Gastrojejunostomy and self-expandable metallic stent placement for malignant gastric outlet obstruction: a meta-analysis_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

ZHAO Zhiqiang ¹ , CHEN Minxue ¹ , NIE Yuanhua ¹ , MA Fulin ¹ , ZHU Zhandi ¹ , CHEN Hao ² , KANG Boxiong ¹ ,  WANG Chen ¹

1. The Fourth Department of General Surgery, The Second Hospital, Lanzhou University, Lanzhou 730000, P. R. China;
2. Department of Tumor Surgery, The Second Hospital, Lanzhou University, Lanzhou 730000, P. R. China;

Corresponding author：

WANG Chen, Email: chenwang@lzu.edu.cn

Keywords：

gastrojejunostomy; self-expandable metallic stent placement; malignant gastric outlet obstruction; meta analysis

DOI：

10.7507/1007-9424.201909099

Video：

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Objective To compare the efficacy and safety in the treatment of malignant gastric outlet obstruction between gastrojejunostomy (GJ) and self-expandable metallic stent (SEMS) placement.Methods The relevant literatures of efficacy and safety of GJ and SEMS placement in the treatment of malignant gastric outlet obstruction were searched in the PubMed, Embase, Cochrane Library, Web of Science, Clinical Trial, VIP, CNKI, Wanfang Data databases. The data were extracted and evaluated by the RevMan 5.3 software.Results A total of 12 articles with 1 505 patients were included, of which 620 underwent the GJ (GJ group) and 885 underwent the SEMS placement (SEMS group); 3 RCTs, 9 non-RCTs. The meta-analysis results showed: the length of hospital stay [MD=5.83, 95%CI (4.24, 7.42), P<0.000 01] and time of postoperative recovery diet [MD=3.41, 95%CI (1.79, 5.03), P<0.000 1] of the SEMS group were significantly shorter than those of the GJ group; Although the incidence of complications of the GJ group was significantly higher than that of the SEMS group [OR=1.85, 95%CI (1.27, 2.70), P=0.001], the technical success rate [OR=2.72, 95%CI (1.13, 6.53), P=0.03] and clinical success rate [OR=1.86, 95%CI (1.35, 2.57), P=0.000 2] were higher and the survival time was longer [MD=38.31, 95%CI (28.98, 47.64), P<0.000 01] of the GJ group as compared with the SEMS group.Conclusions SEMS placement is more effective in recovering dietary capacity, length of hospital stay, and incidence of complications, while GJ is more effective in survival time, technical success rate, and clinical success rate. In clinical practice, we could choose different surgical method according to patient situation.

Citation： ZHAO Zhiqiang, CHEN Minxue, NIE Yuanhua, MA Fulin, ZHU Zhandi, CHEN Hao, KANG Boxiong, WANG Chen. Gastrojejunostomy and self-expandable metallic stent placement for malignant gastric outlet obstruction: a meta-analysis. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2020, 27(8): 985-993. doi: 10.7507/1007-9424.201909099 Copy

1.	Mehta S, Hindmarsh A, Cheong E, et al. Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction. Surg Endosc, 2006, 20(2): 239-242.
2.	Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol, 2002, 97(1): 72-78.
3.	Ly J, O’Grady G, Mittal A, et al. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc, 2010, 24(2): 290-297.
4.	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(2): 92-98.
5.	Khashab M, Alawad AS, Shin EJ, et al. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc, 2013, 27(6): 2068-2075.
6.	Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc, 2010, 71(3): 490-499.
7.	Jeurnink SM, van Eijck CH, Steyerberg EW, et al. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol, 2007, 7: 18.
8.	Topazian M, Ring E, Grendell J. Palliation of obstructing gastric cancer with steel mesh, self-expanding endoprostheses. Gastrointest Endosc, 1992, 38(1): 58-60.
9.	Baron TH. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med, 2001, 344(22): 1681-1687.
10.	Yim HB, Jacobson BC, Saltzman JR, et al. Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc, 2001, 53(3): 329-332.
11.	Sasaki T, Isayama H, Maetani I, et al. Japanese multicenter estimation of WallFlex duodenal stent for unresectable malignant gastric outlet obstruction. Dig Endosc, 2013, 25(1): 1-6.
12.	Hori Y, Naitoh I, Hayashi K, et al. Predictors of outcomes in patients undergoing covered and uncovered self-expandable metal stent placement for malignant gastric outlet obstruction: a multicenter study. Gastrointest Endosc, 2017, 85(2): 340-348.
13.	Kaw M, Singh S, Gagneja H, et al. Role of self-expandable metal stents in the palliation of malignant duodenal obstruction. Surg Endosc, 2003, 17(4): 646-650.
14.	Nassif T, Prat F, Meduri B, et al. Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study. Endoscopy, 2003, 35(6): 483-489.
15.	Shaw JM, Bornman PC, Krige JE, et al. Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction. Br J Surg, 2010, 97(6): 872-876.
16.	Mittal A, Windsor J, Woodfield J, et al. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. Br J Surg, 2004, 91(2): 205-209.
17.	Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005, 5: 13.
18.	Fiori E, Lamazza A, Demasi E, et al. Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group. Am J Surg, 2013, 206(2): 210-217.
19.	Maetani I, Akatsuka S, Ikeda M, et al. Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy. J Gastroenterol, 2005, 40(10): 932-937.
20.	No JH, Kim SW, Lim CH, et al. Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery. Gastrointest Endosc, 2013, 78(1): 55-62.
21.	Park CH, Park JC, Kim EH, et al. Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy. Gastrointest Endosc, 2015, 81(2): 321-332.
22.	Tsauo J, Yoo MW, Song HY, et al. Partially-covered stent placement versus surgical gastrojejunostomy for the palliation of malignant gastroduodenal obstruction secondary to pancreatic cancer. Abdom Radiol (NY), 2016, 41(11): 2233-2240.
23.	Chen YI, Itoi T, Baron TH, et al. EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surg Endosc, 2017, 31(7): 2946-2952.
24.	Yukimoto T, Morisaki T, Komukai S, et al. 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. Intern Med, 2018, 57(11): 1517-1521.
25.	Uemura S, Iwashita T, Iwata K, et al. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology, 2018, May 3. pii: S1424-3903(18)30082-6.
26.	Jang S, Stevens T, Lopez R, et al. Superiority of gastrojejunostomy over endoscopic stenting for palliation of malignant gastric outlet obstruction. Clin Gastroenterol Hepatol, 2019, 17(7): 1295-1302.
27.	Jang SH, Lee H, Min BH, et al. Palliative gastrojejunostomy versus endoscopic stent placement for gastric outlet obstruction in patients with unresectable gastric cancer: a propensity score-matched analysis. Surg Endosc, 2017, 31(10): 4217-4223.
28.	Van Heek NT, De Castro SM, van Eijck CH, et al. The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life. Ann Surg, 2003, 238(6): 894-902.

1. Mehta S, Hindmarsh A, Cheong E, et al. Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction. Surg Endosc, 2006, 20(2): 239-242.
2. Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol, 2002, 97(1): 72-78.
3. Ly J, O’Grady G, Mittal A, et al. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc, 2010, 24(2): 290-297.
4. 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(2): 92-98.
5. Khashab M, Alawad AS, Shin EJ, et al. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc, 2013, 27(6): 2068-2075.
6. Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc, 2010, 71(3): 490-499.
7. Jeurnink SM, van Eijck CH, Steyerberg EW, et al. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol, 2007, 7: 18.
8. Topazian M, Ring E, Grendell J. Palliation of obstructing gastric cancer with steel mesh, self-expanding endoprostheses. Gastrointest Endosc, 1992, 38(1): 58-60.
9. Baron TH. Expandable metal stents for the treatment of cancerous obstruction of the gastrointestinal tract. N Engl J Med, 2001, 344(22): 1681-1687.
10. Yim HB, Jacobson BC, Saltzman JR, et al. Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc, 2001, 53(3): 329-332.
11. Sasaki T, Isayama H, Maetani I, et al. Japanese multicenter estimation of WallFlex duodenal stent for unresectable malignant gastric outlet obstruction. Dig Endosc, 2013, 25(1): 1-6.
12. Hori Y, Naitoh I, Hayashi K, et al. Predictors of outcomes in patients undergoing covered and uncovered self-expandable metal stent placement for malignant gastric outlet obstruction: a multicenter study. Gastrointest Endosc, 2017, 85(2): 340-348.
13. Kaw M, Singh S, Gagneja H, et al. Role of self-expandable metal stents in the palliation of malignant duodenal obstruction. Surg Endosc, 2003, 17(4): 646-650.
14. Nassif T, Prat F, Meduri B, et al. Endoscopic palliation of malignant gastric outlet obstruction using self-expandable metallic stents: results of a multicenter study. Endoscopy, 2003, 35(6): 483-489.
15. Shaw JM, Bornman PC, Krige JE, et al. Self-expanding metal stents as an alternative to surgical bypass for malignant gastric outlet obstruction. Br J Surg, 2010, 97(6): 872-876.
16. Mittal A, Windsor J, Woodfield J, et al. Matched study of three methods for palliation of malignant pyloroduodenal obstruction. Br J Surg, 2004, 91(2): 205-209.
17. Hozo SP, Djulbegovic B, Hozo I. Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol, 2005, 5: 13.
18. Fiori E, Lamazza A, Demasi E, et al. Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group. Am J Surg, 2013, 206(2): 210-217.
19. Maetani I, Akatsuka S, Ikeda M, et al. Self-expandable metallic stent placement for palliation in gastric outlet obstructions caused by gastric cancer: a comparison with surgical gastrojejunostomy. J Gastroenterol, 2005, 40(10): 932-937.
20. No JH, Kim SW, Lim CH, et al. Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery. Gastrointest Endosc, 2013, 78(1): 55-62.
21. Park CH, Park JC, Kim EH, et al. Impact of carcinomatosis and ascites status on long-term outcomes of palliative treatment for patients with gastric outlet obstruction caused by unresectable gastric cancer: stent placement versus palliative gastrojejunostomy. Gastrointest Endosc, 2015, 81(2): 321-332.
22. Tsauo J, Yoo MW, Song HY, et al. Partially-covered stent placement versus surgical gastrojejunostomy for the palliation of malignant gastroduodenal obstruction secondary to pancreatic cancer. Abdom Radiol (NY), 2016, 41(11): 2233-2240.
23. Chen YI, Itoi T, Baron TH, et al. EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surg Endosc, 2017, 31(7): 2946-2952.
24. Yukimoto T, Morisaki T, Komukai S, et al. 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. Intern Med, 2018, 57(11): 1517-1521.
25. Uemura S, Iwashita T, Iwata K, et al. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology, 2018, May 3. pii: S1424-3903(18)30082-6.
26. Jang S, Stevens T, Lopez R, et al. Superiority of gastrojejunostomy over endoscopic stenting for palliation of malignant gastric outlet obstruction. Clin Gastroenterol Hepatol, 2019, 17(7): 1295-1302.
27. Jang SH, Lee H, Min BH, et al. Palliative gastrojejunostomy versus endoscopic stent placement for gastric outlet obstruction in patients with unresectable gastric cancer: a propensity score-matched analysis. Surg Endosc, 2017, 31(10): 4217-4223.
28. Van Heek NT, De Castro SM, van Eijck CH, et al. The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life. Ann Surg, 2003, 238(6): 894-902.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Gastrojejunostomy and self-expandable metallic stent placement for malignant gastric outlet obstruction: a meta-analysis

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