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

Laparoscopic Gastrojejunostomy Versus Endoscopic Stenting as a Palliative Treatment for Gastric Outlet Obstruction

Introduction: Gastric outlet obstruction (GOO) is a common complication in advanced stage upper gastrointestinal malignancies. The symptoms of severe nausea and protracted vomiting can lead to a decline in quality of life and cachexia. Symptoms of GOO can be effectively managed with either operative or nonoperative palliative interventions. In our article, we aim to compare laparoscopic gastrojejunostomy (GJ) to endoscopic stenting as palliative interventions for GOO. Methods: We retrospectively evaluated the charts of patients who underwent palliative procedure for gastric outlet obstruction. Group I included patients who underwent endoscopic stenting, and group II patients underwent Laparoscopic GJ. The groups' demographics (age, gender), length of procedure, length of stay, days to oral intake, overall survival, complications rate, and 30-day mortality rates were compared. Results: Overall, 38 patients were included in the study. Nineteen patients underwent endoscopic stenting and 19 underwent laparoscopic GJ. Comparing the groups, no significant differences were noted. Surgical time was significantly longer than the endoscopic procedures (83 minutes versus 25 minutes, P = .001). No significant differences were noted in days of oral intake initiation, overall survival and 30-day mortality rates. Five patients in the stenting group had complications (26.3%) versus none in the surgical group (P = .046). No postoperative complications were noted. Conclusion: Laparoscopic GJ is a safe and feasible treatment for GOO, demonstrating early resumption of oral intake. The relative short hospital stay, combined with an encouraging postoperative complications profile and low reintervention rate, should be kept in mind especially among patients with longer life expectancy.

Surgical versus endoscopic gastroenterostomy for gastric outlet obstruction: a retrospective multicentric comparative study of technical and clinical success

PURPOSE

Gastric outlet obstruction (GOO) is mainly due to advanced malignant disease. GOO can be treated by surgical gastroenterostomy (SGE), endoscopic enteral stenting (EES), or endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to improve the quality of life.

METHODS

Between 2009 and 2022, patients undergoing SGE or EUS-GE for GOO were included at three centers. Technical and clinical success rates, post-procedure adverse events (AEs), length of hospital stay (LOS), 30-day all-cause mortality, and recurrence of GOO were retrospectively analyzed and compared between SGE and EUS-GE. Predictive factors for technical and clinical failure after SGE and EUS-GE were identified.

RESULTS

Of the 97 patients included, 56 (57.7%) had an EUS-GE and 41 (42.3%) had an SGE for GOO, with 62 (63.9%) GOO due to malignancy and 35 (36.1%) to benign disease. The median follow-up time was 13,4 months (range 1 days-106 months), with no difference between the two groups (p = 0.962). Technical (p = 0.133) and clinical (p = 0.229) success rates, severe morbidity (p = 0.708), 30-day all-cause mortality (p = 0.277) and GOO recurrence (p = 1) were similar. EUS-GE had shorter median procedure duration (p < 0.001), lower post-procedure ileus rate (p < 0.001), and shorter median LOS (p < 0.001) than SGE. In univariate analysis, no risk factors for technical or clinical failure in SGE were identified and abdominal pain reported before the procedure was a risk factor for technical failure in the EUS-GE group. No risk factor for clinical failure was identified for EUS-GE. In the subgroup of GOO due to benign disease, SGE was associated with better technical success (p = 0.035) with no difference in clinical success rate compared to EUS-GE (p = 1).

CONCLUSION

EUS-GE provides similar long-lasting symptom relief as SGE for GOO whether for benign or malignant disease. SGE may still be indicated in centers with limited experience with EUS-GE or may be reserved for patients in whom endoscopic technique fails.

Efficacy and long-term prognosis of gastrojejunostomy for malignant gastric outlet obstruction: A systematic review and Bayesian network meta-analysis

BACKGROUND

Gastrojejunostomy (GJ) is becoming a standard surgical treatment for ameliorating malignant gastric outlet obstruction (MGOO). However, data on the long-term outcomes of MGOO treatment are lacking. This network meta-analysis aimed to compare overall survival (OS) rates and subsequent anticancer treatment outcomes of GJwith other therapies in MGOO.

METHODS

We searched four electronic databases, including PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, from inception to August 1, 2022. Studies reporting OS associated with GJ versus other treatments for MGOO were selected. The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The primary outcome assessed was OS, whereas the secondary outcome was subsequent anticancer treatment. We performed a Bayesian network meta-analysis to produce hazard ratios (HR) and odds ratios (OR) with 95% credible intervals (CrIs).

RESULTS

We identified 24 retrospective studies that included 2473 patients. The studies assessed the outcomes of six treatments to alleviate MGOO. Results showed that GJ (hazard ratio: 0.83, 95% CrI: 0.78-0.88) was the most effective treatment for patients with MGOO, with the greatest surface under the cumulative ranking curve (SUCRA) values (79.9%) versus non-resection, palliative chemotherapy (13.9%) in terms of OS. Similarly, GJ (SUCRA: 46.5%) improved subsequent anticancer treatment requirements, ranking second only to jejunostomy/gastrostomy (JT/GT) (SUCRA: 95.9%).

CONCLUSIONS

Our study demonstrates that GJ improves OS and follow-up treatments versus other non-resection treatments in patients with MGOO. These findings may serve for selecting appropriate therapy for MGOO.

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

A Meta-Analysis of Endoscopic Stenting Versus Surgical Treatment for Malignant Gastric Outlet Obstruction

BACKGROUND AND AIM

Surgical gastrojejunostomy (GJJ) and endoscopic stenting (ES) are the two most available treatments for palliation of malignant gastric obstruction (MGOO). The aim of this study is to compare these two techniques regarding efficacy, safety, time of hospitalization and survival.

METHODS

We performed a literature search from January 2010 to September 2020 to identify available randomized controlled studies and observational studies that compared ES and GJJ for the treatment of MGOO.

RESULTS

A total of 17 studies were found. ES and GJJ showed similar technical and clinical success rate. ES was superior to obtain early oral re-feeding, shorter length of hospitalization and a lower incidence of complications than GJJ. Surgical palliation had a lower recurrence rate of obstructive symptoms and longer overall survival than ES.

CONCLUSIONS

Both procedures have advantages and disadvantages. Probably we should not find the best palliation but the best approach based on the patient characteristics and tumor type.

Endoscopic ultrasound-guided gastroenterostomy for the management of gastric outlet obstruction: A large comparative study with long-term follow-up

Background and study aims  Gastric outlet obstruction (GOO) is traditionally managed with surgical gastroenterostomy (surgical-GE) and enteral stenting (ES). Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is now a third option. Large studies assessing their relative risks and benefits with adequate follow-up are lacking. We conducted a comparative analysis of patients who underwent EUS-GE, ES, or surgical-GE for GOO. Patients and methods  In this retrospective comparative cohort study, consecutive patients presenting with GOO who underwent EUS-GE, ES, or surgical-GE at two academic institutions were reviewed and independently cross-edited to ensure accurate reporting. The primary outcome was need for reintervention. Secondary outcomes were technical and clinical success, length of hospital stay (LOS), and adverse events (AEs). Results  A total of 436 patients (232 EUS-GE, 131 ES, 73 surgical-GE) were included. The median duration of follow-up of the entire cohort was 185.5 days (interquartile range 55.25-454.25 days). The rate of reintervention in the EUS-GE group was lower than in the ES and surgical-GE groups (0.9 %, 12.2 %, and 13.7 %, P  < 0.0001). Technical success was achieved in 98.3 %, 99.2 %, and 100 % ( P  = 0.58), and clinical success was achieved in 98.3 %, 91.6 %, and 90.4 % ( P  < 0.0001) in the EUS-GE, ES, and surgical-GE groups, respectively. The EUS-GE group had a shorter LOS (2 days vs. 3 days vs. 5 days, P  < 0.0001) and a lower AE rate than the ES and surgical-GE groups (8.6 % vs. 38.9 % vs. 27.4 %, P  < 0.0001). Conclusion  This large cohort study demonstrates the safety and palliation durability of EUS-GE as an alternative strategy for GOO palliation in select patients.

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.

How to successfully administer palliative treatment with a stent for malignant gastric outlet obstruction?

Although endoscopic stenting (ES) has been widely used as a less-invasive palliation method for malignant gastric outlet obstruction (GOO), recent reports have highlighted issues related to the procedure. For successful treatment, various aspects must be assessed before considering the practices. First, it is necessary to eliminate cases with contraindications such as coexistence of distal small-bowel obstruction or perforation. Other factors potentially related to clinical failure (i.e., peritoneal carcinomatosis) may require consideration but remain controversial. ES has better short-term outcomes than surgical gastrojejunostomy (GJ). GJ has recently been considered preferable in cases with longer life expectancy because of superior sustainability. Various types of stents are now commercially available, but their ideal structure and mechanical properties have not yet been clarified. Covered metal stent may reduce stent obstruction but is prone to increase stent migration, and its significance remains uncertain. Subsequent chemotherapy after stenting should be considered, as it is expected to prolong patient survival without increasing the risk of adverse events. Furthermore, it may be helpful in preventing tumor ingrowth. In cases with GOO combined with biliary obstruction, biliary intervention is often difficult. Recently, endoscopic ultrasound-guided biliary drainage (EUS-BD) has been widely used as an alternative procedure for endoscopic transpapillary biliary drainage (ETBD). Despite the lack of consensus as to whether ETBD or EUS-BD is preferred, EUS-BD is useful as a salvage technique for cases where ETBD is difficult. To perform stent placement successfully, it is important to pay attention to the above points; however, many remaining issues need to be clarified in the future.

Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis

Background and study aims  Malignant disease accounts for up to 80 % of gastric outlet obstruction (GOO) cases, which may be treated with duodenal self-expanding metal stents (SEMS), surgical gastrojejunostomy (GJ), and more recently endoscopic-ultrasound-guided gastroenterostomy (EUS-GE). These three treatments have not been compared head-to-head in a randomized trial. Methods  We searched the Embase and MEDLINE databases for studies published January 2015-February 2021 assessing treatment of malignant GOO using duodenal SEMS, endoscopic (EUS-GE) or surgical (laparoscopic or open) GJ. Efficacy outcomes assessed included technical and clinical success rates, GOO recurrence and reintervention. Safety outcomes included procedure-related bleeding or perforation, and stent-related events for the duodenal SEMS and EUS-GE arms. Results  EUS-GE had a lower rate of technical success (95.3%) than duodenal SEMS (99.4 %) or surgical GJ (99.9%) ( P  = 0.0048). For duodenal SEMS vs. EUS-GE vs. surgical GJ, rates of clinical success (88.9 % vs. 89.0 % vs. 92.3 % respectively, P  = 0.49) were similar. EUS-GE had a lower rate of GOO recurrence based on limited data ( P  = 0.0036), while duodenal SEMS had a higher rate of reintervention ( P  = 0.041). Overall procedural complications were similar (duodenal SEMS 18.7 % vs. EUS-GE 21.9 % vs. surgical GJ 23.8 %, P  = 0.32), but estimated bleeding rate was lowest ( P  = 0.0048) and stent occlusion rate was highest ( P  = 0.0002) for duodenal SEMS. Conclusions  Duodenal SEMS, EUS-GE, and surgical GJ showed similar clinical efficacy for the treatment of malignant GOO. Duodenal SEMS had a lower procedure-related bleeding rate but higher rate of reintervention.

EUS-guided biliary drainage with LAMS for distal malignant biliary obstruction when ERCP fails: single-center retrospective study and maldeployment management

BACKGROUND

EUS-guided biliary drainage (EUS-BD) with Lumen Apposing Metal Stent (LAMS) is a mini-invasive approach for jaundice palliation in distal malignant biliary obstruction (D-MBO) not amenable to ERCP, with good efficacy and not exiguous adverse events.

AIMS AND METHODS

From January 2015 to December 2019, we retrospectively enrolled all the EUS-BD with electrocautery-enhanced LAMS for biliary decompression in unresectable D-MBO and failed ERCP. Primary study aims were to evaluate technical/clinical success and AEs rate. In case of maldeployment, we estimated the efficacy of an intra-operative rescue therapy. Secondary aims were to assess the jaundice recurrence and gastric outlet obstruction symptoms.

RESULTS

Thirty-six EUS-BD were enrolled over a cohort of 738 patients (ERCP cannulation failure rate was 2.6%): 31 choledocho-duodenostomy and 5 cholecystogastrostomy. A pre-loaded guidewire through the LAMS was systematically used in case of common bile duct ≤ 15 mm or scope instability for a safe/preventive biliary entryway in case of intra-procedural complications. Technical success was 80.6% (29/36 patients). Seven cases of LAMS maldeployment during EUS-guided choledocho-duodenostomy were successfully treated with RT by an over-the-wire fully-covered Self-Expandable Metal Stent (FC-SEMS). The FC-SEMS was released through the novel fistula tract in endoscopic fashion in 5/7 cases and transpapillary in percutaneous-transhepatic-endoscopic rendezvous (1/7) and laparoscopic-endoscopic rendezvous (1/7) in the two remaining cases. The total efficacy of rescue therapy was 100%. Same-session duodenal SEMS was placed in 17 patients with optimal gastric outlet obstruction management. Final clinical success was 100% and no other late adverse events or FC-SEMS migration were observed.

CONCLUSION

EUS-BD with LAMS is effective for jaundice palliation after ERCP failure but with considerable adverse events. Maldeployment remains a serious complication with fatal evolution if not correctly recognized/managed. Rescue therapy must be promptly applied especially in tertiary-care centers with highly skilled endoscopists, interventional radiologist and dedicated surgeon.

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.

Superiority of Laparoscopic Gastrojejunostomy Combined With Multimodality Therapy for Gastric Outlet Obstruction Caused by Advanced Gastric Cancer

BACKGROUND

Data are limited concerning the survival outcomes of patients with gastric outlet obstruction (GOO) caused by advanced gastric cancers according to laparoscopic gastrojejunostomy (LGJ) combined with multimodality therapy (MMT). Therefore, the purpose of this study was to examine the feasibility and efficacy of these therapies.

METHODS

This single-centered, retrospective analysis included data of 184 patients with GOO due to advanced gastric cancer (AGC). Treatment models were: laparoscopic gastrojejunostomy combined with multimodality therapy (LGJ+MMT), endoscopic metal stent placement combined with multimodality therapy (EMSP+MMT), and multimodality therapy (MMT).

RESULTS

Improved oral intake, better nutritional indices, and better response to chemotherapy were observed in the LGJ+MMT group. Subsequent gastrectomy was performed in 43 (61.4%) patients in the LGJ+MMT group, 23 (37.7%) in the EMSP+MMT group, and 11 (20.8%) in the MMT group (P<0.001). LGJ+MMT was associated with better long-term prognosis. As confirmed by propensity scores and multivariate analyses, the 3-year survival rates in the three treatment models were 31.4% with LGJ+MMT, 0% with EMSP+MMT, and 0% with MMT in conversion therapy, and 50.0% with LGJ+MMT, 33.3% with EMSP+MMT, and 23.5% with MMT in NAC. A forest plot revealed that LGJ+MMT was related to a decreased risk of death.

CONCLUSIONS

LGJ combined with MMT was associated with better nutritional status, higher rates of subsequent gastrectomy, and good prognosis. LGJ combined with MMT may improve the long-term survival of patients with GOO caused by AGC.

The Role of Palliative Surgery in Stage IV Gastric Cancer: A Retrospective Study

Background: Palliative chemotherapy is the mainstay of treatment for metastatic gastric adenocarcinoma but in some patients, surgically correctable factors such as obstruction lead to intolerance of further systemic treatment. The aim of this study was to evaluate the role of selective palliative surgery in incurable gastric cancer. Methods: All patients with stage IV and locally advanced unresectable gastric adenocarcinoma treated at a single centre from March 2006 to January 2019 were included. Data were retrieved from a prospectively maintained database. Patients were categorized into palliative surgery (PS) and no surgery (NS). Results: Of 666 patients with gastric cancer treated over the study period, 146 patients had stage IV gastric adenocarcinoma and 121 patients met inclusion criteria. Sites of metastases were peritoneum (55; 46%), non-regional lymph nodes (10; 8%), solid organ (17, 14%), adjacent organ invasion (4, 3.3%) and a combination of factors (32, 26%). Forty-six (38%) patients underwent palliative surgery which included anatomical gastrectomy (total, subtotal, distal or proximal, 78%) gastro-jejunal bypass and feeding jejunostomy (12%). Thirty-day post-operative complications occurred in 24 patients (52%) with one mortality (2.1%). Following surgery, 52% received systemic chemotherapy. For the PS and NS groups respectively, median overall survival was 9.1 versus 9.4 months (p = 0.6) and median progression-free survival was 7.1 versus 6.7 months (p = 0.2) after a follow up period of 7.3 (4.7-13.1) versus 7.8 (2.6-13.4) months (p = 0.46). Conclusion: Targeted surgical intervention for incurable gastric cancer can be used to palliate symptoms and facilitate continuation of systemic therapy with acceptable risks and post-operative outcomes.

Advanced Endoscopic Techniques for the Diagnosis of Pancreatic Cancer and Management of Biliary and GastricOutlet Obstruction

Following high-quality imaging studies for staging, endoscopic ultrasound examination fine needle aspiration/biopsy is the preferred modality for tissue diagnosis of pancreatic cancer. Endoscopic retrograde cholangiopancreatography with metal stent placement is used for palliation of malignant biliary obstruction. Metal stents can be placed in patients with resectable pancreatic cancer in whom surgery is going to be delayed. For palliation of gastric outlet obstruction, endoscopic enteral stenting is often selected because of its less invasiveness. Endoscopic ultrasound-guided biliary drainage for malignant biliary obstruction or gastrojejunostomy for gastric outlet obstruction are emerging less invasive techniques as compared with palliative surgery.

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.

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Relationship between initial management strategy and survival in patients with gastric outlet obstruction due to gastric cancer

BACKGROUND

The optimal management of gastric outlet obstruction (GOO) due to gastric cancer (GC) is unclear. We examined the relationships between clinical and management variables and outcomes in patients with GC having GOO.

METHODS

The GOO management and clinical course were reviewed in patients with GC and GOO. Cox regression and Kaplan-Meier analyses were used to identify variables predictive of overall survival (OS).

RESULTS

The study included 59 patients. Eleven had imaging evidence of metastasis and 35 had pathologically confirmed peritoneal disease. Initial management included resection in 23 patients, feeding jejunostomy ± decompressive gastrostomy (JT/GT) in 25, surgical gastrojejunostomy in five, and endoscopic intervention in six. Seven patients with initial JT/GT underwent resection after neoadjuvant therapy. Median OS (95% confidence interval [CI]) was 21.4 (0.0-45.1) months in the upfront resection group (median follow-up, 14.7 months) and not reached in those with initial JT/GT, neoadjuvant therapy, and later resection (median follow-up, 26.5 months) (P = .18). On multivariable analysis, clinically positive nodes (hazard ratio [HR]: 3.76; 95% CI, 1.17-12.12; P = .03), metastasis on CT (HR: 3.97; 95% CI: 1.53-10.26;P = .01), and resection (HR: 0.37; 95% CI: 0.17-0.79;P = .01) independently predicted OS.

CONCLUSION

In GOO due to GC, OS is similar after treatment with upfront resection compared with JT/GT, neoadjuvant therapy, and later resection. Upfront JT/GT may allow patients to tolerate chemotherapy and improve selection for gastrectomy.

Palliative care for advanced gastric cancer

INTRODUCTION

Proactive palliative care can effectively relieve symptoms early and effectively as well as improve the quality of life of patients with gastric adenocarcinoma (GAC).

AREAS COVERED

The review summarizes palliative care for GAC. GAC caused specific symptoms, such as malignant gastric outlet obstruction (GOO), bleeding, weight loss, and/or ascites, therefore, these symptoms must be addressed specifically.

EXPERT OPINION

Palliative care should start early to control general symptoms, thus may improve the patient's condition to make the patient eligible for anti-cancer treatment. As some stage IV GAC patients can now live longer, palliative interventions become more important. A multimodality interdisciplinary approach is strongly encouraged.

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.

Surgical intervention for malignant bowel obstruction caused by gastrointestinal malignancies

BACKGROUND

Malignant bowel obstruction (MBO) is a common event for end-stage gastrointestinal cancer patients. Previous studies had demonstrated manifestations and clinical management of MBO with mixed malignancies. There still lack reports of the surgical treatment of MBO.

AIM

To analyze the short-term outcomes and prognosis of palliative surgery for MBO caused by gastrointestinal cancer.

METHODS

A retrospective chart review of 61 patients received palliative surgery between January 2016 to October 2018 was performed, of which 31 patients underwent massive debulking surgery (MDS) and 30 underwent ostomy/by-pass surgery (OBS). The 60-d symptom palliation rate, 30-d morbidity and mortality, and overall survival rates were compared between the two groups.

RESULTS

The overall symptom palliation rate was 75.4% (46/61); patients in the MDS group had significantly higher symptom palliation rate than OBS group (90% vs 61.2%, P = 0.016). Patients with colorectal cancer who were in the MDS group showed significantly higher symptom improvement rates compared to the OBS group (overall, 76.4%; MDS, 61.5%; OBS, 92%; P = 0.019). However, patients with gastric cancer did not show a significant difference in symptom palliation rate between the MDS and OBS groups (OBS, 60%; MDS, 80%; P = 1.0). The median survival time in the MDS group was significantly longer than in the OBS group (10.9 mo vs 5.3 mo, P = 0.05).

CONCLUSION

For patients with MBO caused by peritoneal metastatic colorectal cancer, MDS can improve symptom palliation rates and prolong survival, without increasing mortality and morbidity rates.

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.

Superiority of Gastrojejunostomy Over Endoscopic Stenting for Palliation of Malignant Gastric Outlet Obstruction

BACKGROUND & AIMS

Gastric outlet obstruction (GOO) in patients with malignancies causes nausea, vomiting, abdominal pain, malnutrition, and dehydration. Endoscopic placement of self-expandable metallic stent (SEMS) and gastrojejunostomy are the 2 main palliative options. We aimed to compare the outcomes of endoscopic SEMS placement with gastrojejunostomy in a propensity score matched study and identified factors associated with clinical success.

METHODS

We performed a retrospective analysis of patients with malignant GOO who underwent endoscopic SEMS placement (n = 183) or gastrojejunostomy (n = 127) from 2011 through 2017 at a tertiary academic medical center. Clinical success was defined as successful resumption of oral intake and relief of obstructive symptoms after either procedure. A propensity score matched analysis was conducted to compare clinical success rate, luminal patency duration, survival length, and adverse outcomes. We performed multivariable analyses to identify factors associated with clinical success.

RESULTS

Proportions of patients with clinical success did not differ significantly between the SMES group (79.4%) and the gastrojejunostomy group (80.1%) (P = .83). The mean patency duration and survival lengths were significantly longer in the gastrojejunostomy group (169.2 and 193.4 days respectively), compared to the endoscopic stenting group (96.5 and 119.9 days respectively). Poor performance status, presence of ascites and low albumin were independent risk factors for failure of enteral stenting and gastrojejunostomy.

CONCLUSIONS

In a retrospective analysis of patients with GOO, due to cancer, who underwent endoscopic SEMS placement or gastrojejunostomy, we found gastrojejunostomy to provide significant increases in patency duration and survival time. Gastrojejunostomy should therefore be considered the primary treatment option for patients with good performance status and reasonable survival expectancy. Nutritional status, the absence of ascites, and pre-procedure performance status are associated with clinical success.

Comparison of big funnel and individualized stents for management of stomach cancer with gastric outlet obstruction

BACKGROUND

Previous studies reported a similar rate of complications, including stent migration and obstruction, between individualized stents and the standard uncovered stents in gastric outlet obstruction (GOO) caused by distal stomach cancer. The objective of this study was to evaluate the efficacy and safety of funnel stents for management of GOO caused by distal stomach cancer.

METHODS

This study was designed as a multicenter, controlled, prospective, and randomized clinical trial involving 4 hospitals. The individualized stent group (44 cases) received cup and funnel covered stents, and the funnel group (44 cases) received only funnel covered stents for management of GOO caused by distal gastric cancer.

RESULTS

All patients with GOO were treated with cup and funnel stents according to their assigned groups. The rate of GOO resolution was 100% in the funnel group and 97.7% in the individualized stent group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group, and proximal partial stent migration was observed in 1 patient in each group. Stent obstruction caused by tumor ingrowth was observed in 1 patient in the individualized stent group. There was no statistical difference in stent migration, obstruction, and survival between groups.

CONCLUSION

Big funnel stents and individualized stents resulted in similar shaping effect and prevention of stent migration and obstruction, suggesting that funnel shaped stents can be used to treat cup or funnel shaped GOO caused by distal stomach cancer.

Gastric outlet obstruction caused by metastatic tumor of the stomach originating from primary breast cancer: A case report

The most common sites of breast cancer metastasis are the bone, liver, lung and brain, while gastrointestinal metastasis from breast cancer is rare. We herein present the case of a 68-year-old woman who was admitted to our department with nausea and appetite loss. The patient's medical history included right mastectomy with sentinel lymph node biopsy 5 years earlier for invasive lobular carcinoma, measuring 6.2 cm in greatest diameter, without lymphovascular invasion. Two years after the surgery, the patient developed brain metastasis and underwent metastasectomy to control the neurological symptoms, including unsteadiness and asthenia. After the second surgery, the patient received systemic chemotherapy using S-1, followed by bevacizumab plus paclitaxel. However, due to bevacizumab-related cardiotoxicity, the treatment was switched to eribulin. On esophagogastroduodenoscopy, an elevated lesion was identified in the antrum, causing severe narrowing of the gastric outlet. Biopsy and histological examination of the tumor revealed infiltration of the gastric wall by undifferentiated neoplastic cells with poor adhesion, morphologically similar to invasive lobular carcinoma, and immunohistochemical staining was positive for estrogen receptor, mammaglobin and GATA3. Finally, ¹⁸F-2-deoxy-2-fluoro-D-glucose (FDG) positron emission tomography combined with computed tomography imaging revealed FDG uptake across the thickness of the antral wall. The patient was diagnosed with gastric metastasis from the original breast cancer and subsequently underwent endoscopic self-expandable metallic stent (SEMS) placement. There were no procedure-related adverse events, and the patient remained alive under best supportive care 4 months after SEMS placement. To the best of our knowledge, this is the first reported case of gastric outlet obstruction caused by metastatic breast carcinoma managed by SEMS placement. While such a diagnosis is rare, clinicians treating patients with gastric metastases should be aware of possible gastric outlet obstruction and SEMS placement as an effective palliative intervention.

The Palliative Effect of Endoscopic Uncovered Self-expandable Metallic Stent Placement Versus Gastrojejunostomy on Malignant Gastric Outlet Obstruction: A Pilot Study with a Retrospective Chart Review in Saga, Japan

Objective Endoscopic self-expandable metallic stent (SEMS) placement and gastrojejunostomy (GJY) are palliative treatments for malignant gastric outlet obstruction (GOO). The aim of the present study was to compare the palliative effects of these treatments and identify predictors of a poor oral intake after treatment. Methods and Patients In total, 65 patients with GOO at multiple centers in Saga, Japan, were evaluated. Thirty-eight patients underwent SEMS placement, and 27 underwent GJY from January 2010 to December 2016. The characteristics and outcomes of the two groups were compared to detect predictors of treatment failure. Results No significant differences in the technical success, clinical success, post-treatment total protein, hospital discharge, duration from eating disability to death, or post-treatment overall survival were present between the SEMS and GJY groups. More patients in the GJY group than in the SEMS group received chemotherapy (51.4% vs. 26.3%, respectively; p=0.042). The period from treatment to the first meal was longer in the GJY group than in the SEMS group (4.5 vs. 3.0 days, respectively; p=0.013). The present study did not identify any risk factors for failure of SEMS placement. Although the stent length tended to be associated with a poor prognosis, the correlation was not statistically significant (odds ratio: 0.60, 95% confidence interval: 0.36-1.01, p=0.053). Conclusion Patients with GOO started meals more promptly after SEMS than after GJY, but the clinical outcomes were not markedly different between the SEMS and GJY groups. These findings suggest that endoscopic uncovered SEMS placement might be a feasible palliative treatment for GOO.

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.