Gastric cancer is a frequent pathology associated with significant morbidity and mortality and is the fifth most commonly diagnosed type of cancer worldwide. It holds third place in mortality, according to the World Health Organization1,2. Up to 50% of patients have advanced stage disease at diagnosis and only half of the patients with local or regional disease are candidates for potentially curative resection3. Distal gastric cancer is the cause of gastric outlet obstruction (GOO) in 35% of patients4 and its etiology is pancreatic adenocarcinoma in 15–25% of patients5.

By limiting or impeding the progression of the food bolus in the upper gastrointestinal tract, GOO favors the presence of altered electrolytes, malnutrition, and finally death6. Even when outcomes are not dramatic, said obstruction is associated with symptoms of significant quality of life deterioration, such as nausea and/or vomiting (92%), weight loss (63%), early satiety, and bloating7. The diagnosis of GOO depends on clinical suspicion and is confirmed through upper gastrointestinal endoscopy and diagnostic imaging, such as upper gastrointestinal radiography with water-soluble or barium-based contrast material, showing a lack of small bowel filling, or abdominal tomography, showing gastric distension, retained contrast medium and/or air-fluid levels7,8.

Intent-to-cure surgical management in GOO is an option in a very limited number of patients, and the palliative alternatives for the rest of patients do not always function, resulting in considerable morbidity and mortality associated with the procedures4. In the group of patients with GOO and the palliative option, management with self-expanding metal stents (SEMSs) is among the therapeutic possibilities. They are a minimally invasive alternative in nonsurgical palliative treatment, whose goal is to provide lasting relief from the obstructive symptoms so the patient can have a normal diet. There is also the alternative of surgical gastrojejunostomy (SGJ), in which an anastomosis between the stomach and the proximal jejunal segment is constructed. It can be an open or laparoscopic procedure, and given that it is a more invasive intervention, can increase morbidity9–12.

SEMSs are indicated in patients with unresectable or recurrent tumors that have a short life expectancy (on average between 2 and 6 months) and are contraindicated for SGJ. The performance of SGJ requires a better Eastern Cooperative Oncology Group (ECOG) functional status and high Karnofsky performance status score, as well as the absence of ascites, no metastasis to the liver, and an uncompromised nutritional status13,14.

In a randomized trial on 39 patients with GOO assigned to SGJ or SEMS placement, food intake rapidly improved in the SEMS group (5 vs 8 days), but long-term symptom relief was worse (50 vs 72 days), and there were more major complications (6 complications in 4 patients vs 0). There was no difference related to survival or health-associated quality of life. In addition, observational studies suggest that SEMS placement has a similar success rate to that of palliative surgery (90% of patients with clinical improvement), is less costly, and has lower procedure-related morbidity and mortality rates13. A study utilizing a database to compare 425 SEMS placement procedures with 399 SGJs for GOO management described a shorter hospital stay in the SEMS group (8 vs 16 days) and lower cost ($15,366 USD vs $27,391 USD)12.

The present study describes the results of the experience with SEMS placement and SGJ in the management of patients with GOO due to inoperable advanced neoplasia, evaluating the utility, efficacy, and safety of those procedures.

The aim of the present study was to characterize the population of patients diagnosed with malignant GOO that required SEMS placement or SGJ and to describe the technical and clinical success rates of the two interventions.

A retrospective analysis was conducted, sequentially utilizing nonprobability convenience sampling, on patients above 18 years of age that underwent SGJ or SEMS placement for the management of malignant GOO at the Hospital Universitario San Ignacio, within the time frame of January 1, 2010, to July 31, 2019. Patients were identified through databases and surgery logs. The inclusion criteria were patient age >18 years, diagnosis of malignant GOO made through upper gastrointestinal endoscopy (UGIE), upper gastrointestinal tract radiography, and/or abdominal computed tomography (CT), and management procedures. Patients were excluded that underwent SGJ or SEMS placement for benign disease. The medical records were reviewed of all the patients to determine patient demographics, clinical presentation, comorbidities, cancer staging, and radiologic study results.

The behavior of patients with GOO due to advanced gastrointestinal cancer that had SEMS placement or underwent SGJ was described in the present study, taking into consideration the fact that said obstruction can limit or impede progression of the food bolus through the digestive tract, producing malnutrition, electrolyte alterations, and finally death4. The indications for defining one intervention or another are known to be related to the clinical condition of the patient6, which could result in the groups not being comparable. However, in the present retrospective study, we found that age, sex, progression time, comorbidities, hemoglobin level, and type of cancer were similar, with only very slight differences, between the two study groups. With the exception of provenance, the symptoms that led to consultation, the diagnostic tools utilized, the time interval from cancer diagnosis to the appearance of symptoms of GOO, and the presence of metastasis were different in the two groups, and considerably greater in the SEMS group, regarding the last two variables. Unfortunately, data on ascites and tumor location were not obtained in either group, and therefore, could not be included in the analysis, which must be kept in mind when interpreting the results13.

Technical success, as well as clinical success, were slightly higher in the SGJ group, but with no statistically significant differences, and complications appeared to be fewer in the SGJ group. However, the times for beginning oral diet and hospital stay were significantly longer in the SGJ group, which was similar to that described in other studies. Among the statistically significant predictive factors for clinical success were histologic determination of the type of cancer and technical success. However, given their wide confidence intervals, they should be cautiously interpreted, a fact that was verified by the multivariate analysis, in which no factor was a determining one for clinical success.

In clinical practice, patients with pyloric syndrome are treated through SEMS placement, if their clinical condition is more compromised or their life-expectancy is below 3 months, because it is a less invasive technique9. That was reflected in the mean number of days of survival in the patients with a SEMS, compared with those that underwent SGJ. However, the SGJ-related risk of death was lower according to the Kaplan–Meier analysis, a finding that was modified by the multivariate Cox regression analysis, when controlling for the variables of comorbidities, metastasis, or hospital stay was done. Nevertheless, those results should be interpreted with caution, when considering a greater presence of metastasis and a longer time from the diagnosis of cancer in the SEMS group.

Important limitations of the present study were that probability sampling was not performed and the data were sequentially collected by convenience from a single center. Given the low frequency of the type of interventions studied, the sample size was small, which could also have limited the results. In addition, a descriptive analytic study is not the best design for establishing association, which is why we suggest that new studies, with better methodological quality for defining the best type of intervention in relation to efficacy and survival, should be conducted to confirm the findings of the present study. Because the present analysis was a retrospective study, some type of information and measurement bias is inevitable, given that all information is gleaned from what is written in the clinical history. Nevertheless, the information was thoroughly reviewed in an effort to avoid that type of bias as much as possible.

In conclusion, palliative alternatives for managing GOO in cases of distal gastric cancer, such as antroduodenal SEMS placement or SGJ, should be kept in mind. Enteral SEMS placement continues to be useful in distal gastric cancer, especially when surgery is not an option, as is the case of patients with more advanced disease and lower functional status. SGJ is considered in patients with better functional status that would potentially have greater technical and clinical success rates, as well as longer patency intervals. However, the extent of the clinical benefit provided by those procedures and their real impact on quality of life must be evaluated. Another important factor to be contemplated is expense, given that the cost of a SEMS on average is $735 USD, which does not include the additional charges for the resources required and hospital stay. The utility of those procedures is important to evaluate, not only for the rapid resolution of gastroduodenal obstruction, but also to determine whether the general health status of the patient with advanced-stage cancer will be improved or worsened. The possible complications must be assessed, and the risk-benefit of the procedures carefully analyzed12.

The results of the present study were insufficient for making recommendations on the theme, but they do illustrate the need to conduct a multicenter study for stronger results, with a closer follow-up of the patients. Ideally, it should also be a prospective study, to determine the effect the selection of a given intervention has on patients with pyloric syndrome, as well as to establish prognostic factors.

No financial support was received in relation to this article.

The authors declare that there is no conflict of interest.