A systematic review of methods to palliate malignant gastric outlet obstruction

Abstract

The traditional approach to palliating patients with malignant gastric outlet obstruction (GOO) has been open gastrojejunostomy (OGJ). More recently endoscopic stenting (ES) and laparoscopic gastrojejunostomy (LGJ) have been introduced as alternatives, and some studies have suggested improved outcomes with ES. The aim of this review is to compare ES with OGJ and LGJ in terms of clinical outcome.
A systematic literature search and review was performed for the period January 1990 to May 2008. Original comparative studies were included where ES was compared with either LGJ or OGJ or both, for the palliation of malignant GOO.
Thirteen studies met the inclusion criteria (10 retrospective cohort studies, two randomised controlled trials and one prospective study). Compared with OGJ, ES resulted in an increased likelihood of tolerating an oral intake [odds ratio (OR) 2.6, p = 0.02], a shorter time to tolerating an oral intake (mean difference 6.9 days, p < 0.001) and a shorter post-procedural hospital stay (mean difference 11.8 days, p < 0.001). There were no significant differences between 30-day mortality, complication rates or survival. There were an inadequate number of cases to quantitatively compare ES with LGJ.
This review demonstrates improved clinical outcomes with ES over OGJ for patients with malignant GOO. However, there is insufficient data to adequately compare ES with LGJ, which is the current standard for operative management. As these conclusions are based on observational studies only, future large well-designed randomised controlled trials (RCTs) would be required to ensure the estimates of the relative efficacy of these interventions are valid.

Full text

REVIEWS
A systematic review of methods to palliate malignant gastric outlet
obstruction
Jasen Ly ÆGregory O’Grady ÆAnubhav Mittal Æ
Lindsay Plank ÆJohn A. Windsor
Received: 13 December 2008 / Accepted: 26 May 2009 / Published online: 24 June 2009
ÓSpringer Science+Business Media, LLC 2009
Abstract
Background The traditional approach to palliating
patients with malignant gastric outlet obstruction (GOO)
has been open gastrojejunostomy (OGJ). More recently
endoscopic stenting (ES) and laparoscopic gastrojejunos-
tomy (LGJ) have been introduced as alternatives, and some
studies have suggested improved outcomes with ES. The
aim of this review is to compare ES with OGJ and LGJ in
terms of clinical outcome.
Method A systematic literature search and review was
performed for the period January 1990 to May 2008. Ori-
ginal comparative studies were included where ES was
compared with either LGJ or OGJ or both, for the palliation
of malignant GOO.
Results Thirteen studies met the inclusion criteria (10
retrospective cohort studies, two randomised controlled
trials and one prospective study). Compared with OGJ, ES
resulted in an increased likelihood of tolerating an oral
intake [odds ratio (OR) 2.6, p=0.02], a shorter time
to tolerating an oral intake (mean difference 6.9 days,
p\0.001) and a shorter post-procedural hospital stay
(mean difference 11.8 days, p\0.001). There were no
significant differences between 30-day mortality, compli-
cation rates or survival. There were an inadequate number
of cases to quantitatively compare ES with LGJ.
Conclusion This review demonstrates improved clinical
outcomes with ES over OGJ for patients with malignant
GOO. However, there is insufficient data to adequately
compare ES with LGJ, which is the current standard for
operative management. As these conclusions are based on
observational studies only, future large well-designed ran-
domised controlled trials (RCTs) would be required to ensure
the estimates of the relative efficacy of these interventions are
valid.
Keywords Gastric outlet Gastroduodenal obstruction 
Duodenal obstruction Gastrojejunostomy 
Gastric bypass Endoscopy Endoscopic stenting 
Meta-analysis
Gastric outlet obstruction (GOO) is a recognised compli-
cation of malignancies of the upper gastrointestinal (UGI)
tract. The most common causes are pancreatic and gastric
malignancies, with lymphomas, ampullary carcinomas,
biliary tract cancers and metastases also contributing. In
patients with pancreatic cancer, it is estimated that 15–20%
of patients develop gastric outlet obstruction [1]. Associ-
ated symptoms, including nausea, vomiting, abdominal
distension and the sequelae of malnutrition, contribute
substantially to morbidity in patients who are often termi-
nally ill with limited quality and quantity of remaining life.
In the palliative setting, a major clinical goal for patients
with malignant GOO is to restore the ability to tolerate an
oral diet. Given that median survival in this patient group
may be as short as 3–4 months [1,2], an ideal procedure
should restore oral intake quickly, with few complications,
short hospital stay and without negative impact on survival.
The traditional approach for the palliation of malignant
GOO has been open gastrojejunostomy (OGJ). More
recently there have been reports of laparoscopic gastroje-
junostomy (LGJ) [3,4], and although its role has not been
clearly defined, many now believe it to be safer than OGJ
[5]. Over the past decade or so there has also been an
J. Ly G. O’Grady A. Mittal L. Plank J. A. Windsor (&)
Department of Surgery, School of Medicine, Faculty of Medical
and Health Sciences, University of Auckland, Private Bag
92019, Auckland, New Zealand
e-mail: j.windsor@auckland.ac.nz
123
Surg Endosc (2010) 24:290–297
DOI 10.1007/s00464-009-0577-1

increasing experience with the use of palliative endoscopic
stenting (ES); a number of different types of upper GI
stents have since become available [6] and the procedure is
increasingly advocated and performed [7].
Two previous reviews have suggested significant clini-
cal advantages for ES over OGJ [8,9]. Since the publica-
tion of these reviews a number of additional studies have
been published, further comparing the clinical and practical
merits of ES and OGJ. The aim of this study is to provide
an updated systematic review comparing ES with OGJ and
LGJ with respect to ability to tolerate an oral intake, hos-
pital stay, mortality at 30 days, length of survival, com-
plication rate and associated costs.
Methods
Literature search
A comprehensive search for relevant clinical trials was
undertaken for the period January 1990 to May 2008.
Included sources were Medline, EMBASE, Google Scho-
lar, ISI Proceedings, the Cochrane Library and online
registers of controlled clinical trials. The search was not
language restricted and combined the following terms:
‘‘gastric outlet, gastroduodenal or duodenal obstruction’’,
‘‘gastrojejunostomy, gastroenterostomy or surgical bypass’’,
and ‘‘endoscop$ and stent’’. Reference lists of published
articles were hand-searched to ensure inclusion of all possible
studies.
Study inclusion and assessment
Only clinical studies directly comparing endoscopic stent-
ing and gastrojejunostomy for palliative management of
gastric outlet or duodenal obstruction were included. These
included randomised controlled trials (RCTs), prospective
and retrospective cohort comparison studies. Studies were
not excluded on the basis of sample size or language.
Studies reported only in abstract form were excluded, and
when more than one paper reported results from the same
patient population, only the most recent study was included.
Data extraction
Studies were appraised and data were abstracted indepen-
dently by two reviewers on a pre-defined proforma. The
primary clinical outcomes examined were: number of
patients tolerating an oral intake, time to oral intake, length
of hospital stay (after intervention to hospital discharge),
30-day mortality, survival and complications. It was
intended that a cost analysis also be undertaken with regard
to total relative costs of each treatment method; however,
inadequate data was found from the literature to report this
outcome.
Complications were defined as either technical (e.g.
stent failure and migration), surgical (e.g. stent obstruction,
anastomotic leak, peritonitis, haemorrhage or bowel
obstruction) or medical (e.g. respiratory tract infection,
myocardial infarction, acute renal failure or sepsis). Major
complications were defined as being life-threatening or
severe, and usually requiring additional major interventions
or hospitalisation. Minor complications were recognised as
not significantly extending hospital stay, nor leading to
further interventions or hospitalisation. Besides wound
infections, which were defined as a minor complication,
minor complications were not reported in the present study
because of their wide variability and relative infrequency.
Information on LGJ and OGJ populations were collected
separately for subgroup comparison. This was possible in
all but one study by Jeurnink et al. in which the outcomes
for both LGJ and OGJ were grouped together and could not
be extracted [2]. The communicating author of that study
was contacted and reported no evidence of a difference
between patients who had undergone OGJ (33 patients) and
LGJ (9 patients), therefore justifying the combination of
these two patient groups for the purposes of our analysis.
Subgroup analysis was not attempted for the site of the
primary tumour or stent type due to limited availability of
data.
For the purposes of this study we defined oral intake as
the ability to tolerate at least a liquid diet, which repre-
sented a common denominator for all studies and an
appropriate marker of clinical success. This definition also
applies to our measure of mean time to tolerating an oral
intake.
Statistical methodology
All statistical calculations and forest plots were produced
using Review Manager version 5.0.12 (Revman, Cochrane
Collaboration, Copenhagen). Where source studies had
reported median and range instead of mean and variance, we
estimated their mean and variance based on the median,
range and sample size according to the methods described by
Hozo et al. [10]. Data for studies where the mean and vari-
ance were not obtainable were excluded from the analysis.
Odds ratios with 95% confidence intervals (CI) were
calculated for dichotomous variables using the Mantel–
Haenszel method and a random-effects model. Weighted
mean differences with 95% CI were calculated for con-
tinuous variables, using an inverse variance method and a
random-effects model. Heterogeneity was calculated using
a chi-squared test. A significance level of p\0.05 was
considered statistically relevant for outcome and hetero-
geneity measures.
Surg Endosc (2010) 24:290–297 291
123

Forest plots were constructed for number of patients
tolerating an oral intake, mean time to tolerating an oral
intake, length of hospital stay, length of survival and
mortality at 30 days.
Results
In total, 13 studies met the criteria for inclusion in the
review [2–4,11–20]. These included 10 retrospective
cohort comparison studies, two randomised controlled tri-
als (RCTs) and one prospective cohort comparison study
(Table 1). No studies comparing ES versus OGJ or LGJ
were excluded.
Outcome data for a total of 514 patients were included.
The characteristics of each of the studies are displayed on
Table 1. One RCT looked exclusively at ES versus LGJ
[3]; the other 12 studies looked at ES versus either OGJ or
LGJ. Between the ES and GJJ (OGJ and LGJ combined)
groups, males were 1.5 times more likely to have received
ES than females (OR 1.58 [5], p=0.03). Mean age was
similar between ES and GJJ (p=0.48). The site of the
primary tumour was pooled for all studies and is displayed
in Table 2.
Endoscopic stenting versus open gastrojejunostomy
A total of 12 studies reported data comparing ES versus
OGJ. From these studies, 244 patients were treated with ES
and 218 patients with OGJ (the latter figure includes nine
patients receiving LGJ who could not be distinguished; see
‘‘Methods’’).
Ability to tolerate an oral intake was reported in 11
studies. Patients were more likely to tolerate an oral intake
following ES than after OGJ (OR 2.62; CI: 1.17, 5.86;
p=0.02; Fig. 1).
Mean time to oral intake was reported in nine studies, of
which six provided sufficient information for analysis (see
‘‘Methods’’). Patients were more likely to tolerate an oral
diet earlier following ES than with OGJ (mean difference
7 days; CI: 8.75, 5.02 days; p\0.001; Fig. 2).
Length of hospital stay was reported in 12 studies, of
which nine provided sufficient information for analysis.
Patients were more likely to be discharged from hospital
Table 1 Included studies
Author Journal Year Study type Country ES OGJ LGJ Total Mean age
(years)
Jeurnink SM, et al. J Surg Oncol 2007 Retrospective cohort The Netherlands 53 33 9 95 64
El-Shabrawi A, et al. Eur Surg 2006 Retrospective cohort Austria 22 17 – 39 73
Mehta S, et al. Surg Endosc 2006 Randomised controlled
trial
England 13 – 14 27 69
Espinel J, et al. Surg Endosc 2006 Retrospective cohort Spain 24 17 – 41 77
Mejia A, et al. Rev Col Gastroenterol
Sp.
2006 Retrospective cohort Columbia 15 15 – 30 58
Del Piano M, et al. Gastrointest Endosc 2005 Retrospective cohort Italy 24 23 – 47 75
Maetani I, et al. J Gastroenterol 2005 Retrospective cohort Japan 22 22 – 44 69
Fiori E, et al. Anticancer Res 2004 Randomised controlled
trial
Italy 9 9 – 18 71
Mittal A, et al. Br J Surg 2004 Retrospective cohort New Zealand 16 16 14 46 66
Maetani I, et al. Endoscopy 2004 Retrospective cohort Japan 20 19 – 39 70
Johnsson E, et al. World J Surg 2004 Prospective cohort Sweden 21 15 – 36 75
Wong YT, et al. Surg Endosc 2002 Retrospective cohort USA 6 17 – 23 NR*
Yim HB, et al. Gastrointest Endosc 2001 Retrospective cohort USA/Singapore 12 15 – 29 68
Totals 257 218 37 514 70
* Not reported
Table 2 Site of the primary tumour
Site of obstruction No. of patients
Pancreas 240
Stomach 94
Duodenum 20
Gallbladder/biliary tract 41
Metastases 29
Other* 28
Not specified

62
Total 514
* Other intra-abdominal malignancies

Cause not specified in two studies
292 Surg Endosc (2010) 24:290–297
123

sooner following ES than with OGJ (mean difference
12 days; CI: 15.65, 7.94 days; p\0.001; Fig. 3).
Length of survival was reported in 10 studies, of which
four provided sufficient information for analysis. There
was no significant difference in the length of survival fol-
lowing ES than with OGJ (mean difference 26 days; CI: –
69.03, 16.40 days; p=0.23; Fig. 4).
Mortality at 30 days was reported in nine studies. There
was no significant difference in mortality at 30 days for
patients undergoing ES versus OGJ (OR 0.83; CI: 0.32,
2.18; p=0.71; Fig. 5).
Comparison of procedure time was reported in only two
studies and could not be compared statistically. Maetani
et al. [11] found that on average it took 30 min for ES and
118 min for OGJ (p\0.0001), while Fiori et al. [18] found
that the average operating times were 40 and 93 min,
respectively (p\0.0001) [11,18].
Major complications were reported in 12 studies. There
were no significant differences in the rates of major com-
plications between patients undergoing ES versus OGJ (OR
1.04; CI: 0.47, 2.29; p=0.93). However, patients under-
going OGJ suffered more major medical complications
Fig. 1 Likelihood of tolerating an oral intake
Fig. 2 Mean time to oral intake
Fig. 3 Length of hospital stay
Surg Endosc (2010) 24:290–297 293
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such as respiratory tract infections, myocardial infarction
and acute renal failure. In patients undergoing ES the
majority of the complications were procedure related
(surgical or technical), including stent fracture, migration
and obstruction (Table 3). Wound infections were more
common in patients undergoing OGJ (ten) compared with
ES (zero).
Significant heterogeneity in all outcomes was noted.
Endoscopic stenting versus laparoscopic
gastrojejunostomy
A total of three studies reported data comparing ES with
LGJ. These studies could not be quantitatively compared
due to the small total number of procedures reported. A
summary analysis was therefore undertaken (Table 4).
Overall, ES demonstrated significant benefits across a
range of outcomes when compared with LGJ. Mehta et al.
[3] showed that ES resulted in a shorter length of hospital
stay [5.2 days, standard deviation (SD) 1.1 days] compared
with LGJ (11.4 days, SD 2.4 days) (p=0.02) and fewer
complications (zero and eight patients, respectively) [3]. In
the study by Mittal et al. [4], ES resulted in a shorter time
to tolerating an oral intake (0 and 4 days, respectively) and
a shorter length of hospital stay (2 and 7 days, respec-
tively), although with a decreased length of survival (56
and 119 days, respectively) [4].
Discussion
This review has demonstrated improved outcomes with ES
over OGJ for the palliation of symptoms associated with
Fig. 4 Length of survival
Fig. 5 Mortality at 30 days
Table 3 Major complications
ES OGJ
Major surgical complications
Stent fracture 2 –
Stent migration 6 –
Stent obstruction 10 –
Anastomotic leak – 2
Peritonitis 1 2
Other* 7 –
Major medical complications
Respiratory tract infection 1 6
Myocardial infarction – 3
Acute renal failure – 3
Sepsis – 2
Liver failure – 1
Not described

13 14
Total 46 57
* Includes pancreatitis, obstructive jaundice, tumour haemorrhage,
and bowel obstruction

Complications were reported by studies but not characterised
294 Surg Endosc (2010) 24:290–297
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malignant GOO and thereby potentially improved quality
of life. Patients undergoing ES are more likely to tolerate
an earlier oral intake (average 7 days) and leave hospital
earlier (average 12 days) with a comparable complication
rate (average 15–16%). These benefits for ES were dem-
onstrated without a significant increase in 30-day mortality
or decrease in length of survival.
In terms of complications, it was found that OGJ
resulted in substantially more major medical complications
such as respiratory tract infection, myocardial infarction
and acute renal failure. ES complications, by contrast,
usually related to technical factors leading to the need for
repeat intervention rather than major morbidity. Although
there were similar rates of overall complications, the
spectrum of complications suffered by the two groups was
therefore shown to favour patients undergoing ES.
There was inadequate data available to evaluate the
potential cost savings from ES over OGJ, particularly
because there is much heterogeneity in the way that these
costs have been measured in past studies. However, it is
anticipated that significant cost savings would arise in
favour of ES, directly from both the procedural costs and
from the substantial reduction in hospital stay, as well as
indirectly from the reduced procedural time and from
resulting improvements in staff productivity [4,14,16,17].
However, these potential savings may be at least partly
offset by potentially higher rates of re-intervention among
ES patients (discussed below), and it would therefore be
beneficial if future studies formally reported the cost dif-
ferences between the treatments in greater detail.
There was insufficient data in the literature to perform an
analysis comparing LGJ with OGJ or ES. Based on currently
available data, ES appears to provide some benefit with
respect to shorter time to tolerating an oral intake and shorter
time to hospital discharge compared with LGJ. When com-
pared with OGJ, Jeurnink et al. found that LGJ (33 OGJ
versus 9 LGJ) appeared to be more favourable in terms of
tolerating an oral intake, length of hospital stay and the rate of
complications, but found no statistical difference between the
two (Jeurnink SM, Personal communication, 2008). Navarra
et al. published a randomised controlled trial in 2005 com-
paring LGJ with OGJ in 24 patients (12 each) [21]. The study
showed that LGJ resulted in significantly less intraoperative
blood loss, shorter time to tolerating solid food intake and
lower rate of complications, but no evidence of a difference
in the hospital stay post-operatively. Conversely, in a retro-
spective study published in 1998 by Bergamaschi et al., only
intraoperative blood loss and hospital stay were significantly
different (22 OGJ versus 9 LGJ) [22]. Variation in outcomes
between these two studies is likely explained by their small
sample sizes and therefore low power. A high rate of con-
version to open surgery has also been noted in some LGJ
studies [23]. Overall, these studies support the observation
that LGJ is now the preferred standard for the operative
management of GOO, although additional randomised con-
trolled studies would be beneficial to further validate this
opinion [5].
Our findings are consistent with a previous meta-anal-
ysis published by Hosono et al. [8] which compared fewer
patients (154 ES versus 153 OGJ from 9 studies, compared
with 244 ES versus 218 OGJ from 12 studies here) [8].
Hosono et al. found less-marked improvements with
respect to restarting an oral intake (5.4 days difference) and
length of hospital stay (9.7 days difference), but no evi-
dence of a difference in the rate of complications or in
mortality at 30 days. Hosono et al. did not comment on the
length of survival or compare the costs of the procedures.
An important limitation of this study was the necessary
decision to restrict our analysis of outcomes, and especially
complications, to a 30-day post-procedure window. Few
data were available on longer-term outcomes for these
patients. With longer follow-up it might be expected that
ES patients would have greater rates of re-intervention due
to late tumour in-growth and stent migration. The need for
repeat stenting due to these events would decrease the
benefits attributed to ES, especially in terms of cost. In a
systematic review of ES and GJJ, for example, Jeurnink
et al. found a higher rate of recurrent obstructive symptoms
(18% after ES versus 1% for GJJ) for the ES group, and
therefore concluded that GJJ may remain the preferable
Table 4 Summary analysis
Investigator No. of
patients
(ES)
No. of
patients
(LGJ)
Patient characteristics Study
duration
Major findings
Jeurnink SM,
et al. 2007
53 9 Symptomatic malignant
gastric outlet obstruction
12 years Shorter hospital stay (6 vs. 14 days) following ES
Mehta S,
et al. 2006
13 14 Symptomatic malignant
gastric outlet obstruction
3 years Shorter hospital stay (5 vs. 11 days, p=0.02), less post-operative
pain and fewer complications (0 vs. 8) following ES
Mittal A,
et al. 2004
16 14 Symptomatic malignant
gastric outlet obstruction
13 years Shorter time to tolerating an oral intake (0 vs. 4 days)
and shorter length of post-procedural stay (2 vs. 7 days),
but reduced length of survival (56 vs. 119 days) following ES
Surg Endosc (2010) 24:290–297 295
123

procedure in patients with a longer expected duration of
survival [9]. The predominance of technical complications
following ES found in this study supports this observation.
However other factors must also be considered before more
definitive guidelines can be developed. It is likely, for
example, that the relative longer-term benefits of ES and
OGJ would depend on the different types of malignancy
responsible for GOO, due to differing durations of survival.
Stent technology and palliative oncology therapies are also
important and evolving research areas of relevance to this
question. In particular, ongoing advances in stent design
may be expected to reduce long-term stent failure, chal-
lenging any potential benefits for OGJ in patients with a
longer duration of survival [24].
Both Jeurnink et al. and Mittal et al. reported shorter
length of survival in patients undergoing ES compared with
OGJ. This finding was not supported by the present review,
but it should be noted that only four out of ten studies could
be used to answer this question [4,12,15,17]. In non-ran-
domised retrospective cohorts, such as most of those evalu-
ated here, patient selection bias is likely to be significant. For
example, clinicians may select more advanced cases or
patients with greater co-morbidities (and thus higher oper-
ative risk) to undergo ES, decisions that will translate to
changes in survival duration when the treatments are com-
pared. Data were also unavailable on the primary site of
obstruction, which as stated above, may influence length of
survival as patients with pancreatic or biliary malignancies
may have reduced survival compared with other groups [25].
We found few RCTs in the published literature for
inclusion in this review and therefore used cohort studies,
which are less than optimal because of their potential for
bias. Significant heterogeneity was, for example, noted
between studies for all major outcomes reported here. This
likely reflects differences between the patient populations
in terms of the site or stage of the primary tumour, and
specific treatment details such as the types of stents used,
surgical or endoscopic expertise and the way in which
outcomes were reported. In addition, neither of the RCTs
identified in this review contributed to measurement of the
primary outcomes.
Research questions that still remain include subpopula-
tions who may still benefit from OGJ such as those with
longer expected duration of survival, or whether ES with
improved stent technology becomes the superior option.
Additionally, patients may be discovered to have irresec-
table disease with GOO only after resection has been sur-
gically attempted, presenting a choice between on-table ES
or OGJ. Future studies might confirm whether the benefits
of ES extend to this particular scenario.
In conclusion, this study suggests improved outcomes
for ES over OGJ, and therefore palliative patients with
malignant GOO may be better palliated with ES when
compared with OGJ. However, there was insufficient data
to make an adequate comparison between ES and LGJ,
which is now widely believed to be the preferred operative
standard for the treatment of malignant GOO. Furthermore,
as the use of cohort studies is highly susceptible to bias, it
is impossible to ensure that current estimates regarding the
relative efficacy of these interventions are valid. Further
well-designed RCTs are therefore necessary to validate the
findings of this review.
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