Laparoscopic stomach-partitioning gastrojejunostomy is an effective palliative procedure to improve quality of life in patients with malignant gastroduodenal outlet obstruction

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.

Stomach-partitioning versus conventional gastrojejunostomy for unresectable gastric cancer with gastric outlet obstruction: A propensity score matched cohort study

BACKGROUND

Stomach partitioning gastrojejunostomy (SPGJ) was introduced to deal with delayed gastric emptying (DGE). This study aimed to compare the short- and long-term outcomes of SPGJ versus conventional gastrojejunostomy (CGJ).

METHOD

This cohort study analyzed 108 patients who underwent gastrojejunostomy for unresectable gastric cancer: 70 patients underwent SPGJ, and 38 patients underwent CGJ between 2018 and 2022. Propensity score-matched (PSM) analysis was used to balance the baseline characteristics.

RESULTS

After PSM, there were 26 patients in each group. SPGJ group had significantly lower incidence of DGE (3.8% vs. 34.6%), vomiting (3.8% vs. 42.3%), and prokinetics requirement (11.5% vs. 46.2%). SPGJ group had significantly shorter time to solid diet tolerance (4.1 days vs. 5.7 days) and postoperative hospital stay (7.7 days vs. 9.3 days). There was no significant difference in relapse reinterventions, gastric outlet obstruction (GOO) recurrence, conversion surgery, and survival outcomes.

CONCLUSIONS

SGPJ was associated with lower rate of DGE, prokinetics requirement, and shorter time of solid diet tolerance compared to CGJ in the treatment of unresectable gastric cancer patients with GOO.

Is vagotomy necessary in palliative surgery for incurable advanced gastric cancer?: a retrospective case-control study

BACKGROUND

The interplay between the nervous system and cancer plays an important role in the initiation and progression of gastric cancer. Few studies have presented evidence that the sympathetic nervous system inhibits the occurrence and development of gastric cancer while the parasympathetic nervous system promotes the growth of gastric cancer. To investigate the effect of vagotomy, which is the resection of a parasympathetic nerve innervating the stomach, on the progression of gastric cancer, a retrospective study was conducted comparing the prognosis of simple palliative gastrojejunostomy (PGJ) and palliative gastrojejunostomy with vagotomy (PGJV).

METHODS

From January 01, 2000, to December 31, 2021, the medical records of patients who underwent PGJ or PGJV because of gastric outlet obstruction due to incurable advanced gastric cancer at the Yeungnam University Medical Center were retrospectively reviewed. Patients were divided into two groups: locally unresectable gastric cancer (LUGC) or gastric cancer with distant metastasis (GCDM), according to the reason for gastrojejunostomy, and factors affecting overall survival (OS) were analyzed.

RESULTS

There was no significant difference in surgical outcomes and postoperative complications between the patients with PGJV and patients with PGJ. In univariate analysis, vagotomy was not a significant factor for OS in the GCDM group (HR 1.14, CI 0.67-1.94, p value 0.642), while vagotomy was a significant factor for OS in the LUGC group (HR 0.38, CI 0.15-0.98, p value 0.045). In multivariate analysis, when vagotomy is performed together with PGJ for LUGC, the OS can be significantly extended (HR 0.25, CI 0.09-0.068, p value 0.007).

CONCLUSIONS

When PGJ for LUGC was performed with vagotomy, additional survival benefits could be achieved with low complication risk. However, to confirm the effect of vagotomy on the growth of gastric cancer, further prospective studies using large sample sizes are essential.

Scoring Systems May be Effective in Predicting Mortality Associated with Palliative Emergency Gastrointestinal Surgery: A Retrospective Observational Study

Background

Palliative emergency gastrointestinal surgery is associated with significant morbidity and mortality and weighing up the benefits and harms during the decision-making may be challenging. There are very few studies on surgery in palliative patient population. The aim of this retrospective study was to evaluate morbidity and mortality after palliative emergency gastrointestinal surgery and the usability of scoring systems in predicting the outcome.

Methods

Consecutive adult patients undergoing palliative emergency surgery at a tertiary hospital during the period 2015 to 2016 were included. Pre- and post-operative functional status, morbidity and mortality of patients were assessed. The predictive value of the American Society of Anesthesiologists (ASA) classification, the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (ACS NSQIP SRC) and Palliative index (PI) in estimating morbidity and mortality were determined.

Results

A total of 93 patients (age 69 [28–92] years, 51% female) were included. Typical indications for surgery were bowel obstruction (52%) and securing food intake (30%). Pre-operatively two patients (2.2%) were totally dependent in daily activities, while post-operatively the respective share was 34% at discharge from hospital. The incidence of post-operative complications was 37% and 14% died during the hospital stay. One-, three-month and one-year mortality rates were 41%, 63% and 87%, respectively. While ASA score, PI score and ACS NSQIP did not predict post-operative morbidity, both ASA score and ACS NSQIP SRC predicted post-operative mortality.

Conclusions

Palliative emergency laparotomy is associated with significant post-operative mortality and morbidity. Scorings, such as ASA score and ACS NSQIP SRC predict mortality in this patient population.

The therapeutic strategy for advanced gastric cancer with pyloric stenosis and liver metastasis; successfully treated by gastro-jejunal bypass and chemotherapy first, followed by curative R0 resection

BACKGROUND

The indication of surgical resection for liver metastasis from gastric cancer (GC) is still limited and controversial because of its more aggressive oncological characteristics than liver metastasis from colorectal cancer. Pyloric stenosis causes an inadequate oral intake and malnutrition in GC patients. We herein report a case of GC with these two factors that was successfully treated by the combination of gastro-jejunal bypass and chemotherapy, followed by curative R0 resection.

CASE PRESENTATION

A 60-year-old man was diagnosed with type 2 GC with liver metastasis and pyloric stenosis, which was confirmed as the HER2-positive type. He underwent gastrojejunostomy and received capecitabine and cisplatin (XP) + trastuzumab chemotherapy. After three courses of the XP + trastuzumab regimen, shrinkage of the primary lesion and liver metastasis was confirmed and his nutritional parameters markedly improved with a stable oral intake after bypass surgery. He underwent curative R0 resection by distal gastrectomy with D2 lymphadenectomy and partial hepatectomy. Histologically, viable tumor cells were observed in less than one-third of the primary lesion, and only scar tissue without viable cancer cells was noted in the resected liver specimen. His postoperative course was uneventful, and recurrence has not been detected in the 30 months after surgery without adjuvant chemotherapy.

CONCLUSION

The present case report describes a successful strategy for advanced GC with pyloric stenosis and liver metastasis.

Laparoscopic stomach-partitioning gastrojejunostomy in preparation for distal gastrectomy and Billroth-II reconstruction after neoadjuvant chemotherapy for advanced gastric cancer with gastric outlet obstruction: A case report

Gastrojejunostomy has been performed as a palliative treatment for unresectable, advanced gastric cancer patients with gastric outlet obstruction (GOO). However, its role before neoadjuvant chemotherapy (NAC) has not been established. We present the case of a 72-year-old man with distal advanced gastric cancer with GOO. Computed tomography showed para-aortic lymph node (PAN) metastasis without other distal metastasis. We performed laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ), which avoided new gastrojejunostomy reconstruction when performing distal gastrectomy after NAC. His oral intake improved after surgery and NAC was successfully administered on postoperative day 14, without surgical complications. After completion of NAC, the patient underwent radical distal gastrectomy with gastrojejunostomy reused as Billroth-II reconstruction. A histological examination revealed no residual cancer cells. LSPGJ, with partitioning on the expected resection line in distal gastrectomy after NAC, can be useful for treating advanced gastric cancer with GOO when NAC followed by curative gastrectomy is planned.

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

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

A systematic review and meta-analysis comparing partial stomach partitioning gastrojejunostomy versus conventional gastrojejunostomy for malignant gastroduodenal obstruction

PURPOSE

Partial stomach partitioning gastrojejunostomy (PSPGJ) was introduced as a palliative treatment for malignant gastric outlet obstruction (MGO) caused by unresectable gastric or periampullary cancers and suggested to offer advantages over conventional gastrojejunostomy (CGJ) in reducing the risk for delayed gastric emptying (DGE). However, insufficient evidence is available to allow a comprehensive view of the true value of PSPGJ. The present study aimed to show the advantages of PSPGJ in terms of alleviating DGE and improving postoperative recovery compared to CGJ.

METHODS

A systematic literature search was performed, and studies comparing DGE and other perioperative and postoperative data including operation time, blood loss, total postoperative complications, anastomotic leak, postoperative period before oral intake, and/or hospital stay between PSPGJ and CGJ for MGO were incorporated. Risk ratio (RR) for binary variables and weighted mean difference (WMD) for continuous variables were calculated, and meta-analyses were performed.

RESULTS

Seven studies containing 207 patients were included. The risk for DGE was significantly lower after PSPGJ (RR 0.32; 95%CI 0.17 to 0.60; P < 0.001). PSPGJ significantly reduced the postoperative hospital stay (WMD -6.1 days; 95%CI -8.9 to -3.3 days; P < 0.001). No significant differences were observed in the other variables between the groups.

CONCLUSIONS

PSPGJ for MGO seems to offer significant advantages in terms of alleviating DGE and improving postoperative recovery compared to CGJ.

Effectiveness of laparoscopic stomach-partitioning gastrojejunostomy for patients with gastric outlet obstruction caused by advanced gastric cancer

BACKGROUND

Distal advanced gastric cancer (AGC) occasionally causes gastric outlet obstruction (GOO). We developed a laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) to restore the ability of food intake.

METHODS

This was a retrospective study performed at a single institution. Of consecutive 78 patients with GOO caused by AGC between 2006 and 2012, 43 patients who underwent LSPGJ were enrolled. The procedure was performed in an antiperistaltic Billroth II fashion, and the afferent loop was elevated and fixed along the staple line of the proximal partitioned stomach. Then, patients for whom R0 resection was planned received chemotherapy prior to laparoscopic gastrectomy. The primary end point was food intake at the time of discharge, which was evaluated using the GOO scoring system (GOOSS). Short- and long-term outcomes were assessed as secondary end points. Overall survival was estimated and compared between the groups who received neoadjuvant chemotherapy followed by surgery (NAC group), definitive chemotherapy followed by curative resection (Conversion group), and best supportive care (BSC group).

RESULTS

The median operative time was 92 min, blood loss did not exceed 30 g in any patient, and postoperative complications (Clavien-Dindo grade ≥2) were only seen in four patients (9.3 %). The median time to food intake was 3 days, and GOOSS scores were significantly improved in 41 patients (95.3 %). Chemotherapy was administered to 38 patients (88.4 %), of whom 11 later underwent radical resection, and 4 of 11 patients underwent conversion surgery following definitive chemotherapy. Median survival times were significantly superior in the NAC (n = 7; 46.8 months) and Conversion (n = 4; 35.9 months) groups than in the BSC group (n = 26; 12.2 months); however, the difference was not significant between the Conversion and NAC groups.

CONCLUSIONS

LSPGJ is a feasible and safe minimally invasive induction surgery for patients with GOO from surgical and oncological perspectives.

Laparoscopic stomach-partitioning gastrojejunostomy with reduced-port techniques for unresectable distal gastric cancer

BACKGROUND

The improvement of quality of life is of great importance in managing patients with far-advanced gastric cancer. We report a new cure and less invasive method of creating a stomach-partitioning gastrojejunostomy in reduced-port laparoscopic surgery for unresectable gastric cancers with gastric outlet obstruction.

MATERIALS AND METHODS

A 2.5-cm vertical intraumbilical incision was made, and EZ Access (Hakko Co., Ltd., Tokyo, Japan) was placed. After pneumoperitoneum was created, an additional 5-mm trocar was inserted in the right upper abdomen. A gastrojejunostomy was performed in the form of an antiperistaltic side-to-side anastomosis, in which the jejunal loop was elevated in the antecolic route and anastomosed to the greater curvature of the stomach using an endoscopic linear stapler. The jejunal loop together with the stomach was dissected with additional linear staplers just proximal to the common entry hole so that a functional end-to-end gastrojejunostomy was completed. At the same time, the stomach was partitioned using a linear stapler to leave a 2-cm-wide lumen in the lesser curvature. Subsequently, jejunojejunostomy was performed 30 cm distal to the gastrojejunostomy, and the stomach-partitioning gastrojejunostomy resembling Roux-en Y anastomosis was completed.

RESULTS

All patients resumed oral intake on the day of operation. Neither anastomotic leakage nor anastomotic stricture was observed.

CONCLUSIONS

Our less invasive palliative operation offers the utmost priority to improve quality of life for patients with unresectable gastric cancer.