-guided gastroenterostomy (EUS-GE) is a developing modality in the management of gastric outlet obstruction (GOO) with several technical approaches, including the direct and balloon-assisted techniques. The aim of this study was to compare the direct with the balloon-assisted modality while further defining the role of EUS-GE in GOO.

METHODS

This multicenter, retrospective study involved consecutive patients who underwent EUS-GE with the direct or balloon-assisted technique for GOO (January 2014 to October 2016). The primary outcome was technical success. Secondary outcomes were success (ability to tolerate at least a full fluid diet), procedure time, and rate/severity of adverse events (AEs).

RESULTS

A total of 74 patients (44.6% women; mean age 63.0 ± 11.7 years) underwent EUS-GE for GOO (direct gastroenterostomy, n = 52; balloon-assisted gastroenterostomy, n = 22). GOO was of malignant and benign etiology in 66.2% and 33.8% of patients, respectively. Technical success was achieved in 94.2% of the direct and 90.9% of the balloon-assisted approach (P = .63). Mean procedure time was shorter with the direct technique (35.7 ± 32.1 minutes vs 89.9 ± 33.3 minutes, P < .001). The clinical success rate was 92.3% for the direct technique and 90.9% for the balloon-assisted modality (P = 1.00), with a mean time to oral intake of 1.32 ± 2.76 days. The AE rate was 6.8% with only 1 severe AE noted. Rate of AEs, postprocedure length of stay, need for reintervention, and survival were similar between the 2 groups.

CONCLUSIONS

EUS-GE is effective and safe in the management of GOO. The direct technique may be the preferred method given its shorter procedure time when compared with the balloon-assisted approach. Prospective trials are needed to confirm these findings.

Laparoscopic gastrojejunostomy versus duodenal stenting in unresectable gastric cancer with gastric outlet obstruction

Purpose

To compare the outcome between laparoscopic gastrojejunostomy (LapGJ) and duodenal stenting (DS) in terms of oral intake, nutritional status, patency duration, effect on chemotherapy and survival.

Methods

Medical records of 115 patients, who had LapGJ or duodenal stent placement between July 2005 and September 2015 in Seoul National University Bundang Hospital, have been reviewed retrospectively. Oral intake was measured with Gastric Outlet Obstruction Scoring System. Serum albumin and body weight was measured as indicators of nutritional status. The duration of patency was measured until the date of reintervention. Chemotherapy effect was calculated after the procedures. Survival period and oral intake was analyzed by propensity score matching age, sex, T-stage, comorbidities, and chemotherapy status.

Results

Forty-three LapGJ patients and 58 DS patients were enrolled. Improvement in oral intake was shown in LapGJ group versus DS group (88% vs. 59%, P = 0.011). Serum albumin showed slight but significant increase after LapGJ (+0.75 mg/dL vs. −0.15 mg/dL, P = 0.002); however, there was no difference in their body weight (+5.1 kg vs. −1.0 kg, P = 0.670). Patients tolerated chemotherapy longer without dosage reduction after LapGJ (243 days vs. 74 days, P = 0.006) and maintained the entire chemotherapy regimen after the procedure longer in LapGJ group (247 days vs. 137 days, P = 0.042). LapGJ showed significantly longer survival than DS (220 vs. 114 days, P = 0.004).

Conclusion

DS can provide faster symptom relief but LapGJ can provide improved oral intake, better compliance to chemotherapy, and longer survival. Therefore, LapGJ should be the first choice in gastric outlet obstruction patients for long-term and better quality of life.

Laparoscopic Gastrojejunostomy for Patients with Unresectable Gastric Cancer with Gastric Outlet Obstruction

BACKGROUND

There have been no comparative studies of open gastrojejunostomy (OGJ) and laparoscopic gastrojejunostomy (LGJ) in gastric cancer (GC) patients with gastric outlet obstruction (GOO) to explore both short- and long-term outcomes. The aim of this study was to compare the safety and feasibility of short-term oral intake as well as the long-term oncological outcome of OGJ and LGJ.

METHODS

This was a retrospective study of 53 consecutive unresectable GC patients who underwent GJ for GOO in our institute. OGJ (n = 23) was performed between 2010 and 2012 and LGJ (n = 30) was performed between 2013 and 2015.

RESULTS

We found a higher rate of postoperative delayed gastric emptying in the OGJ group than in the LGJ group (26.1 vs 0%; P = 0.004). OGJ had more unfavorable results regarding the median time to resumption of oral feeding (4 vs 2 days; P < 0.001). Palliative LGJ did not offer survival benefit over OGJ in patients with unresectable GC with GOO.

CONCLUSION

LGJ is a useful and feasible alternative to OGJ regarding short-term outcomes.

Palliative gastrojejunostomy versus endoscopic stent placement for gastric outlet obstruction in patients with unresectable gastric cancer: a propensity score-matched analysis

BACKGROUND

It remains unclear whether selection of treatment modality affects the survival of patients with malignant gastric outlet obstruction (GOO). We compared the effect of gastrojejunostomy (GJ) and endoscopic self-expandable metallic stent (SEMS) placement on the long-term outcomes of patients with malignant GOO caused by unresectable gastric cancer.

METHOD

We conducted a retrospective study of gastric cancer patients undergoing GJ or endoscopic SEMS placement for the palliation of malignant GOO. To reduce the effect of selection bias, we performed a propensity score-matching analysis between two groups.

RESULTS

In a propensity-matched analysis (45 and 99 in GJ and SEMS groups, respectively), clinical success rates were comparable between the GJ and SEMS groups (95.6 and 96.0%), while the SEMS group showed significantly shorter hospital stays than the GJ group. The GJ group showed a significantly longer reintervention period and overall survival (393 and 129 days) compared to the SEMS group. In multivariate Cox regression analysis, GJ, low ECOG scale (good performance status), and additional chemo- or radiation therapy were identified as independent favorable predictors of overall survival. GJ was also identified as an independent protective predictor against reintervention.

CONCLUSION

We found that palliative GJ was significantly associated with longer overall survival and lower risk of reintervention than SEMS placement in patients with malignant GOO caused by unresectable gastric cancer. Given very limited expected survival in selected patients with unresectable gastric cancer and more favorable short-term outcomes in cases of SEMS placement, individualized approach might be required in treatment decision between palliative GJ and SEMS placement.

Palliative Therapy for Gastric Outlet Obstruction Caused by Unresectable Gastric Cancer: A Meta-analysis Comparison of Gastrojejunostomy with Endoscopic Stenting

Background:

Gastrojejunostomy (GJJ) and endoscopic stenting (ES) are palliative treatments for gastric outlet obstruction (GOO) caused by gastric cancer. We compared the outcomes of GJJ with ES by performing a meta-analysis.

Methods:

Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis. Procedure time, time to resumption of oral intake, duration of hospital stay, patency duration, and overall survival days were compared using weighted mean differences (WMDs). Technical success, clinical success, procedure-related mortality, complications, the rate of re-obstruction, postoperative chemotherapy, and reintervention were compared using odds ratios (ORs).

Results:

Nine studies were included in the analysis. Technical success and clinical success were not significantly different between the ES and GJJ groups. The ES group had a shorter procedure time (WMD = −80.89 min, 95% confidence interval [CI] = −93.99 to −67.78, P < 0.001), faster resumption of oral intake (WMD = −3.45 days, 95% CI = –5.25 to −1.65, P < 0.001), and shorter duration of hospital stay (WMD = −7.67 days, 95% CI = −11.02 to −4.33, P < 0.001). The rate of minor complications was significantly higher in the GJJ group (OR = 0.13, 95% CI = 0.04–0.40, P < 0.001). However, the rates of major complications (OR = 6.91, 95% CI = 3.90–12.25, P < 0.001), re-obstruction (OR= 7.75, 95% CI = 4.06–14.78, P < 0.001), and reintervention (OR= 6.27, 95% CI = 3.36–11.68, P < 0.001) were significantly lower in the GJJ group than that in the ES group. Moreover, GJJ was significantly associated with a longer patency duration (WMD = −167.16 days, 95% CI = −254.01 to −89.31, P < 0.001) and overall survival (WMD = −103.20 days, 95% CI = −161.49 to −44.91, P = 0.001).

Conclusions:

Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer. ES is associated with better short-term outcomes. GJJ is preferable to ES in terms of its lower rate of stent-related complications, re-obstruction, and reintervention. GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.

EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction

BACKGROUND AND AIMS

Endoscopic enteral stenting (ES) in malignant gastric outlet obstruction (GOO) is limited by high rates of stent obstruction. EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers sustained patency without tumor ingrowth/overgrowth. The aim of this study is to compare EUS-GE with ES in terms of (1) symptom recurrence and need for re-intervention, (2) technical success (proper stent positioning as determined via endoscopy and fluoroscopy), (3) clinical success (ability to tolerate oral intake without vomiting), and (4) procedure-related adverse events (AEs).

METHODS

Multicenter retrospective study of all consecutive patients who underwent either EUS-GE at four centers between 2013 and 2015 or ES at one center between 2008 and 2010.

RESULTS

A total of 82 patients (mean age 66-years ± 13.5 and 40.2% female) were identified: 30 in EUS-GE and 52 in ES. Technical and clinical success was not significantly different: 86.7% EUS-GE versus 94.2% ES (p = 0.2) and 83.3% EUS-GE versus 67.3% ES (p = 0.12), respectively. Symptom recurrence and need for re-intervention, however, was significantly lower in the EUS-GE group (4.0 vs. 28.6%, (p = 0.015). Post-procedure mean length of hospitalization was comparable at 11.3 days ± 6.6 for EUS-GE versus 9.5 days ± 8.3 for ES (p = 0.3). Rates and severity of AEs (as per the ASGE lexicon) were also similar (16.7 vs. 11.5%, p = 0.5). On multivariable analysis, ES was independently associated with need for re-intervention (OR 12.8, p = 0.027).

CONCLUSION

EUS-GE may be ideal for malignant GOO with comparable effectiveness and safety to ES while being associated with fewer symptom recurrence and requirements for re-intervention.

Endoscopic approach to gastrointestinal bypass in malignant gastric outlet obstruction

PURPOSE OF REVIEW

Malignant gastric outlet obstruction (GOO) is a debilitating complication of cancer associated with a poor prognosis. The primary aim in the management of malignant GOO is usually palliation starting with the reinstitution of luminal patency with either surgical bypass or enteral stenting. These traditional modalities, however, have important limitations. Endoscopic bypass is a novel approach to GOO and may be an ideal technique, in which a sustained bypass can be created through a minimally invasive approach. The goal of this review is to describe the technical aspects as well as the clinical data of endoscopic bypass.

RECENT FINDINGS

A review of this novel technique is timely given recent developments of several accessories and techniques that allow for safer and easier endoscopic bypass including the advent of the lumen apposing stent, a specialized double-balloon enteric tube, the EUS-assisted technique, and the natural orifice transluminal surgery approach. In addition, accumulating and promising data have emerged supporting the endoscopic approach to gastric bypass.

SUMMARY

Endoscopic bypass is a novel and developing field of therapeutic endoscopy with improving technique and promising clinical data. This review will help to shed light on the current status and future direction of this intricate endoscopic modality.

Cost-effectiveness of palliative surgery versus nonsurgical procedures in gastrointestinal cancer patients

Palliative care is an essential component to multidisciplinary cancer care. Improved symptom control, quality of life (QOL), and survival have resulted from its utilization. Cost-effectiveness and utility analyses are significant variables that should be considered in comparing benefits and costs of medical interventions to determine if certain treatments are economically justified. This is a review on the cost-effectiveness of palliative surgery compared to other nonsurgical palliative procedures in patients with unresectable gastrointestinal cancers. J. Surg. Oncol. 2016;114:316-322. © 2016 Wiley Periodicals, Inc.

Treatment of gastric outlet obstruction that results from unresectable gastric cancer: Current evidence

Malignant gastric outlet obstruction (GOO) is a common condition that results from locally advanced malignancies in the upper gastrointestinal tract, such as pancreatic, gastric, and other carcinomas. Two types of procedures for malignant GOO, namely, gastrojejunostomy (GJ) with laparotomy or a laparoscopic approach and endoscopic stenting (ES), are currently available. Although numerous previous reports have clarified the benefits and drawbacks of each procedure, whether GJ or ES should be used in patients with GOO that results from gastric cancer who may have a longer life expectancy than patients with other malignancies has not been determined. In this review, which focuses on gastric cancer-induced GOO, we analyzed the two systematic reviews and a meta-analysis that compared GJ and ES and outlined the current status of GOO treatment. We also provide an updated review that includes laparoscopic GJ. Various data from 13 studies in one review and 6 studies in another review were analyzed. Although the main results of the present review indicated that both GJ and ES were efficacious treatments in patients with GOO that resulted from gastric cancer, current evidence suggests that GJ may be the preferable procedure given its good performance status and improved prognosis in gastric cancer patients.

Self-expandable metal stent placement for malignant duodenal obstruction distal to the bulb

OBJECTIVE

Self-expandable metal stents (SEMS) are widely used for the palliative management of malignant proximal gastroduodenal obstruction because of its low morbidity and mortality rates compared with surgical bypass. However, stent placement for duodenal obstruction beyond the first part of the duodenum is considered technically difficult and is not routinely performed. We report our experience with SEMS placement for these patients.

METHODS

Between 2006 and 2015, 51 patients with unresectable or metastatic malignancy underwent SEMS placements under combined endoscopic and fluoroscopic guidance. Eighteen patients had intestinal obstruction distal to the duodenal bulb. Their demographics, technical and clinical outcomes, periprocedural morbidity and mortality, length of hospital stay, further interventions and overall survival were analysed.

RESULTS

Out of the 18 cases, nine cases of intestinal obstruction were due to primary malignancy of the pancreas, three due to gastric malignancy, three from other locoregional cancers and three were the result of metastases. In 12 patients, the obstruction involved the second part (D2), in four the third part (D3) and in two the fourth part (D4) of the duodenum. A front-facing therapeutic gastroscope was used to visualize the duodenum before the stricture was crossed under direct vision and fluoroscopic guidance, with a catheter and guidewire, and a through-the-scope SEMS deployed using an 'over-the-wire' technique. Technical success rate was 89%. The mean gastric outlet obstruction scores improved from 0.63 to 2.57 (P<0.0001). Four patients died within 30 days of the procedure, although none of the deaths were procedure related. The median length of postprocedural hospital stay was 4 days and the median overall survival was 58 days.

Outcome for self-expandable metal stents in malignant gastroduodenal obstruction: single-center experience with 104 patients

BACKGROUND

Malignant gastric outlet obstruction (GOO) leads to malnutrition and limits quality of life. Gastrojejunostomy has been the traditional treatment for GOO. Recently, the results of releasing duodenal obstruction with self-expandable metal stents (SEMS) have been encouraging.

METHODS

After the exclusion of 13 patients with gastrojejunal or jejunal strictures and 1 patient with intraabdominal lymphoma, the authors palliated the malignant GOO in 104 patients with 130 SEMS at a single center during the years 1999-2007.

RESULTS

The GOO was caused by pancreatic (n = 51), gastric (n = 24), duodenal (n = 7), biliary (n = 5), and other (n = 17) malignancies. Of the 104 patients, 76 (73%) did well with only one enteral stent placement, 21 (20.2%) required two stent placements, 4 (3.8%) required three stent placements, and 1 required four stent placements. The median dysphagia score was 0 before stenting and 2 after treatment (p < 0.001). Immediate failure occurred after 10 procedures (7.7%). Among the 104 patients, 6 (5.8%) died of stent placement-related reasons. Complications occurred for 13 patients (12.5%). The median hospital stay was 3 days, and the overall survival time was 62 days (range, 1-933 days). Of 11 patients with concomitant biliary obstruction and GOO, 10 (91%) underwent successful enteral and biliary stent placement within the same session. Of 15 patients experiencing jaundice after enteral stent placement, 6 (40%) underwent endoscopic biliary drainage successfully.

CONCLUSION

Enteral stenting is a safe and effective way to treat GOO. Gastrojejunostomy should be preserved for cases in which endoscopic stenting is not successful or possible.

Stent under-expansion on the procedure day, a predictive factor for poor oral intake after metallic stenting for gastric outlet obstruction

BACKGROUND AND AIM

Self-expandable metallic stents (SEMS) have been widely accepted as palliation therapy for malignant gastric outlet obstruction (GOO). However, the factors predictive of poor oral intake after SEMS placement have not been elucidated sufficiently. We aimed to clarify both the patient and stent-related predictive factors.

METHODS

We retrospectively reviewed 126 consecutive patients who underwent uncovered SEMS placement for malignant GOO between April 2010 and March 2013 at a university hospital and two tertiary care referral centers.

RESULTS

Technical success of SEMS placement was achieved in all 126 (100%) patients. Improved oral intake was observed in 111 (88.1%) patients. A Karnofsky performance status ≤ 40 (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.02-1.28; P = 0.041), peritoneal dissemination (OR, 1.20; 95% CI, 1.01-1.26; P = 0.038), and under-expansion of the SEMS on the procedure day (OR, 1.55; 95% CI, 1.26-1.62; P < 0.001) were independent predictive factors for poor improvement on the GOO scoring system, according to multivariate analysis.

CONCLUSIONS

SEMS under-expansion was a stent related, while poor performance status and peritoneal dissemination were patient related, predictive factors for poor oral intake after SEMS placement for malignant GOO.

Safety and benefits of self-expandable metallic stents with chemotherapy for malignant gastric outlet obstruction

BACKGROUND AND AIM

The influence of chemotherapy on placement of self-expandable metallic stents (SEMS) for malignant gastric outlet obstruction (MGOO) has not been evaluated extensively. We investigated the influence of chemotherapy on the clinical outcomes of SEMS placement for MGOO.

METHODS

A total of 152 cancer patients with MGOO from a university hospital and affiliate hospitals were included. The patients were classified according to chemotherapy status and evaluated for palliative efficacy and safety of SEMS placement.

RESULTS

Technical success rate, time to oral intake, and parameters indicating improvement of physical condition did not differ between the with- and without-chemotherapy groups after stent placement. Re-intervention and stent migration were significantly more frequent in the with-chemotherapy group than in the without-chemotherapy group after stent placement (re-intervention, 32.4% vs 7.8%, P = 0.0005; stent migration, 13.5% vs 1.7%, P = 0.0097). The frequency of adverse events did not differ between the with- and without-chemotherapy groups. Although chemotherapy after stent placement was an independent predictive factor for shortening the stent patency period (hazard ratio [HR], 3.10; P = 0.0264), the use of additional stents facilitated uneventful recovery and further prolonged survival time (HR, 0.60; P = 0.0132).

CONCLUSIONS

Various cancer patients with MGOO can undergo SEMS placement safely regardless of chemotherapy, and concurrent chemotherapy after stent placement can prolong survival time, although re-intervention and stent migration may be increased.

Gastrointestinal stenting: Current status and imaging features

The use of stents in the gastrointestinal tract has been subjected to major changes. Initially, the use of stents was restricted to malignant strictures in patients with metastatic disease. But thanks to reduction of the morbidity and mortality rates, they are now used with curative intention and in patients with benign diseases after careful selection. However, for patients presenting with colon obstruction due to an advanced colon carcinoma, the mortality and morbidity are still high. The purpose of this review is to provide an overview of indications, techniques and further developments of the stents in the gastrointestinal tract and to highlight the predominant role of multidetector row computed tomography (MDCT) in the detection of potential complications.

Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy

BACKGROUND

Self-expandable metal stent (SEMS) placement and palliative gastrojejunostomy (GJJ) are palliative treatment options for malignant gastric outlet obstruction.

OBJECTIVE

To compare clinical outcomes of palliative treatments for gastric outlet obstruction caused by unresectable gastric cancer.

DESIGN

Retrospective study.

SETTING

University-affiliated tertiary-care hospital in the Republic of Korea.

PATIENTS

Two hundred fifty-six patients with gastric outlet obstruction caused by unresectable gastric cancer.

INTERVENTION

SEMS placement and palliative GJJ.

MAIN OUTCOME MEASUREMENTS

Patency duration and overall survival duration.

RESULTS

In total, 217 and 39 patients underwent SEMS placement and palliative GJJ, respectively, as an initial palliative treatment. Treatment modality affected reobstruction after clinical success (hazard ratio [HR] [95% confidence interval {CI}], 0.5 [0.3-0.8] of palliative GJJ). In addition, carcinomatosis with ascites was an independent associated factor of clinical success and reobstruction (HR [95% CI], 0.3 [0.1-0.7] and 1.4 [1.0-2.0], respectively). In a subgroup of patients with good performance who had neither carcinomatosis nor ascites, patency duration and overall survival duration did not differ between the 2 groups (P = .079 and P = .290, respectively). In patients with good performance who had carcinomatosis without ascites, patency duration was longer in the palliative GJJ group than in the SEMS placement group (P = .016). Overall survival, however, did not differ between the 2 groups (P = .062). In a subgroup of patients with good performance who had carcinomatosis with ascites, both patency duration and overall survival were longer in the palliative GJJ group than in the SEMS placement group (P = .007 and P = .012, respectively).

LIMITATIONS

Nonrandomized, retrospective study.

CONCLUSION

Long-term clinical outcomes of the palliative treatment modality for gastric outlet obstruction caused by unresectable gastric cancer were affected by carcinomatosis and ascites status.

Endoscopic self-expandable metallic stenting for palliation of malignant gastric outlet obstruction in Southeast Asia

BACKGROUND

Malignant gastric outlet obstruction (GOO) is a pre-terminal event in the natural history of gastric and pancreaticobiliary cancers. The use of endoscopic placement of self-expandable metallic stents (SEMS) is a less invasive alternative palliative option for these patients. This is the first study in Southeast Asia to evaluate the clinical efficacy and safety of endoscopic SEMS placement in patients with malignant GOO.

METHODS

A retrospective review of our department's database in endoscopic SEMS placement for the treatment of malignant GOO was performed. Twenty-four patients with advanced or metastatic malignancy that underwent placement of SEMS for treatment of malignant GOO between January 2003 and July 2013 were analysed. The GOO severity score was used as an objective means of assessing patients' oral intake.

RESULTS

Technical success rate was 100%. All patients resumed oral intake of liquids within the same day of stent placement. Clinical success was achieved in 21 patients (87.5%). There was a significant improvement of GOO severity score from 0.62 ± 1.0 (mean ± standard deviation) before stent placement to 2.04 ± 0.86 after stent placement (P < 0.001). Complication rate was 12.5%. Stent-related complications observed include stent migration (two patients) and tumour ingrowth (one patient). Serious complications such as gastrointestinal haemorrhage or perforation did not occur in any patients. The median survival after stent placement was 57 days (95% confidence interval, 12.2-101.8 days). None of the patients died from stent-related complications.

CONCLUSION

Endoscopic SEMS placement is a minimally invasive, safe and effective option for the palliation of malignant GOO.

A newly designed stent for management of malignant distal duodenal stenosis

PURPOSE

To evaluate the clinical effectiveness of a newly designed stent for the treatment of malignant distal duodenal stenosis.

METHODS

From March 2011 to May 2013, six patients with malignant duodenal stenosis underwent fluoroscopically guided placement of the new duodenal stent consisting of braided, nested stent wires, and a delivery system with a metallic mesh inner layer. Primary diseases were pancreatic cancer in three patients, gastric cancer in two patients, and endometrial stromal sarcoma in one patient. Duodenal obstructions were located in the horizontal part in two patients, the ascending part in two patients, and the duodenojejunal flexure in two patients. Technical success, defined as the successful stent deployment, clinical symptoms before and after the procedure, and complications were evaluated.

RESULTS

Technical success was achieved in all patients. No major complications were observed. Before treatment, two patients could not take any food and the gastric outlet obstruction scoring system (GOOSS) score was 0; the other four patients could take only liquids orally (GOOSS score = 1). After treatment, five patients could take soft food (GOOSS score = 2) and one patient could take a full diet (GOOSS score = 3). The mean duration of primary stent patency was 115.7 days.

CONCLUSIONS

The newly designed stent is associated with a high degree of technical success and good clinical outcome and may be clinically effective in the management of malignant distal duodenal obstruction.

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials

BACKGROUND

Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. During the last decade, endoscopic self-expandable metal stents (SEMS) have been used. This meta-analysis aimed to compare surgical GJ and endoscopic stenting in palliation of malignant gastric outlet obstruction (GOO).

METHODS

A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 3 randomized controlled trials (RCTs) and 14 non-RCTs reporting on patients who underwent surgical GJ or endoscopic stenting for malignant gastroduodenal outflow obstruction.

RESULTS

THE RESULTS OF THE THREE RCTS DEMONSTRATED THAT SEMS RESULTED IN COMPARABLE MAJOR [ODDS RATIO (OR): 0.62, 95% confidence intervals (CI): 0.021-18.371] and minor (OR: 0.32, 95% CI: 0.049-2.089) complications in a shorter time to tolerating an oral intake (SEMS: 3.55 days and GJ: 7.15 days) and shorter hospital stay (SEMS: 5.1 days and GJ: 12.13 days, however, statistical insignificant P value =0.11). Among the non RCTs: SEMS resulted in a shorter time to tolerating an oral intake (SEMS: 1.48 days and GJ: 8.07 days, P value <0.01), similar rate of complications (OR: 0.33, 95% CI: 0.1-1.08), lower mortality (OR: 0.5, 95% CI: 0.21-1.20, P value <0.01) and a shorter hospital stay (SEMS: 7.61 days and GJ: 19.04 days, P value <0.0001). There was no significant difference between median survival times among RCTs and non RCTs.

CONCLUSIONS

These findings suggest that stent placement is associated with better short-term outcomes and hence, duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. However, a large RCT is needed to systematically compare stent placement with GJ with regard to medical effects, quality of life and costs.

Endoscopic treatment of malignant gastric and duodenal strictures: a prospective, multicenter study

BACKGROUND

Malignant gastric outlet obstruction is often treated by stent placement.

OBJECTIVE

To investigate the outcomes of stent placement in the palliative treatment of malignant neoplasms.

DESIGN

Prospective, observational, multicenter registry.

SETTING

Six tertiary care centers in 5 countries.

PATIENTS

A total of 108 adult patients with malignant gastric outlet obstruction.

INTERVENTIONS

Placement of an uncovered, self-expandable, metal duodenal stent.

MAIN OUTCOME MEASUREMENTS

The primary endpoint was stent patency at 14 days after stent implantation. Secondary endpoints included stent patency at 1, 2, 3, and 6 months, gastric outlet obstruction scoring system (GOOSS) scores at 14 days and 1, 2, 3, and 6 months after stent deployment, technical success, adverse events, and patient survival (ie, confirmed duration of the implant).

RESULTS

Technical success was achieved in 99.1% of stent placements. Stent patency at 14 days was 94.6%. Kaplan-Meier estimates of stent patency were 92.9% at 1 month, 86.2% at 2 months, 81.9% at 3 months, and 63.4% at 6 months. At 14 days, GOOSS scores increased by a median of 1 point. The overall GI adverse event rate was 32.4%; however, the stent-related adverse event rate was 19.4%. The median implant duration was 47 days (range 0-195 days).

LIMITATIONS

Observational study, no control group.

CONCLUSIONS

Duodenal stent placement resulted in prompt relief of malignant gastric outlet obstruction and improved GOOSS scores. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00991614.).

Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases

BACKGROUND

Gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. There is a paucity of published data on this subject in our setting. This study was undertaken to highlight the etiological spectrum and treatment outcome of gastric outlet obstruction in our setting and to identify prognostic factors for morbidity and mortality.

METHODS

This was a descriptive prospective study which was conducted at Bugando Medical Centre between March 2009 and February 2013. All patients with a clinical diagnosis of gastric outlet obstruction were, after informed consent for the study, consecutively enrolled into the study. Statistical data analysis was done using SPSS computer software version 17.0.

RESULTS

A total of 184 patients were studied. More than two-third of patients were males. Patients with malignant gastric outlet obstruction were older than those of benign type. This difference was statistically significant (p < 0.001). Gastric cancer was the commonest malignant cause of gastric outlet obstruction where as peptic ulcer disease was the commonest benign cause. In children, the commonest cause of gastric outlet obstruction was congenital pyloric stenosis (13.0%). Non-bilious vomiting (100%) and weight loss (93.5%) were the most frequent symptoms. Eighteen (9.8%) patients were HIV positive with the median CD 4+ count of 282 cells/μl. A total of 168 (91.3%) patients underwent surgery. Of these, gastro-jejunostomy (61.9%) was the most common surgical procedure performed. The complication rate was 32.1 % mainly surgical site infections (38.2%). The median hospital stay and mortality rate were 14 days and 18.5% respectively. The presence of postoperative complication was the main predictor of hospital stay (p = 0.002), whereas the age > 60 years, co-existing medical illness, malignant cause, HIV positivity, low CD 4 count (<200 cells/μl), high ASA class and presence of surgical site infection significantly predicted mortality ( p< 0.001). The follow up of patients was generally poor as more than 60% of patients were lost to follow up.

CONCLUSION

Gastric outlet obstruction in our setting is more prevalent in males and the cause is mostly malignant. The majority of patients present late with poor general condition. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with gastric outlet obstruction are to be avoided.

Gastric outlet obstruction in gastric cancer: a comparison of three palliative methods

BACKGROUND

Gastric outlet obstruction (GOO) commonly occurs in advanced gastric cancer. Our aim was to evaluate the results of endoscopic stenting (ES), palliative resection (PR), and gastrojejunostomy (GJ) as palliation of GOO.

METHODS

A total of 97 patients (50 ES, 26 PR, 21 GJ) were included in this retrospective study. All the patients had primary gastric cancer and symptoms of GOO.

RESULTS

Compared to surgery, ES resulted in a faster improvement on oral intake and symptom relief (P < 0.001) and a shorter hospitalization (P < 0.001). Complication rates, hospital re-admissions, occurrence of biliary obstruction, and the number of patients receiving chemotherapy were similar. The median symptom-free and overall survival were longest in the PR group (P < 0.001). In multivariate survival analysis, independent prognostic factors were age, BMI, pre-procedure GOOSS, palliative resection as treatment modality, and chemotherapy.

CONCLUSIONS

In gastric cancer and GOO, the clinical condition of the patient before treatment affects survival and should be taken into account in determining the treatment. PR seems to provide a survival benefit and should be considered as treatment option for patients suitable for surgery. For patients unfit for surgery, ES provides rapid and efficient palliation. Chemotherapy also seems to improve survival in gastric cancer and GOO.

Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery

BACKGROUND

In patients with gastric outlet obstruction (GOO) caused by gastric cancer, choosing between self-expandable metal stent (SEMS) placement and gastrojejunostomy (GJJ) is of concern, especially in those with good performance status.

OBJECTIVE

To compare SEMS placement and GJJ.

DESIGN

Retrospective study.

SETTING

Single tertiary referral center.

PATIENTS

Patients with an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 who had GOO caused by unresectable gastric cancer.

INTERVENTIONS

SEMS placement and GJJ.

MAIN OUTCOME MEASUREMENTS

Success rate, adverse events, patency, and survival duration.

RESULTS

Of the 113 patients in this study, 72 underwent SEMS placement and 41 underwent GJJ. The 2 groups did not differ in the technical and clinical success and incidence of early adverse events. However, the rate of late adverse events was significantly higher in the SEMS group (44.4% vs 12.2%; P < .001). The median patency duration was shorter after SEMS placement than after GJJ (125 days vs 282 days; P = .001), even after additional SEMS placement (210 days vs 282 days; P = .044). The median survival was also significantly shorter after SEMS placement than after GJJ (189 days vs 293 days; P = .003). Survival differed between treatments in patients with ECOG 0-1 (P = .006) but not in those with an ECOG performance status of 2 (P = .208).

LIMITATIONS

Retrospective and single-center study.

CONCLUSIONS

GJJ is preferable to SEMS placement for the palliation of GOO caused by unresectable or metastatic gastric cancer in patients with a good performance status, especially ECOG 0-1.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model.

METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope.

RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to six stitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction.

CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.

Effects of the temporary placement of a self-expandable metallic stent in benign pyloric stenosis

BACKGROUND/AIMS

The use of self-expandable metallic stents (SEMS) is an established palliative treatment for malignant stenosis in the gastrointestinal tract; therefore, its application to benign stenosis is expected to be beneficial because of the more gradual and sustained dilatation in the stenotic portion. We aimed in this prospective observational study to evaluate the efficacy and safety of temporary SEMS placement in benign pyloric stenosis.

METHODS

Twenty-two patients with benign stenosis of the prepylorus, pylorus, and duodenal bulb were enrolled and underwent SEMS placement. We assessed symptom improvement, defined as an increase of at least 1 degree in the gastric-outlet-obstruction scoring system after stent insertion.

RESULTS

No major complications were observed during the procedures. After stent placement, early symptom improvement was achieved in 18 of 22 patients (81.8%). During the follow-up period (mean 10.2 months), the stents remained in place successfully for 6 to 8 weeks in seven patients (31.8%). Among the 15 patients (62.5%) with stent migration, seven (46.6%) showed continued symptomatic improvement without recurrence of obstructive symptoms.

CONCLUSIONS

Despite the symptomatic improvement, temporary SEMS placement is premature as an effective therapeutic tool for benign pyloric stenosis unless a novel stent is developed to prevent migration.

Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group

BACKGROUND

The authors report the final results of a prospective single-center randomized study whose aim was to compare the endoscopic placement of self-expandable stents with open surgical gastroenterostomy to relieve gastric outlet obstruction (GOO) in patients with advanced antropyloric adenocarcinoma. A systematic review of the medical literature from December 1999 to December 2011 was carried out to determine the results of endoscopic stenting in patients with GOO from unresectable primary cancer of the antropyloric region.

METHODS

In the prospective study, 18 patients with advanced adenocarcinoma of the antropyloric region and symptoms of GOO were enrolled. In 9 patients, self-expandable stents were placed, and in 9 patients, open surgical gastroenterostomy was performed. Patients were followed until death. Six hundred seventy-two patients with primary unresectable cancer of the antropyloric region and GOO syndrome who underwent endoscopic stenting were identified from the literature.

RESULTS

In the prospective study of 18 patients, there was no case of postprocedural mortality. Efficient gastric emptying resumed more quickly in patients who received stents, although 3 months after the procedures, there was no difference between the 2 groups. Mean crude survival was 258 days in patients who received stents and 283 days in those who underwent surgical gastroenterostomy (P = NS). In patients who underwent stent placement, there were 2 cases of stent migration and 2 cases of food impaction, which were resolved with endoscopy at a mean follow-up of 70 days. In the 672 patients from the literature, operative mortality and morbidity were very low. In prospective studies, complications related to stents were more common than previously thought.

CONCLUSIONS

Endoscopic placement of metallic stents offers an effective therapy in patients with advanced primary adenocarcinoma of the antropyloric region and poor general condition. In patients with longer life expectancies, the form of therapy should be chosen individually, considering that surgical gastroenterostomy has fewer complications in the medium term and that in patients with endoscopic stenting, very careful follow-up is required, with the possibility of new operative endoscopy in half of the patients.

Comparison of uncovered and covered stents for the treatment of malignant duodenal obstruction caused by pancreaticobiliary cancer

BACKGROUND

Few clinical studies to date have compared different types of self-expandable metallic stents (SEMS) and their outcomes in patients with pure duodenal obstruction caused by pancreaticobiliary cancer. The aim of this study was to compare the clinical effectiveness and side effects of uncovered and covered SEMS for the palliation of duodenal obstruction caused by pancreaticobiliary cancer.

METHODS

We retrospectively analyzed all patients with pancreaticobiliary cancer who underwent upper endoscopy with SEMS placement for malignant duodenal obstruction at the National Cancer Center of Korea between April 2003 and December 2010. The technical and clinical success rates of the procedure, complications, and durations of stent patency and overall survival were evaluated.

RESULTS

We identified 70 patients with a mean age of 51.2 years (range = 39-81 years); of these, 46 (65.7 %) had pancreatic cancer, 9 (12.9 %) had bile duct cancer, 11 (15.7 %) had gallbladder cancer, and 4 (5.7 %) had cancer of the ampulla of Vater. Twenty-four patients (34.3 %) received covered SEMSs and 46 (65.7 %) received uncovered SEMSs. Technical and clinical success rates were similar for the covered and uncovered stent groups. The complication rate was higher in the covered than in the uncovered group (62.5 vs. 34.8 %, P = 0.025), due primarily to a significantly higher stent migration rate (20.8 vs. 0 %, P = 0.004). Perforation as a late complication occurred in four patients, two in each group (8.3 vs. 4.3 %, P = 0.425). Stent patency tended to be shorter for covered than for uncovered duodenal stents (13.7 ± 8.6 weeks vs. not reached, P = 0.069).

CONCLUSIONS

The use of uncovered stents may be a preferred option for duodenal obstruction secondary to pancreaticobiliary malignancies, since they were effective in preventing stent migration and tended to have longer patency than covered stents. Careful attention should be paid to signs and symptoms of perforation during follow-up.

Partial stomach-partitioning gastrojejunostomy and the success of this procedure in terms of palliation

BACKGROUND

In the 1990s, partial stomach-partitioning gastrojejunostomy (PSPG) was introduced. Benefits of this method are that it preferentially shunts food away from the obstructed duodenum or pylorus, thus reducing reflex emesis.

METHODS

A retrospective review of patients undergoing PSPG for malignant obstruction from 1999 to 2011 was performed. Ability to tolerate oral intake in the postoperative period and at last follow-up was the criterion for a successful bypass.

RESULTS

Fifty-five patients with locally advanced or metastatic tumors underwent PSPG. The median follow-up period was 8 months. No patient developed signs of gastric outlet obstruction after PSPG. Seventy-five percent of patients had pancreatic or duodenal and 25% had nonpancreatic cancers. Nine patients developed postoperative complications. The perioperative mortality rate was zero. Median overall survival was 9 months. All patients were tolerating an enteral diet on the day of discharge, and as of the last follow-up, 95% were tolerating their enteral diets.

CONCLUSIONS

This and a previous study from the authors' institution show that PSPG is a good alternative for palliative bypass in the setting of malignant gastric outlet obstruction over classic gastrojejunostomy.