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Digestive Diseases and Sciences

, Volume 52, Issue 1, pp 276–281 | Cite as

Surgical Bypass Versus Endoscopic Stenting for Malignant Gastroduodenal Obstruction: A Decision Analysis

  • Ali SiddiquiEmail author
  • Stuart J. Spechler
  • Sergio Huerta
Original Article

Abstract

The treatment options for palliating malignant gastroduodenal obstruction include open gastrojejunostomy (OGJ), laparoscopic gastrojejunostomy (LGJ), and endoscopic stenting (ES). The aim of this study was to compare the clinical outcomes and costs among ES, OGJ, and LGJ in patients who present with gastroduodenal obstruction from advanced upper gastrointestinal tract cancer. We designed a model for patients with malignant gastroduodenal obstruction. We analyzed success rates, complication rates and costs of the three treatment modalities: ES, OGJ, and LGJ. Baseline outcomes and costs were based on published reports. Success was defined as no major procedure-related and long-term complications over a 1-month period. Failure of therapy was defined as recurrent symptoms or death due to a procedural complication. Sensitivity analyses and cost-effectiveness analyses for the various strategies were performed. ES resulted in the lowest mortality rate and the lowest cost of the three treatment options analyzed. Mortality in the OGJ group was 2.1 times that in the ES cohort and 1.8 times that in the LGJ cohort. Sensitivity analyses confirmed ES as the dominant strategy. In conclusion, ES is the preferred treatment for palliation of duodenal obstruction due to advanced upper gastrointestinal tract cancer.

Keywords

Pancreatic cancer Gastric cancer Duodenal cancer Duodenal obstruction Gastric outlet obstruction Self-expanding metal stents Open gastrojejunostomy Laparoscopic gastrojejunostomy 

References

  1. 1.
    Lillemoe KD, Cameron JL, Hardacre JM, et al. (1999) Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg 230:322–328PubMedCrossRefGoogle Scholar
  2. 2.
    van Heek NT, van Geenen RC, Busch OR, et al. (2002) Palliative treatment in “peri”-pancreatic carcinoma: stenting or surgical therapy? Acta Gastroenterol Belg 65:171–175PubMedGoogle Scholar
  3. 3.
    Kulke MH (2002) Metastatic pancreatic cancer. Curr Treat Options Oncol 3:449–457PubMedCrossRefGoogle Scholar
  4. 4.
    Khullar SK, DiSario JA (1996) Gastric outlet obstruction. Gastrointest Endosc Clin North Am 6:585–603Google Scholar
  5. 5.
    Adler DG, Baron TH (2002) Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol 97:72–78PubMedCrossRefGoogle Scholar
  6. 6.
    Alam TA, Baines M, Parker MC (2003) The management of gastric outlet obstruction secondary to inoperable cancer. Surg Endosc 17:320–323PubMedCrossRefGoogle Scholar
  7. 7.
    Bozzetti F, Bonfanti G, Audisio RA, et al. (1987) Prognosis of patients after palliative surgical procedures for carcinoma of the stomach. Surg Gynecol Obstet 164:151–154PubMedGoogle Scholar
  8. 8.
    Kazanjian KK, Reber HA, Hines OJ (2004) Laparoscopic gastrojejunostomy for gastric outlet obstruction in pancreatic cancer. Am Surg 70:910–913PubMedGoogle Scholar
  9. 9.
    Sarr MG, Cameron JL (1982) Surgical management of unresectable carcinoma of the pancreas. Surgery 91:123–133PubMedGoogle Scholar
  10. 10.
    Di Fronzo LA, Cymerman J, Egrari S, et al. (1999) Unresectable pancreatic carcinoma: correlating length of survival with choice of palliative bypass. Am Surg 65:955–958PubMedGoogle Scholar
  11. 11.
    Lawrence W Jr, McNeer G (1958) The effectiveness of surgery for palliation of incurable gastric cancer. Cancer 11:28–32PubMedCrossRefGoogle Scholar
  12. 12.
    Choi YB (2002) Laparoscopic gatrojejunostomy for palliation of gastric outlet obstruction in unresectable gastric cancer. Surg Endosc 16:1620–1626PubMedCrossRefGoogle Scholar
  13. 13.
    Wong YT, Brams DM, Munson L, et al. (2002) Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation. Surg Endosc 16:310–312PubMedCrossRefGoogle Scholar
  14. 14.
    Yim HB, Jacobson BC, Saltzman JR, et al. (2001) Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc 53:329–332PubMedGoogle Scholar
  15. 15.
    Steiner C, Elixhauser A, Schnaier J (2002) The healthcare cost and utilization project: an overview. Eff Clin Pract 5:143–151PubMedGoogle Scholar
  16. 16.
    Yeo TP, Hruban RH, Leach SD, et al. (2002) Pancreatic cancer. Curr Probl Cancer 26:176–275PubMedCrossRefGoogle Scholar
  17. 17.
    Singh SM, Longmire WP Jr, Reber HA (1990) Surgical palliation for pancreatic cancer. The UCLA experience. Ann Surg 212:132–139PubMedCrossRefGoogle Scholar
  18. 18.
    Bergamaschi R, Marvik R, Thoresen JE, et al. (1998) Open versus laparoscopic gastrojejunostomy for palliation in advanced pancreatic cancer. Surg Laparosc Endosc 8:92–96PubMedCrossRefGoogle Scholar
  19. 19.
    Mittal A, Windsor J, Woodfield J, et al. (2004) Matched study of three methods for palliation of malignant pyloroduodenal obstruction. Br J Surg 91:205–209PubMedCrossRefGoogle Scholar
  20. 20.
    Ghanem AM, Hamade AM, Sheen AJ, et al. (2006) Laparoscopic gastric and biliary bypass: a single-center cohort prospective study. J Laparoendosc Adv Surg Tech A 16:21–26PubMedCrossRefGoogle Scholar
  21. 21.
    Mehta S, Hindmarsh A, Cheong E, et al. (2006) Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction. Surg Endosc 20:239–242PubMedCrossRefGoogle Scholar
  22. 22.
    Topazian M, Ring E, Grendell J (1992) Palliation of obstructing gastric cancer with steel mesh, self-expanding endoprostheses. Gastrointest Endosc 38:58–60PubMedGoogle Scholar
  23. 23.
    Feretis C, Benakis P, Dimopoulos C, et al. (1996) Palliation of malignant gastric outlet obstruction with self-expanding metal stents. Endoscopy 28:225–228PubMedCrossRefGoogle Scholar
  24. 24.
    Holt AP, Patel M, Ahmed MM (2004) Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice? Gastrointest Endosc 60:1010–1017PubMedCrossRefGoogle Scholar
  25. 25.
    Lindsay JO, Andreyev HJ, Vlavianos P, et al. (2004) Self-expanding metal stents for the palliation of malignant gastroduodenal obstruction in patients unsuitable for surgical bypass. Aliment Pharmacol Ther 19:901–905PubMedCrossRefGoogle Scholar
  26. 26.
    Johnsson E, Thune A, Liedman B (2004) Palliation of malignant gastroduodenal obstruction with open surgical bypass or endoscopic stenting: clinical outcome and health economic evaluation. World J Surg 28:812–817PubMedCrossRefGoogle Scholar
  27. 27.
    Del PM, Ballare M, Montino F, et al. (2005) Endoscopy or surgery for malignant GI outlet obstruction? Gastrointest Endosc 61:421–426CrossRefGoogle Scholar
  28. 28.
    Maosheng D, Ohtsuka T, Ohuchida J, et al. (2001) Surgical bypass versus metallic stent for unresectable pancreatic cancer. J Hepatobil Pancreat Surg 8:367–373CrossRefGoogle Scholar
  29. 29.
    Bethge N, Breitkreutz C, Vakil N (1998) Metal stents for the palliation of inoperable upper gastrointestinal stenoses. Am J Gastroenterol 93:643–645PubMedCrossRefGoogle Scholar
  30. 30.
    Espinel J, Sanz O, Vivas S, et al. (2006) Malignant gastrointestinal obstruction: endoscopic stenting versus surgical palliation. Surg Endosc 20(7):1083–1087Google Scholar
  31. 31.
    Ely CA, Arregui ME (2003) The use of enteral stents in colonic and gastric outlet obstruction. Surg Endosc 17:89–94PubMedCrossRefGoogle Scholar
  32. 32.
    Brandabur JJ, Kozarek RA, Ball TJ, et al. (1988) Nonoperative versus operative treatment of obstructive jaundice in pancreatic cancer: cost and survival analysis. Am J Gastroenterol 83:1132–1139PubMedGoogle Scholar
  33. 33.
    Raikar GV, Melin MM, Ress A, et al. (1996) Cost-effective analysis of surgical palliation versus endoscopic stenting in the management of unresectable pancreatic cancer. Ann Surg Oncol 3:470–475PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • Ali Siddiqui
    • 1
    • 3
    Email author
  • Stuart J. Spechler
    • 1
  • Sergio Huerta
    • 2
  1. 1.Division of GastroenterologyVA North Texas Health Care System and University of Texas Southwestern Medical SchoolDallasUSA
  2. 2.Division of GI/Endocrine SurgeryVA North Texas Health Care System and University of Texas Southwestern Medical SchoolDallasUSA
  3. 3.Division of GastroenterologyVA North Texas Health Care System (111B1)DallasUSA

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