To cut or not to cut; that is the question: surgical versus endoscopic gastrojejunostomy for the palliation of malignant gastric outlet obstruction.

A gastric outlet obstruction is a common adverse event of multiple GI malignancies, with pancreatic adenocarcinoma and gastric adenocarcinoma being the most common causes.1Samad A. Khanzada T.W. Shoukat I. Gastric outlet obstruction: change in etiology.Pak J Surg. 2007; 23: 29-32Google Scholar The symptoms generally include generalized abdominal pain, weight loss, nausea, and postprandial emesis secondary to the mechanical obstruction. Various treatment modalities are available to alleviate symptoms and allow the patient to successfully resume oral intake and ultimately continue with oncologic treatment. These treatment options include enteral stenting, surgical gastrojejunostomy (GJ), EUS-guided GJ, and decompressive PEG tube placement for patients who will likely not undergo further oncologic therapies. Each modality has its risks and benefits, with certain patient populations having a greater benefit with a certain modality. The present study by Canakis et al2Canakis A. Bomman S. Lee D.U. et al.Benefits of EUS-guided gastroenterostomy over surgical gastrojejunostomy in the palliation of malignant gastric outlet obstruction: a large multicenter experience.Gastrointest Endosc. 2023; 98: 348-359.e30Abstract Full Text Full Text PDF Scopus (2) Google Scholar set out to compare EUS-guided GJ with surgical GJ over a 7-year period at 6 different medical centers. The optimal treatment for a malignant gastric outlet obstruction (mGOO) is definitive oncologic surgery. However, for example, only about 15% of patients with pancreatic adenocarcinoma present with resectable disease.3Ansari D. Gustafsson A. Andersson R. Update on the management of pancreatic cancer: surgery is not enough.W J Gastroenterol. 2015; 21: 3157-3165Crossref PubMed Scopus (126) Google Scholar Therefore, these patients require either neoadjuvant therapy or palliative treatment if they are unresectable. Thus, mGOO presents a potentially challenging adverse event for the 85% of patients who are not initially candidates for surgery. Historically, many of these patients have undergone open laparotomy and a palliative surgical GJ to bypass the obstruction. Now this operation is frequently performed with minimally invasive techniques, either laparoscopically or robotically, but it still carries the risks associated with invasive surgery in an especially challenging patient population. With the advent of, and rapid advances in, EUS techniques and the development of lumen-apposing metal stents, transluminal access has become possible and is now used for multiple indications with good clinical results. This has now led to the use of this technique to access the jejunum from the stomach and subsequent placement of a lumen-apposing metal stent to the jejunum from the stomach.4Tyberg A. Perez-Miranda M. Sanchez-Ocaña R. et al.Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience.Endosc Int Open. 2016; 4: E276-E281Crossref PubMed Google Scholar This then creates an endoscopic GJ that allows oral intake to bypass the mGOO. This retrospective study included 310 patients, of whom 187 underwent endoscopic GJ and 123 underwent surgical GJ. Because this was not a randomized trial, there were some inherent differences in the patient population between groups. Of note, patients in the endoscopic group had lower albumin, likely because of the increased risk of a surgical anastomosis in patients with severe malnutrition. They were also older, had a higher chance of having ascites, underwent the procedure more for duodenal and metastatic lesions, underwent the procedure more for malignant causes than for benign causes, were more likely to be admitted for their mGOO, and had higher rates of using chemotherapy at the time of the mGOO diagnosis compared with the surgical GJ group. The overall conclusion between the 2 patient groups is that patients who underwent an endoscopic GJ were sicker than patients who underwent a surgical GJ. With that being said, procedural success was equally high between the groups; however, patients who underwent endoscopic GJ had lower rates of adverse events, quicker times to chemotherapy resumption, quicker time to the resumption of oral intake, and decreased length of stay. This did come at the cost of much higher rates of reintervention at almost 10 times that in patients who underwent surgical GJ. These results were replicated when further groups were formed of patients who underwent laparoscopic surgical GJ and open surgical GJ. As expected, laparoscopic GJ showed improved outcomes compared with open GJ, but the above results remained when laparoscopic or open surgical GJ were compared with endoscopic GJ. This study provides excellent insights into using the recent advancements in advanced endoscopic techniques to treat a very complex and morbid condition. It showed that using this endoscopic technique is not only feasible but efficacious and safe. When compared with the comparable surgical technique, it does seem to offer a viable solution, especially for patients who may be malnourished or in a more advanced stage of their particular disease. However, both the endoscopic and surgical interventions are palliative procedures aimed at improving quality of life and enabling the resumption of uninterrupted oral intake, which many studies have shown is essential for not only these patients’ nutrition but also their state of mind.5Xu N. An Q. Correlation between dietary score and depression in cancer patients: data from the 2005–2018 National Health and Nutrition Examination Surveys.Front Psychol. 2022; 13M978913Google Scholar The goals of any palliative procedure should be to palliate the symptomatology safely and quickly, with little interruption to other treatments while also being a durable solution. Although endoscopic GJ has shown to be very effective in resolving the symptoms and enabling further oncologic treatments quickly, it does carry with it a fairly high rate of reinterventions, especially when compared with surgical GJ. This potentially means additional readmissions, additional procedure-related concerns, and potential additional morbidity for a procedure that is entirely palliative in nature. Therefore, the short-term benefits of the endoscopic approach must be weighed against the greater need for additional procedures in the longer term. In reference to patient selection, the endoscopic approach may be more appropriate for malnourished patients, patients with a higher clinical frailty scale score, or patients without the expectation of prolonged survival secondary to their overall disease burden. Another endoscopic therapy for mGOO, duodenal stenting with a self-expandable metal stent, has been used successfully for some time but also carries a high rate of reinterventions.6Boghossian M.B. Funari M.P. De Moura D.T. et al.EUS-guided gastroenterostomy versus duodenal stent placement and surgical gastrojejunostomy for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.Langenbeck Arch Surg. 2021; 406: 1803-1817Crossref PubMed Scopus (23) Google Scholar This procedure is less technically demanding, does not require the use of EUS, and therefore could be more widely accepted by endoscopists not trained in EUS. This approach may be suitable for extremely frail patients or patients approaching or in hospice care who need palliation to remain at home and allow for oral intake. Although some studies have compared enteral stenting, endoscopic GJ, and surgical GJ, a valuable follow-up study to this current study would be the addition of patients in this patient population who have undergone enteral stenting.Thankfully, there are many current options in the treatment of mGOO, but each of them carries its own set of risks, benefits, and adverse events. This study will aid oncologists and endoscopists in the difficult task of determining which approach would be ideal for a certain patient. Dr Lyons is a consultant for Steris Endoscopy. Dr Marks is a consultant for Boston Scientific and Steris Endoscopy.