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

Palliative Surgery for Patients with Gastroesophageal Junction or Gastric Cancer: A Report on Clinical Observational Outcomes

BACKGROUND

Few studies have focused on palliative surgery in patients with advanced gastroesophageal junction (GEJ) or gastric cancer. We sought to evaluate clinical observational outcomes following palliative surgery in this population.

PATIENTS AND METHODS

Patients with GEJ or gastric cancer who underwent palliative surgery (1/2010-11/2022) were identified. The primary outcomes were symptom improvement, ability to tolerate an oral diet, discharge to home, 30 "good days" without hospitalization, and receipt of systemic treatment. Postoperative outcomes and survival were secondarily evaluated.

RESULTS

Among 93 patients, the median age was 59 (IQR 47-68) years, and the median Eastern Cooperative Oncology Group Performance Status (ECOG-PS) was 1 (range 0-3). The most frequent indication for palliative surgery was primary tumor obstruction [75 (81%) patients]. The most common procedures were feeding tube placement in 60 (65%) and intestinal bypass in 15 (16%) patients. A total of 75 (81%) patients experienced symptom improvement. Of these, 19 (25%) developed recurrent and 49 (65%) developed new symptoms. ECOG-PS was significantly associated with symptom-free time. Among those who underwent a bypass, resection, or ostomy creation for malignant obstruction, 16 (80%) tolerated an oral diet. Postoperatively, 87 (94%) were discharged home, 72 (77%) had 30 good days, and 64 (69%) received systemic treatment. Postoperative complications occurred in 35 (38%) patients, and 7 (8%) died within 30 days. The median survival time was 7.7 (95% CI 6.4-10.40) months.

CONCLUSIONS

Patients with incurable GEJ or gastric cancer can benefit from palliative surgery. Prognosis and performance status should inform goals-of-care discussions and patient selection for surgical palliation.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

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.

Endoscopic duodenal stenting is efficient, but has higher rate of reoperations than gastrojejunostomy in palliative treatment for gastric outlet obstruction

BACKGROUND

Surgical gastrojejunostomy has traditionally been the palliative treatment of choice for patients with advanced malignancies and gastric outlet obstruction syndrome. Recently, palliative endoscopic duodenal stenting has increased in popularity. We report outcomes after gastrojejunostomy and duodenal stenting when used for palliative indications.

METHODS

Consecutive patients undergoing palliative gastrojejunostomy or palliative endoscopic duodenal stenting in a Finnish tertiary referral center between January 2015 and December 2020 were included. The postoperative outcomes of these two palliative interventions were compared. The main outcome measures were mortality and morbidity, rate of reoperations, postoperative oral intake ability, and length of hospital stay.

RESULTS

A total of 88 patients, 46 (52%) patients underwent palliative gastrojejunostomy and 42 (48%) duodenal stenting. All patients had malignant disease, most typically hepatopancreatic cancer. Nineteen (44%) patients in duodenal stenting group and 4 (8.7%) patients in gastrojejunostomy group required subsequent interventions due to persisting or progressing symptoms (p < 0.001). Median delay until first oral intake was 2 days (1-24) after gastrojejunostomy and 0 days (0-3) after stenting (p < 0.001). Postoperative morbidity was 30% after gastrojejunostomy and 45% after stenting (p < 0.001). Median length of hospital stay was 7 days (1-27) after surgery and 5 days (0-20) after endoscopy (p < 0.001).

CONCLUSIONS

Patients undergoing endoscopic duodenal stenting are more able to initiate rapid oral intake and have shorter hospital stay. On the other hand, there are significantly more reoperations in stenting group. If the patient's life expectancy is short, we recommend stenting, but for patients whose life expectancy is longer, gastrojejunostomy could be a better procedure, for the reasons mentioned above.

Distal Gastrectomy for Symptomatic Stage IV Gastric Cancer Contributes to Prognosis with Acceptable Safety Compared to Gastrojejunostomy

Simple Summary

For symptomatic stage IV gastric cancer involving major symptoms such as bleeding or obstruction, palliative surgery may be considered an option to relieve symptoms. Palliative gastrectomy or gastrojejunostomy is selected depending on the resectability of the primary tumor and/or surgical risk. However, treatment policies differ depending on the institution as to whether gastrectomy or gastrojejunostomy should be performed for symptomatic stage IV gastric cancer. We considered that gastrectomy might contribute more to prognosis than gastrojejunostomy for gastric cancer located in the middle or lower-third region where total gastrectomy can be avoided. Here, we compare the prognosis of gastrectomy and gastrojejunostomy for symptomatic stage IV gastric cancer. We demonstrate that distal gastrectomy for symptomatic stage IV gastric cancer located in the middle or lower-third regions contributes to prognosis with acceptable safety when compared to gastrojejunostomy.

Abstract

Background: The prognostic prolongation effect of reduction surgery for asymptomatic stage IV gastric cancer (GC) is unfavorable; however, its prognostic effect for symptomatic stage IV GC remains unclear. We aimed to compare the prognosis of gastrectomy and gastrojejunostomy for symptomatic stage IV GC. Methods: This multicenter retrospective study analyzed record-based data of patients undergoing palliative surgery for symptomatic stage IV GC in the middle or lower-third regions between January 2015 and December 2019. Patients were divided into distal gastrectomy and gastrojejunostomy groups. We compared clinicopathological features and outcomes after propensity score matching (PSM). Results: Among the 126 patients studied, 46 and 80 underwent distal gastrectomy and gastrojejunostomy, respectively. There was no difference in postoperative complications between the groups. Regarding prognostic factors, surgical procedures and postoperative chemotherapy were significantly different in multivariate analysis. Each group was further subdivided into groups with and without postoperative chemotherapy. After PSM, the data of 21 well-matched patients with postoperative chemotherapy and 8 without postoperative chemotherapy were evaluated. Overall survival was significantly longer in the distal gastrectomy group (p = 0.007 [group with postoperative chemotherapy], p = 0.02 [group without postoperative chemotherapy]). Conclusions: Distal gastrectomy for symptomatic stage IV GC contributes to prognosis with acceptable safety compared to gastrojejunostomy.

Palliative Gastrectomy vs. Gastrojejunostomy for Advanced Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Advanced gastric cancer is the fifth leading cause of cancer-related deaths. Patients with metastatic advanced gastric cancer commonly develop a gastric outlet obstruction that considerably worsens their quality of life. Surgical interventions such as gastrojejunostomy and palliative gastrectomy are commonly administered to alleviate this obstruction. However, whether one intervention is better than another at improving morbidity- and mortality-related outcomes is unclear. Thus, in this meta-analysis, we compare outcomes of palliative gastrectomy and gastrojejunostomy (overall hospital stay length, time to oral intake, survival, and complication rates) in patients with metastatic advanced gastric cancer to identify the best procedure.

Objective: To compare morbidity and mortality outcomes of palliative gastrectomy and gastrojejunostomy in patients with metastatic advanced gastric cancer.

Methods: We followed the PRISMA guidelines to systematically search Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE for relevant studies. We conducted a random-effects meta-analysis to find differential outcomes between palliative gastrectomy and gastrojejunostomy among variables such as time to oral intake, overall hospital stay length, complication rates, and survival in patients with metastatic advanced gastric cancer.

Results: From 963 studies, we found 7 eligible studies with 642 patients (70.3 ± 4.7 years) who had undergone palliative gastrectomy or gastrojejunostomy. Our meta-analysis revealed an insignificant (p > 0.05) differences in terms of overall survival duration (Hedge's g, 1.22), complication risks (odds ratio, 1.35), and time to oral intake (g, 0.62) and hospital stay length (g, 0.12) between patients undergoing gastrojejunostomy and palliative gastrectomy.

Conclusion: In this present study we observed no statistically significant differences in terms of morbidity and mortality outcomes after palliative gastrectomy and gastrojejunostomy in patients with metastatic advanced gastric cancer. Therefore, no conclusions can be drawn for the variables evaluated. This study provides a preliminary overview of the risks associated with gastrojejunostomy and palliative gastrectomy to help gastroenterologists manage patients with metastatic advanced-stage gastric cancer.

Palliative Gastrectomy versus Gastrojejunostomy for advanced Gastric cancer with outlet obstruction: a propensity score matching analysis

Background

Gastric outlet obstruction (GOO) is a late complication of advanced gastric cancer, and it is controversial how to select the therapeutic strategies: gastrojejunostomy and palliative gastrectomy? Therefore, this study was to compare the surgical and survival outcomes of gastrojejunostomy and palliative gastrectomy.

Methods

In total, 199 gastric cancer patients with outlet obstruction treated by surgery between January 2000 and December 2015 at Sun Yat-sen University Cancer Center were retrospectively reviewed. Patients were divided into gastrojejunostomy group and palliative gastrectomy group. Propensity score matching (PSM) was performed to balance the selection bias.

Results

After 1:1 PSM, a total of 104 patients were included for final analysis. The median overall survival (OS) times in the gastrojejunostomy group and palliative gastrectomy group were 8.50 and 11.87 months, respectively (P = 0.243). The postoperative complication rates in the gastrojejunostomy group and palliative gastrectomy group were 19.23% (10/52) and 17.31% (9/52), respectively (P = 0.800), and no treatment-related death was observed. Multivariate analysis showed that periton0eal seeding (P = 0.014) and chemotherapy (P < 0.001) were independent prognostic factors. Among them, peritoneal seeding was a risk factor and postoperative chemotherapy was a protective factor.

Conclusions

Our results indicated that although the surgical complications of palliative gastrectomy were manageable, it showed no survival benefit. Therefore, relieving obstruction symptom, improving patients’ quality of life and creating better conditions for chemotherapy appear to be the main therapeutic strategies for advanced gastric cancer with GOO.

Effect of preoperative nutrition therapy type and duration on short-time outcomes in gastric cancer patient with gastric outlet obstruction

Objective

To avoid perioperative complications caused malnutrition, nutrition therapy is necessary in gastric outlet obstruction (GOO) patients. Compared to parenteral nutrition (PN), enteral nutrition (EN) is associated with many advantages. This study aimed to investigate whether preoperative EN has beneficial clinical effects compared to preoperative PN in gastric cancer patients with GOO undergoing surgery.

Methods

According to the methods of preoperative nutrition therapy, 143 patients were divided into EN group (n=42) and PN group (n=101) between January 2013 and December 2017 at the Chinese People’s Liberation Army General Hospital. Multiple logistic regression models were used to assess the association between the methods of preoperative nutrition therapy and postoperative day of flatus passage. The generalized additive model and two-piecewise linear regression model were used to calculate the inflection point of the preoperative nutritional therapy time on the postoperative day of flatus passage in the PN group.

Results

EN shortened the postoperative day of flatus passage in gastric cancer patients with GOO, which is a protective factor, especially in patients who underwent non-radical operations and the postoperative day of flatus passage reduced when the preoperative PN therapy was up to 3 d and a longer PN therapy (>3 d) did not accelerate the postoperative recovery of gastrointestinal functions.

Conclusions

Preoperative EN therapy would benefit gastric cancer patients with GOO by accelerating postoperative recovery. For patients with absolute obstruction, no more than 3-day PN therapy is recommended if patients can tolerate general anesthesia and surgery.

Surgical Outcomes and Survival Prognostic Factors for Palliative Gastrectomies in Stage IV Resectable Gastric Cancer Outlet Obstruction Patients

Purpose

Currently, there is no clear evidence to support any specific treatment as a principal therapy for stage IV gastric cancer outlet obstruction (GCOO) patients. This study evaluated the outcomes of palliative gastrectomies and survival prognostic factors in patients with stage IV resectable GCOO.

Materials and Methods

We retrospectively reviewed the medical records of 48 stage IV GCOO patients who underwent palliative gastrectomies between June 2010 and December 2019. Palliative gastrectomies were performed only in patients with resectable disease. Early surgical outcomes and prognostic factors were analyzed using univariate and multivariate analyses.

Results

There were no specific risk factors for postoperative complications, except for being underweight. Severe postoperative complications developed in five patients, and most of the patients underwent interventional procedures and received broad-spectrum antibiotics for intra-abdominal abscesses. The multivariate survival analysis showed that palliative chemotherapy is a positive prognostic factor, while the specific type of hematogenous and lymphatic metastasis is a negative prognostic factor.

Conclusions

We recommend that the treatment method for stage IV GCOO should be selected according to each patient's physical condition and tumor characteristics. In addition, we suggest that palliative gastrectomies can be performed in stage IV resectable GCOO patients without unfavorable prognostic factors (types of hematogenous and lymphatic metastases).

Peri-operative Outcomes and Survival Following Palliative Gastrectomy for Gastric Cancer: a Systematic Review and Meta-analysis

BACKGROUND

Many patients with gastric cancer present with late stage disease. Palliative gastrectomy remains a contentious intervention aiming to debulk tumour and prevent or treat complications such as gastric outlet obstruction, perforation and bleeding.

METHODS

We conducted a systematic review of the literature for all papers describing palliative resections for gastric cancer and reporting peri-operative or survival outcomes. Data from peri-operative and survival outcomes were meta-analysed using random effects modelling. Survival data from patients undergoing palliative resections, non-resective surgery and palliative chemotherapy were also combined. This study was registered with the PROSPERO database (CRD42019159136).

RESULTS

One hundred and twenty-eight papers which included 58,675 patients contributed data. At 1 year, there was a significantly improved survival in patients who underwent palliative gastrectomy when compared to non-resectional surgery and no treatment. At 2 years following treatment, palliative gastrectomy was associated with significantly improved survival compared to chemotherapy only; however, there was no significant improvement in survival compared to patients who underwent non-resectional surgery after 1 year. Palliative resections were associated with higher rates of overall complications versus non-resectional surgery (OR 2.14; 95% CI, 1.34, 3.46; p < 0.001). However, palliative resections were associated with similar peri-operative mortality rates to non-resectional surgery.

CONCLUSION

Palliative gastrectomy is associated with a small improvement in survival at 1 year when compared to non-resectional surgery and chemotherapy. However, at 2 and 3 years following treatment, survival benefits are less clear. Any survival benefits come at the expense of increased major and overall complications.

Clinicopathological Characteristics and Incidence of Gastric Cancer in Eastern India: A Retrospective Study

PURPOSE

To study the association of gastric cancer with various clinicopathological traits in eastern India which can be used as an important factor for further analysis, understanding of the diseases and amelioration of patients.

METHODS

The retrospective study includes the patients who underwent subtotal or total gastrectomy from surgical oncology department of Chittaranjan National Cancer Institute (hospital) of West Bengal, India between 2014 and 2018. The study includes 751 gastric cancer patients from Chittaranjan National Cancer Institute. We used electronic hospital records to collect data on various clinical parameters and other information. We used Microsoft Office Excel 2007 spreadsheets for the statistical analyses.

RESULTS

Incidence of gastric cancer is associated with mid age (40-59 years) group male patients and lymph node metastasis. Frequency of gastric cancer is highest in the antrum (42.21%). Of the mid age group gastric cancer patients, 35.02% were having much high risk of developing diffused type of adenocarcinoma (P < 0.00001). Tobacco intake in form of smoking was found as an important risk factor in gastric cancer development with risk ratio and odds ratio of 1.18 and 3.14 respectively.

CONCLUSION

Collectively, the results of the present study confirm that incidence of diffused type of gastric cancer is increasing as an alarming rate in mid age group male patients and tobacco intake in the form of smoking as an independent risk factor for this type of cancer in eastern India. This result can be used to manage gastric carcinoma in future prospective clinical studies and in patient's improvement.

The Predictive and Prognostic Factors in Patients with Gastric Cancer Accompanied by Gastric Outlet Obstruction

Purpose

This study is aimed at evaluating the clinicopathological features and prognostic significance of gastric outlet obstruction (GOO) in patients with distal gastric cancer.

Methods

A retrospective review of 1564 individuals with distal gastric cancer from 2002 to 2010 was performed. In total, 157 patients had GOO. The clinicopathological features of the patients with GOO were compared with those of the patients without GOO. A Kaplan-Meier survival analysis and Cox proportional hazard model were used to assess the overall survival.

Results

The patients with distal gastric cancer with GOO generally presented more aggressive pathologic features, a poorer nutritional status, more duodenal infiltration, and peritoneal dissemination than those with cancer without GOO. In the univariate analysis, curability, GOO, age, prealbumin, albumin, hemoglobin (Hb), the tumor size, the macroscopic type, lymph node metastasis, and the depth of invasion had a statistically significant influence on prognosis. The multivariate analysis showed that curability, GOO, the tumor size, lymph node metastasis, and the depth of invasion were independent prognostic factors.

Conclusions

Gastric cancer with GOO exhibits aggressive biological features and has poor outcomes. The multivariate analysis showed that curability, GOO, the tumor size, lymph node metastasis, and the depth of invasion were independent prognostic factors. The gastric outlet status should be considered in the selection of surgical treatment methods for patients with gastric cancer.

Local Heat Treatment for Suppressing Gastroduodenal Stent-Induced Tissue Hyperplasia Using Nanofunctionalized Self-Expandable Metallic Stent in Rat Gastric Outlet Model

Despite the promising results from the placement of covered or uncovered self-expandable metallic stent (SEMS) as a nonsurgical therapeutic option for the malignant gastric outlet obstruction (GOO), the long patency of the stent is still limited because of stent-induced tissue hyperplasia. Here, a local heat treatment using a nanofunctionalized SEMS is proposed for suppressing stent-induced tissue hyperplasia during GOO treatment. Highly efficient photothermal gold nanoparticle (GNP) transducer-coated SEMSs (GNP-SEMSs) were prepared for local heat treatment in rat gastric outlet. The in vivo heating temperature in rat gastric outlet model was evaluated and compared with in vitro heating temperature. Three groups of our developed 45 rat gastric outlet models were used: group A, noncoated SEMS only; group B, GNP-SEMS plus local heating; and group C, GNP-SEMS only to investigate in vivo efficacy of GNP-SEMS mediated local heating. Ten rats per group were sacrificed for 4 weeks, and five rats per group were sacrificed immediately after local heat treatment. The in vivo heating temperature was found to be 10.8% lower than the in vitro heating temperatures. GNP-SEMSs were successfully placed through a percutaneous approach into the rat gastric outlet (n = 45). The therapeutic effects of GNP-SEMS were assessed by histologic examination including hematoxylin-eosin, Masson trichrome, immunohistochemistry (TUNEL and CD31), and immunofluorescence (Ki67), and the results showed significant prevention of tissue hyperplasia following stent placement without adjacent gastrointestinal tissue damage. GNP-SEMS-mediated local heating could be an alternative therapeutic option for the suppression of tissue hyperplasia following stent placement in benign and malignant GOOs.

Influence of peritoneal carcinomatosis on perioperative outcome in palliative gastric bypass for malignant gastric outlet obstruction - a retrospective cohort study

Background

Malignant gastric outlet obstruction (GOO) is commonly associated with the presence of peritoneal carcinomatosis (PC) and preferably treated by surgical gastrojejunostomy (GJJ) in patients with good performance. Here, we aim to investigate the role of PC as a risk factor for perioperative morbidity and mortality in patients with GOO undergoing GJJ.

Methods

Perioperative data of 72 patients with malignant GOO who underwent palliative GJJ at our institution between 2010 and 2019 were collected within an institutional database.

To compare perioperative outcomes of patients with and without PC, extensive group analyses were carried out.

Results

A set of 39 (54.2%) patients was histologically diagnosed with concomitant PC while the remaining 33 (45.8%) patients showed no clinical signs of PC. In-house mortality due to surgical complications was significantly higher in patients with PC (9/39, 23.1%) than in patients without PC (2/33, 6.1%, p = .046). Considerable differences were observed in terms of surgical complications such as anastomotic leakage rates (2.8% vs. 0%, p = .187), delayed gastric emptying (33.3% vs. 15.2%, p = .076), paralytic ileus (23.1% vs. 9.1%, p = .113), and pneumonia (17.9% vs. 12.1%, p = .493) without reaching the level of statistical significance.

Conclusions

PC is an important predictor of perioperative morbidity and mortality patients undergoing GJJ for malignant GOO.

Surgical management of metastatic gastric cancer: moving beyond the guidelines

Despite decreasing incidence, gastric cancer remains a major health problem worldwide and is associated with poor survival. The poor survival is mainly attributed to delayed presentation which may cause local or systemic metastases. The standard of care for patients with metastatic gastric cancer (MGC) is palliative chemotherapy with best supportive care. Although the survival has improved owing to advances in chemotherapeutic agents, it is still unsatisfactory, and some perspective changes are needed in the management of MGC to improve the outcomes. Therefore, various alternative treatment strategies for MGC have formed the most important research topics. Liver-directed treatment (LDT) options such as liver resection, radiofrequency ablation (RFA), microwave ablation (MWA), and hepatic artery infusion chemotherapy (HAIC) have been studied in the management of liver metastasis from gastric cancer (LMGC). Intraperitoneal chemotherapy (IPC) in addition to cytoreductive surgery (CRS) aiming to remove all macroscopic tumor focus resulting from peritoneal dissemination is the treatment option for peritoneal metastasis, while para-aortic lymph node dissection is the treatment option for para-aortic lymph node metastasis which is considered to be M1 disease. Conversion surgery is a novel concept aiming at R0 resection for originally unresectable or marginally resectable tumors after a remarkably good response to the chemotherapy. Large amounts of data in the literature have demonstrated the benefits of individualized approaches such as the combination of systemic and local treatment options in selected patient groups. In this review, we aimed to explore the current and future treatment options by reviewing the literature on this controversial topic.

Big End Double-Layer Stents for the Treatment of Gastric Outlet Obstruction Caused by Stomach Cancer

Objectives

This study is aimed at evaluating the efficacy and safety of the big end double-layer uncovered self-expanding metal stents (SEMS) for the treatment of gastric outlet obstruction (GOO) caused by distal stomach cancer.

Methods

Seventy three patients receiving big end double-layer uncovered SEMS for the treatment of GOO caused by distal gastric cancer will be included in this multicenter prospective clinical trial. The main outcome measures included the functional outcome, the complications, the reinterventional rates, the average treatment charges, and the mean survival time. Monthly telephone calls were needed to assess the food intake until the patients died.

Results

The technical and the clinical success rates were 98.6%. The stent obstruction caused by tumor ingrowth was observed in one patient (1.4%). The incidence of food impaction was 2.9% (2/70) and the reinterventional rate was 4.3% (3/70). However, stent migration and obstruction caused by overgrowth were not observed. No perforation and severe bleeding were observed. The median cost of endoscopic stenting and total hospitalization (including reinterventions) for the big end double-layer uncovered SEMS in this study was $2945 and $3408, respectively. The mean survival time was 212.5 days.

Conclusions

The placement of big end double-layer uncovered SEMS is a safe and effective modality and has the potential to be one of the options for the treatment of GOO caused by the distal gastric cancer.

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.

The Effects of Pre-Operative Enteral Nutrition from Nasal Feeding Tubes on Gastric Outlet Obstruction

We examined gastric outlet obstruction (GOO) patients who received two weeks of strengthening pre-operative enteral nutrition therapy (pre-EN) through a nasal–jejenal feeding tube placed under a gastroscope to evaluate the feasibility and potential benefit of pre-EN compared to parenteral nutrition (PN). In this study, 68 patients confirmed to have GOO with upper-gastrointestinal contrast and who accepted the operation were randomized into an EN group and a PN group. The differences in nutritional status, immune function, post-operative complications, weight of patients, first bowel sound and first flatus time, pull tube time, length of hospital stay (LOH), and cost of hospitalization between pre-operation and post-operation were all recorded. Statistical analyses were performed using the chi square test and t-test; statistical significance was defined as p < 0.05. The success rate of the placement was 91.18% (three out of 31 cases). After pre-EN, the levels of weight, albumin (ALB), prealbumin (PA), and transferrin (TNF) in the EN group were significantly increased by pre-operation day compared to admission day, but were not significantly increased in the PN group; the weights in the EN group were significantly increased compared to the PN group by pre-operation day and day of discharge; total protein (TP), ALB, PA, and TNF of the EN group were significantly increased compared to the PN group on pre-operation and post-operative days one and three. The levels of CD3+, CD4+/CD8+, IgA, and IgM in the EN group were higher than those of the PN group at pre-operation and post-operation; the EN group had a significantly lower incidence of poor wound healing, peritoneal cavity infection, pneumonia, and a shorter first bowel sound time, first flatus time, and post-operation hospital stay than the PN group. Pre-EN through a nasal–jejunum feeding tube and placed under a gastroscope in GOO patients was safe, feasible, and beneficial to the nutrition status, immune function, and gastrointestinal function, and sped up recovery, while not increasing the cost of hospitalization.

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.

Surgical and Survival Outcome Following Truly Palliative Gastrectomy in Patients with Incurable Gastric Cancer

BACKGROUND AND OBJECTIVES

Gastrectomy is sometimes performed even in patients with incurable factors, particularly when they have urgent symptoms. The aim of this study was to clarify the clinicopathological characteristics of patients undergoing palliative gastrectomy and to identify prognostic factors.

METHODS

This study included consecutive 137 gastric cancer patients with urgent symptoms who underwent gastrectomy with macroscopic residual tumor at Shizuoka Cancer Center. Clinicopathological characteristics and surgical outcomes were investigated. In addition, we used the Cox proportional hazards model to identify independent prognostic factors.

RESULTS

Of 137 patients, urgent symptoms were bleeding in 58 patients and stenosis in 112 patients. Postoperative complications were observed in 58 patients (42 %). Chemotherapy was given after surgery in 94 patients (70 %). Median survival time for all patients was 9.9 months, and was longer in patients receiving chemotherapy (11.1 months) than in those not receiving chemotherapy (6.8 months; p = 0.002). Multivariate analysis identified macroscopic type (hazard ratio, 0.471; 95 % confidence interval, 0.364-0.927) as an independent prognostic factor.

CONCLUSIONS

The postoperative complication rate was high and survival outcome was poor in patients undergoing palliative gastrectomy. Postoperative chemotherapy may carry a better survival outcome, so we should try to give chemotherapy after palliative gastrectomy.

Surgical palliation of gastric outlet obstruction in advanced malignancy

Gastric outlet obstruction (GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract. Palliative treatment of patients’ symptoms who present with GOO is an important aspect of their care. Surgical palliation of malignancy is defined as a procedure performed with the intention of relieving symptoms caused by an advanced malignancy or improving quality of life. Palliative treatment for GOO includes operative (open and laparoscopic gastrojejunostomy) and non-operative (endoscopic stenting) options. The performance status and medical condition of the patient, the extent of the cancer, the patients prognosis, the availability of a curative procedure, the natural history of symptoms of the disease (primary and secondary), the durability of the procedure, and the quality of life and life expectancy of the patient should always be considered when choosing treatment for any patient with advanced malignancy. Gastrojejunostomy appears to be associated with better long term symptom relief while stenting appears to be associated with lower immediate procedure related morbidity.

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.

Gastroduodenal stent placement versus surgical gastrojejunostomy for the palliation of gastric outlet obstructions in patients with unresectable gastric cancer: a propensity score-matched analysis

OBJECTIVES

To compare the outcomes between stent placement and surgical gastrojejunostomy (GJ) for the palliation of gastric outlet obstruction (GOO) in patients with unresectable gastric cancer.

METHODS

A retrospective study was performed in a single university hospital in 224 patients with GOO, and who were treated either by stent placement (n = 124) or surgical GJ (n = 100). The outcomes were assessed with reference to the following variables with the use of propensity-score matching: success rates; complications; dysphagia scores, albumin, and body mass index; survival; symptom-free duration; and hospitalization.

RESULTS

We identified a well-balanced cohort of 74 pairs of patients, matched on the basis of propensity score. The dysphagia score 7 days after treatment was significantly better in the stent group (P < 0.001). Albumin level 1 month after treatment was significantly lower in the stent group (P < 0.001). Symptom-free duration and hospitalization were significantly longer in the surgery group (P = 0.002, P < 0.001, respectively). The recurrence rate was significantly higher in the stent group (P = 0.032).

CONCLUSIONS

Stent placement can provide faster symptom relief and shorter hospitalization, while surgical GJ can provide longer symptom-free duration, less recurrent obstruction symptoms and better nutritional status.

KEY POINTS

• The two methods are equally effective in palliating gastric outlet obstruction symptoms • The stent group showed rapid and efficient palliation of symptoms • Recurrent symptoms were more frequent in the stent group • Surgical gastrojejunostomy provides a longer symptom-free duration and better nutritional status.

Prevalence of Malnutrition Among Gastric Cancer Patients Undergoing Gastrectomy and Optimal Preoperative Nutritional Support for Preventing Surgical Site Infections

BACKGROUND

Malnutrition is an independent risk factor for postoperative mortality and morbidity in major gastrointestinal surgery. The aim of this study was to investigate the prevalence of malnutrition and identify the optimal preoperative nutritional support for preventing postoperative surgical site infections (SSIs) in malnourished gastric cancer patients undergoing gastrectomy.

METHODS

We analyzed 800 patients with gastric cancer who underwent gastrectomy. Nutritional risk factors included weight loss >10 % within 6 months, body mass index <18.5 kg/m(2), Subjective Global Assessment Grade C, and serum albumin <3.0 g/dl. Adequate energy intake was defined as receiving ≥25 kcal/kg ideal body weight per day. Optimal nutritional support was examined in terms of both duration and calorie intake.

RESULTS

Overall, 152 patients (19.0 %) were classified as malnourished. The incidence of SSIs was significantly higher in malnourished patients than in well-nourished patients (35.5 vs. 14.0 %; p < 0.0001). The incidence of SSIs in malnourished patients was significantly lower in the well-supported group receiving adequate energy support for at least 10 days than in the poorly-supported group, which received inadequate or no energy support or adequate energy support for <10 days (17.0 vs. 45.4 %; p = 0.0006). In multivariate analysis, well-managed nutritional support was identified as an independent factor associated with fewer SSIs (odds ratio 0.14; 95 % confidence interval 0.05-0.37; p = 0.0002).

CONCLUSIONS

Malnutrition, a risk factor for SSI, was prevalent in gastric cancer patients preoperatively. Well-managed preoperative nutritional support decreased the incidence of postoperative SSIs in malnourished patients.

Role of Surgery in the Management for Gastric Cancer with Synchronous Distant Metastases

Optimal treatment of patients with gastric cancer with synchronous distant metastases is palliative chemotherapy. However, occasionally gastrectomy should be selected due to control bleeding from tumors, perforation, or obstruction. The aim of this study is to evaluate the survival benefits of non-curative gastrectomy for patients with synchronous distant metastasis. Total 78 gastric cancer patients with synchronous distant metastasis treated in our hospital between 2003 and 2012 were enrolled in this study. Of these, 74 patients (95 %) received S1 based chemotherapy. During the treatment, 37 patients (47.4 %) underwent palliative gastrectomy because of bleeding from tumors (n = 15), tumor perforation (n = 6), and obstruction (n = 16). Survival benefits were compared in resected and non-resected patients, retrospectively. The two groups were clinicopathologically similar. Palliative gastrectomy was performed safely (morbidity: 10.8 % and mortality: 0) in resection group. However, resection showed survival benefits only in 13 patients (16.7 %) with single metastasis and without peritoneal metastasis. Their 2-year survival rate was 40 % and their median survival was 19 months. Non-curative gastrectomy with precise surgical techniques followed careful postoperative nutrition management may improve survival only for patients with a single metastatic site, except for peritoneal dissemination.

Palliative distal gastrectomy offers no survival benefit over gastrojejunostomy for gastric cancer with outlet obstruction: retrospective analysis of an 11-year experience

Background

Either palliative distal gastrectomy or gastrojejunostomy are the initial treatment options for locally advanced gastric cancer with outlet obstruction when curative-intent resection is not feasible. Since chemotherapy is the mainstay for unresectable gastric cancer, the clinical value of palliative distal gastrectomy is controversial.

Methods

We retrospectively reviewed the clinical data of patients with gastric cancer with outlet obstruction treated at our institution between January 2002 and December 2012. We compared the clinical outcomes of palliative distal gastrectomy with those of gastrojejunostomy patients and the factors affecting overall survival were evaluated.

Results

Elective palliative distal gastrectomy and gastrojejunostomy were performed in 18 and 25 patients, respectively. The median overall survival times in the gastrojejunostomy and palliative distal gastrectomy groups were statistically equivalent at 8.8 and 8.3 months, respectively (P = 0.73), despite the more locally advanced tumors in the gastrojejunostomy as compared with the palliative distal gastrectomy group. A multivariate Cox regression analysis showed absence of postoperative chemotherapy and higher postoperative complication grade to be associated with worse clinical outcomes.

Conclusions

Palliative distal gastrectomy offers neither survival nor palliative benefit as compared to gastrojejunostomy. Minimizing the morbidity of intervention for outlet obstruction, followed by chemotherapy, appears to be the optimal initial strategy for incurable gastric cancer with outlet obstruction.