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Teoh AYB, Lakhtakia S, Tarantino I, Perez-Miranda M, Kunda R, Maluf-Filho F, Dhir V, Basha J, Chan SM, Ligresti D, Ma MTW, de la Serna-Higuera C, Yip HC, Ng EKW, Chiu PWY, Itoi T. Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:124-132. [PMID: 38061378 DOI: 10.1016/s2468-1253(23)00242-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel endoscopic method to palliate malignant gastric outlet obstruction. We aimed to assess whether the use of EUS-GE with a double balloon occluder for malignant gastric outlet obstruction could reduce the need for reintervention within 6 months compared with conventional duodenal stenting. METHODS The was an international, multicentre, randomised, controlled trial conducted at seven sites in Hong Kong, Belgium, Brazil, India, Italy, and Spain. Consecutive patients (aged ≥18 years) with malignant gastric outlet obstruction due to unresectable primary gastroduodenal or pancreatobiliary malignancies, a gastric outlet obstruction score (GOOS) of 0 (indicating an inability in intake food or liquids orally), and an Eastern Cooperative Oncology Group performance status score of 3 or lower were included and randomly allocated (1:1) to receive either EUS-GE or duodenal stenting. The primary outcome was the 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction (ie, restenosis of the stent due to tumour ingrowth, tumour overgrowth, or food residue; stent migration; or stent fracture) within 6 months, analysed in the intention-to-treat population. Prespecified secondary outcomes were technical success (successful placement of a stent), clinical success (1-point improvement in gastric outlet obstruction score [GOOS] within 3 days), adverse events within 30 days, death within 30 days, duration of stent patency, GOOS at 1 month, and quality-of-life scores. This study is registered with ClinicalTrials.gov (NCT03823690) and is completed. FINDINGS Between Dec 1, 2020, and Feb 28, 2022, 185 patients were screened and 97 (46 men and 51 women) were recruited and randomly allocated (48 to the EUS-GE group and 49 to the duodenal stent group). Mean age was 69·5 years (SD 12·6) in the EUS-GE group and 64·8 years (13·0) in the duodenal stent group. All randomly allocated patients completed follow-up and were analysed. Reintervention within 6 months was required in two (4%) patients in the EUS-GE group and 14 (29%) in the duodenal stent group [p=0·0020; risk ratio 0·15 [95% CI 0·04-0·61]). Stent patency was longer in the EUS-GE group (median not reached in either group; HR 0·13 [95% CI 0·08-0·22], log-rank p<0·0001). 1-month GOOS was significantly better in the EUS-GE group (mean 2·41 [SD 0·7]) than the duodenal stent group (1·91 [0·9], p=0·012). There were no statistically significant differences between the EUS-GE and duodenal stent groups in death within 30 days (ten [21%] vs six [12%] patients, respectively, p=0·286), technical success, clinical success, or quality-of-life scores at 1 month. Adverse events occurred 11 (23%) patients in the EUS-GE group and 12 (24%) in the duodenal stent group within 30 days (p=1·00); three cases of pneumonia (two in the EUS-GE group and one in the duodenal stent group) were considered to be procedure related. INTERPRETATION In patients with malignant gastric outlet obstruction, EUS-GE can reduce the frequency of reintervention, improve stent patency, and result in better patient-reported eating habits compared with duodenal stenting, and the procedure should be used preferentially over duodenal stenting when expertise and required devices are available. FUNDING Research Grants Council (Hong Kong Special Administrative Region, China) and Sociedad Española de Endoscopia Digestiva.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Manuel Perez-Miranda
- Department of Gastroenterology and Hepatology, University Hospital Rio Hortega, Valladolid, Spain
| | - Rastislav Kunda
- Department of Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Department of Gastroenterology-Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Fauze Maluf-Filho
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Department of Gastroenterology of University of São Paulo, São Paulo, Brazil; National Council for Scientific and Technological Development-CNPq, Brazil
| | - Vinay Dhir
- Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, India
| | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Mark Tsz Wah Ma
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | | | - Hon Chi Yip
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Enders Kwok Wai Ng
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
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Sánchez-Aldehuelo R, Subtil Iñigo JC, Martínez Moreno B, Gornals J, Guarner-Argente C, Repiso Ortega A, Peralta Herce S, Aparicio JR, Rodríguez de Santiago E, Bazaga S, Juzgado D, González-Panizo F, Albillos A, Vázquez-Sequeiros E. EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video). Gastrointest Endosc 2022; 96:1012-1020.e3. [PMID: 35870508 DOI: 10.1016/j.gie.2022.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/29/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Traditionally, palliative treatment of malignant gastric outlet obstruction (GOO) has been surgical, but surgical treatment carries significant morbidity and mortality rates. Endoscopic placement of a duodenal self-expandable metal stent (D-SEMS) has been proven to be successful for this indication in the short term. However, D-SEMSs are likely to malfunction over time. EUS-guided gastroenterostomy (EUS-GE) may help overcome these limitations. We aimed to evaluate stent failure-free survival at 3 months. METHODS A nationwide multicenter, observational study of D-SEMS and EUS-GE procedures for patients with malignant GOO was conducted at 7 academic centers from January 2015 to June 2020. Stent failure-free survival at 1, 3, and 6 months; technical and clinical success; adverse events (AEs); and patient survival were evaluated in both groups and compared. RESULTS Ninety-seven patients were included in the D-SEMS group and 79 in the EUS-GE group. Pancreatic cancer was the main underlying malignancy in 53.4%. No statistically significant differences regarding technical (92.8% vs 93.7%) or clinical success (83.5% vs 92.4%) were found. AE rates did not differ between groups (10.3% vs 10.1%), although 2 events in the EUS-GE group required surgical management. Patients in the EUS-GE group had improved stent patency when compared with those patients in the D-SEMS group at 3 months (92.23% vs 80.6%; adjusted hazard ratio, .37; P = .033). CONCLUSIONS EUS-GE seems to have improved patency outcomes when compared with D-SEMS placement for palliative treatment of malignant GOO. Prospective trials are needed to fully compare their efficacy and AE profile.
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Affiliation(s)
- Rubén Sánchez-Aldehuelo
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | | | - Belén Martínez Moreno
- Unidad de Endoscopia, ISABIAL, Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joan Gornals
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carlos Guarner-Argente
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alejandro Repiso Ortega
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Sandra Peralta Herce
- Unidad de Endoscopia, Servicio de Digestivo, Clínica Universidad de Navarra, Pamplona, Spain
| | - José Ramón Aparicio
- Unidad de Endoscopia, ISABIAL, Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Enrique Rodríguez de Santiago
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Sergio Bazaga
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Diego Juzgado
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
| | - Fernando González-Panizo
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
| | - Agustín Albillos
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Enrique Vázquez-Sequeiros
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain; Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
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Hong J, Chen Y, Li J, Hu P, Chen P, Du N, Huang T, Chen J. Comparison of gastrojejunostomy to endoscopic stenting for gastric outlet obstruction: An updated Systematic Review and Meta-analysis. Am J Surg 2022; 223:1067-1078. [PMID: 34728070 DOI: 10.1016/j.amjsurg.2021.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/06/2021] [Accepted: 10/21/2021] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Jiaze Hong
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Yizhou Chen
- Emergency Medical Center, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhejiang, China.
| | - Jiayu Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Peidong Hu
- Schools of Medicine & Nursing Sciences, Huzhou University, Huzhou, Zhejiang, China.
| | - Ping Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
| | - Nannan Du
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Tongmin Huang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China.
| | - Jingjie Chen
- Department of General Surgery, HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang, China.
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Suder-Castro L, Ramírez-Solís M, Hernández-Guerrero A, de la Mora-Levy J, Alonso-Lárraga J, Hernández-Lara A. Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2020. [DOI: 10.1016/j.rgmxen.2019.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Suder-Castro LS, Ramírez-Solís ME, Hernández-Guerrero AI, de la Mora-Levy JG, Alonso-Lárraga JO, Hernández-Lara AH. Predictors of self-expanding metallic stent dysfunction in malignant gastric outlet obstruction. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 85:275-281. [PMID: 32229056 DOI: 10.1016/j.rgmx.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/16/2019] [Accepted: 08/08/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION AND OBJECTIVES Self-expanding metallic stents (SEMS) are the ideal treatment for malignant gastric outlet obstruction (MGOO) in patients with a short life expectancy, but stent dysfunction is frequent. The primary aim of our study was to identify the predictive factors of SEMS dysfunction in MGOO and the secondary aim was to determine the technical success, clinical success, and nutritional impact after SEMS placement. MATERIAL AND METHODS A retrospective, longitudinal study was conducted at the gastrointestinal endoscopy department of the Instituto Nacional de Cancerología in Mexico City. Patients diagnosed with MGOO that underwent SEMS placement within the time frame of January 2015 to May 2018 were included. We utilized the gastric outlet obstruction scoring system (GOOSS) to determine clinical success and SEMS dysfunction. RESULTS The study included 43 patients, technical success was 97.7% (n=42), and clinical success was 88.3% (n=38). SEMS dysfunction presented in 30.2% (n=13) of the patients, occurring in<6 months after placement in 53.8% (n=7) of them. In the univariate analysis, the histologic subtype, diffuse gastric adenocarcinoma (p=0.02) and the use of uncovered SEMS (p=0.02) were the variables associated with dysfunction. Albumin levels and body mass index did not increase after SEMS placement. Medical follow-up was a mean 5.8 months (1-24 months). CONCLUSIONS SEMS demonstrated adequate technical and clinical efficacy in the treatment of MGOO. SEMS dysfunction was frequent and diffuse type gastric cancer and uncovered SEMS appeared to be dysfunction predictors.
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Affiliation(s)
- L S Suder-Castro
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México.
| | - M E Ramírez-Solís
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - A I Hernández-Guerrero
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - J G de la Mora-Levy
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - J O Alonso-Lárraga
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
| | - A H Hernández-Lara
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Cancerología, Ciudad de México, México
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Leiyuan S, Jianli X, Zhengzhong Z, Guangyan J, Dailiang Z. Comparison of Treatment Outcomes of Endoscopic Stenting and Laparoscopic Gastrojejunostomy for Malignant Gastric Outlet Obstruction. Am Surg 2018. [DOI: 10.1177/000313481808400654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To compare the clinic outcomes of endoscopic stenting and laparoscopic gastrojejunostomy (LGJ) for patients with malignant gastric outlet obstruction (GOO). We retrospectively reviewed 63 patients with malignant GOO that underwent endoscopic stenting [Stent Group (SG), n = 29] or LGJ [Laparoscopic Group (LG), n = 34]. Then, we evaluated the medical effects, postoperative hospital stay, and hospitalization expenses in both groups. Compared to LG, SG has a shorter operation time [SG: (41.1 ± 9.3) minutes vs LG: (137.4 ± 21.7) minutes, P = 0.000], less intra-operative blood loss [(23.7 ± 9.0) mL vs (121.1 ± 24.3) mL, P = 0.000], relatively lower hospitalization expenses [(2272.7 ± 413.9) $ vs (5182.4 ± 517.3) $, P = 0.000]. Besides, the median intake time was significantly shorter in the SG than that in the LG [(0.9 ± 0.3) days vs (4.1 ± 0.6) days, P = 0.000]. However, there were no significant differences between SG with LG in surgical success rate (100 vs 100%, P = 1.000), length of hospital stay [(6.1 ± 3.3) days vs (10.9 ± 4.7) days, P = 0.422], recurrent obstructive rate (37.9 vs 26.5%, P = 0.949) and median survivals [(141.4 ± 81.4) days vs (122.7 ± 88.8) days, P = 0.879]. Endoscopic stenting and LGJ are both relatively safe and effective treatments for patients with malignant GOO. But we suggest that endoscopic stenting should be considered first in patients with malignant GOO because it has many advantages over LGJ.
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Affiliation(s)
- Shuai Leiyuan
- Department of General Surgery, Jiangjin Central Hospital of Chongqing, Chongqing, China
| | - Xu Jianli
- Department of General Surgery, Jiangjin Central Hospital of Chongqing, Chongqing, China
| | - Zhao Zhengzhong
- Department of Endoscopic Treatment Center, Jiangjin Central Hospital of Chongqing, Chongqing, China
| | - Ji Guangyan
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhu Dailiang
- Department of General Surgery, Jiangjin Central Hospital of Chongqing, Chongqing, China
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Zhou WZ, Yang ZQ. Stenting for malignant gastric outlet obstruction: Current status. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Nagaraja V, Eslick GD, Cox MR. Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials. J Gastrointest Oncol 2014; 5:92-8. [PMID: 24772336 DOI: 10.3978/j.issn.2078-6891.2014.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 03/15/2014] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. During the last decade, endoscopic self-expandable metal stents (SEMS) have been used. This meta-analysis aimed to compare surgical GJ and endoscopic stenting in palliation of malignant gastric outlet obstruction (GOO). METHODS A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 3 randomized controlled trials (RCTs) and 14 non-RCTs reporting on patients who underwent surgical GJ or endoscopic stenting for malignant gastroduodenal outflow obstruction. RESULTS THE RESULTS OF THE THREE RCTS DEMONSTRATED THAT SEMS RESULTED IN COMPARABLE MAJOR [ODDS RATIO (OR): 0.62, 95% confidence intervals (CI): 0.021-18.371] and minor (OR: 0.32, 95% CI: 0.049-2.089) complications in a shorter time to tolerating an oral intake (SEMS: 3.55 days and GJ: 7.15 days) and shorter hospital stay (SEMS: 5.1 days and GJ: 12.13 days, however, statistical insignificant P value =0.11). Among the non RCTs: SEMS resulted in a shorter time to tolerating an oral intake (SEMS: 1.48 days and GJ: 8.07 days, P value <0.01), similar rate of complications (OR: 0.33, 95% CI: 0.1-1.08), lower mortality (OR: 0.5, 95% CI: 0.21-1.20, P value <0.01) and a shorter hospital stay (SEMS: 7.61 days and GJ: 19.04 days, P value <0.0001). There was no significant difference between median survival times among RCTs and non RCTs. CONCLUSIONS These findings suggest that stent placement is associated with better short-term outcomes and hence, duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. However, a large RCT is needed to systematically compare stent placement with GJ with regard to medical effects, quality of life and costs.
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Affiliation(s)
- Vinayak Nagaraja
- The Whiteley-Martin Research Centre, Discipline of Surgery, The Sydney Medical School Nepean, Penrith, New South Wales, Australia
| | - Guy D Eslick
- The Whiteley-Martin Research Centre, Discipline of Surgery, The Sydney Medical School Nepean, Penrith, New South Wales, Australia
| | - Michael R Cox
- The Whiteley-Martin Research Centre, Discipline of Surgery, The Sydney Medical School Nepean, Penrith, New South Wales, Australia
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Biliary stenting versus surgical bypass for palliation of periampullary malignancy. Indian J Gastroenterol 2013; 32:82-9. [PMID: 23229915 DOI: 10.1007/s12664-012-0274-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2011] [Accepted: 10/11/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Patients with periampullary cancers may not be suitable for curative resection due to locally advanced disease, metastases, or poor health. Biliary stenting and surgical bypass are utilized for symptom control, but the true benefit of one technique over the other is not clear. METHODS A retrospective analysis of case records was undertaken of patients with periampullary (pancreatic head/uncinate process, distal bile duct, and ampulla of Vater and surrounding duodenum) malignancy treated between June 2004 and June 2010 in a tertiary center by palliative biliary stenting or palliative surgical bypass. RESULTS Of the 69 patients included in the analysis, combined biliary and gastric bypass was performed on 28, while 41 underwent biliary stent (metallic, n = 39) insertion. Patients undergoing stenting were significantly older and less likely to be offered chemotherapy than those from the surgical bypass group. Overall, there were significantly more complications in the stent insertion group (85 %) than the surgical bypass group (36 %) (p = 0.003). The stent group required significantly more subsequent procedures than the surgical bypass group. Metal stent obstruction occurred in 16 of 39 (41 %) patients, with a median stent patency of 224 days. The overall median survival of patients in this study was 7 months with no significant difference between the groups (p = 0.992). The presence of metastases at presentation was the only independent factor associated with decreased survival. CONCLUSION There was no survival difference between stenting vs. surgical bypass for palliation of periampullary cancer. There was, however, a high rate of stent occlusion and need for repeat procedures in patients treated by metal stenting, suggesting that stenting may be best suited to patients predicted as having the shortest survival.
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Roy A, Kim M, Christein J, Varadarajulu S. Stenting versus gastrojejunostomy for management of malignant gastric outlet obstruction: comparison of clinical outcomes and costs. Surg Endosc 2012; 26:3114-9. [PMID: 22549377 PMCID: PMC3472065 DOI: 10.1007/s00464-012-2301-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Accepted: 04/02/2012] [Indexed: 01/01/2023]
Abstract
Background Although endoscopic stenting is increasingly performed, surgical gastrojejunostomy (GJ) is still considered the gold standard for relief of malignant gastric outlet obstruction (GOO). The aim of this study is to compare clinical outcomes and hospital costs between patients undergoing GJ or stenting for management of malignant GOO. Methods A retrospective claims analysis of the Medicare (MedPAR) database was conducted to identify all inpatient hospitalizations for GJ or endoscopic stenting for malignant GOO during 2007–2008. The main outcome measure evaluated using the MedPAR database was a comparison of the total length of hospital stay (LOS) and costs associated with both techniques. As MedPAR is a claims database that does not provide outcomes at patient level, a single-institution retrospective study was conducted to compare the rates of technical and treatment success, post-procedure LOS, and delayed complications per patient between the two techniques. Results The MedPAR claims data evaluated 425 stenting and 339 GJ hospitalizations. Compared with GJ, median LOS (8 vs. 16 days; p < 0.0001) and median cost (US $15,366 vs. US $27,391; p < 0.0001) per claim were both significantly lower for stenting. Stenting was more commonly performed at urban versus rural hospitals (89 % vs. 11 %; p < 0.0001), teaching versus non-teaching hospitals (59 % vs. 41 %, p = 0.0005), and academic institutions (56 % vs. 44 %; p = 0.0157). The institutional patient data analysis included 29 patients who underwent stenting and 75 who underwent surgical GJ. While both modalities were technically successful and relieved gastric outlet obstruction in all cases, compared with surgical GJ, the median post-procedure LOS was significantly lower for enteral stenting (1.5 vs. 10.7 days, p < 0.0001). There was no difference in rates of delayed complications between stenting and surgical GJ (13.8 % vs. 6.7 %; p = 0.26). Conclusions While the technical and clinical outcomes of surgical GJ and endoscopic stenting appear comparable, stent placement is less costly and is associated with shorter length of hospital stay. Dissemination of endoscopic stenting beyond teaching, academic hospitals located in urban areas as a treatment for malignant GOO is important given its implications for patient care and resource utilization.
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Affiliation(s)
- Ann Roy
- Health Economics and Reimbursement, Boston Scientific Corporation, Natick, MA, USA.
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Is intraoperative confirmation of malignancy during pancreaticoduodenectomy mandatory? J Gastrointest Surg 2012; 16:370-5. [PMID: 22033700 DOI: 10.1007/s11605-011-1728-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 10/05/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Differentiating between chronic pancreatitis and pancreatic adenocarcinoma can be difficult due to considerable overlap in disease presentation and radiological signs and the frequent co-existence of the two conditions. In this situation, surgeons may have to proceed to "blind" pancreaticoduodenectomy or attempt to confirm malignancy intraoperatively with frozen section (FS) histology. METHODS This study attempted to ascertain the false-negative and false-positive rates of undertaking pancreaticoduodenectomies (PD) based on clinical suspicion (CS) or after intraoperative confirmation of malignancy using FS histology. RESULTS Of patients, 13.6% (nine out of 66) underwent a benign PD in the CS group; 6.7% of patients had a missed malignancy in the FS group (n = 62), but intraoperative histology prevented PD in 35% of patients with benign disease in the FS group. Specificity and sensitivity of intraoperative FS in detecting malignancy was 100% and 89.7%, respectively. Sensitivity of clinical assessment in detecting malignancy was 86.4%. CONCLUSIONS In experienced hands, intraoperative confirmation of malignancy is effective and will avoid resection in patients with benign disease. However, for many surgeons the chance of missing a small tumour with a false-negative biopsy will be unacceptable and they would prefer to undertake a "blind" resection and accept the mortality risk of pancreaticoduodenectomy for benign disease.
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Hariharan D, Constantinides VA, Froeling FEM, Tekkis PP, Kocher HM. The role of laparoscopy and laparoscopic ultrasound in the preoperative staging of pancreatico-biliary cancers--A meta-analysis. Eur J Surg Oncol 2010; 36:941-8. [PMID: 20547445 DOI: 10.1016/j.ejso.2010.05.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 10/13/2009] [Accepted: 05/10/2010] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Staging laparoscopy (SL) may prevent non-therapeutic laparotomy in patients with otherwise resectable pancreatico-biliary cancers, but evidence is inconclusive. This meta-analysis aims to ascertain the true benefit of SL. METHODS All studies undertaking SL as a diagnostic sieve were included and data homogenised. Standard meta-analytical tools with emphasis on sensitivity testing and meta-regression to detect the cause for heterogeneity between studies were used. RESULTS 29 studies satisfied the criteria. 3305 patients underwent SL of which 12 were incomplete. Morbidity (n = 15) and mortality (n = 1) was low. True yield of SL for pancreatic/perpancreatic cancers (PPC) was 25% (95% CI 24-27) with a Diagnostic Odds Ratio (DOR) of 104 (95% CI 48-227). Resection rate improved from 61% to 80%. For proximal biliary cancers (PBC), SL increased the curative resection rate from 27% to 50%, with true yield of 47% (95% CI 42-52) and a DOR 61 (95% CI 19-189). Sub-group analysis for detection of liver and peritoneal lesions demonstrated a sensitivity of 88% (95% CI 83-92) and 92% (95% CI 84-96) for PPC; 83% (95% CI 69-92) and 93% (95% CI 81-99) for PBC, respectively. There was no between-study heterogeneity for peritoneal lesions. However for detection of local invasion, sensitivity was low: 58% (95% CI 51-65) for PPC and only 34% (95% CI 22-47) for PBC. Meta-regression did not reveal any cause for the observed heterogeneity between studies. CONCLUSION SL offers significant benefit to patients with resectable pancreatico-biliary cancers in avoiding non-therapeutic laparotomy and should be adopted in routine clinical practice in a judicious algorithm.
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Affiliation(s)
- D Hariharan
- Queen Mary University of London, Institute of Cancer, Barts and the London School of Medicine and Dentistry, London, UK
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