Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

Table 1 Systematic review and meta-analysis: Stents vs gastrojejunostomy

Ref.	Type of study	GJ studies	Surgery	Endoscopic stent	No differences
Minata et al[8], 2016	Systematic review	LGJ (Mehta 2006, Jeurnink 2010) OGJ (Jeurnink 2010, Fiori 2013)	Lower re-intervention rate	Less invasive COVERED: Higher migration UNCOVERED: Higher obstruction	Technical success Complications
Nagaraja et al[13], 2014	Meta-analisis	Laparoscopic GJ (Mittal 2004, Mehta 2006, Jeurnink 2007, Jeurnink 2010)		Shorter LOS	Technical and clinical outcomes
Ly et al[38], 2010	Systematic review	Open GJ (Jeurnink 2007, El-Shabrawi 2006, Mehta 2006, Espinal 2006, Mejia 2006, del Piano 2005, Maetani 2005, Fiori 2004, Mittal 2004, Maetani 2004, Johnsson 2004, Wong 2002, Yim 2001) Laparoscopic GJ (Jeurnink 2007, Mehta 2006, Mittal 2004)	More major medical complications	More likely to tolerate an oral intake More likely to tolerate an oral diet earlier Shorter LOS	Survival 30 d-mortality Major complications

LOS: Length of stay; GJ: Gastrojejunostomy.

Table 2 Systematic review of laparoscopic gastrojejunostomy for gastrict obstruction due to advanced hepatobiliary cancer

Ref.	n	Type of study	HPB Etiology	Biliary obstruction	Operating time	Perioperative morbidity	Time to initiate intake	Time to solid food	LOS	Duration of food intake	Comment
All HPB Malignancy
Jeurnink et al[60], 2007	95	Cohort: GJ (42) vs duodenal stent (53)	GJ: All patients (laparoscopy: 10)	GJ: 17 previous treatment	ND	GJ: 4 major (hemorrhage, severe pain, cholangitis, respiratory failure); 13 minor (mild pain, wound infection, nausea and vomiting)	ND	GJ: 10.1 ± 4.8 d	GJ: 18d (4-55)	ND
Hamade et al[4], 2005	21	Cohort: laparoscopic GJ/CJ/GJ+CJ	All patients	5 biliary bypass, 8 GJ+biliary bypass	gastric bypass 75 min, GJ+CJ 130 min	1 pneumonia, 1 central line sepsis, 1 wound abscess	ND	ND	4 d (1-14)	9 patients untill death	Includes pre-treatment, profilactic and terapeutic GJ
Denley et al[9], 2005	18	Case series: LGJ	All patients	ND	ND	2 reconversions, 1 leak, 1 sepsis, 1 DGE	ND	ND	6 (3-22)	15 patients untill death
Kazanjian et al[5], 2004	9	Case series: LGJ	All patients	ND	116 min (75-300)	1 DGE, 1 Cholangitis	ND	4 d (3-6)	7 d (5-18)	ND	4 patient previous stent
Alam et al[61], 2003	8	Case series: LGJ	All patients	ND	135 min	Pneumonia (1)	ND	4 (2-7)	7 (5-13)	7 patients untill death
Kuriansky et al[62], 2000	12	Case series: LGJ+biliary bypass	All patients	12 CCJ	89.16 min (35-150)	2 wound infection, 1 pneumonia, 2 DGE, 1 reintervention (bleeding)	ND	ND	6.4 (5-17)	All patients untill death
Casaccia et al[63], 1999	6	Case series: LGJ	All patients	4 ES. 2 Laparoscopic CCJ	82 min (60-135)	1 Bleeding (transfusion)	ND	ND	4.5 (4-6)	ND
Casaccia et al[64], 1998	5	Case series: LGJ	All patients	4 ES. 1 laparoscopic CCJ	ND	1 Bleeding (transfusion)	ND	ND	4 (4-6)	ND
Rhodes et al[65], 1995	16	Case series: laparoscopic CCJ ± GJ (5GJ, 3 both, 9CCJ)	All patients	ND	75 min	1 DGE, 1 ictus	ND	ND	4 d (3-33)	ND	Results of the entire data series
Wilson et al[57], 1992	2	Case series: LGJ	All patients	ND	120 min	None	2d	3 d, 4 d	4-5 d	1 patient untill death
Mixed malignancies
Zhang et al[66], 2011	28	Case series: LGJ for benign/malignant disease	7 HPB malignancy	ND	170 min	2 reinterventions (anastomotic leak, trocar site hemorrhage), 2 bleeding controlled by endoscopy, 1 ileus, 5 DGE	3d	5 d	8 d (2-83)	ND	Results of the entire data series
Guzman et al[3], 2009	20	Cohort: LGJ AND OGJ	Laparoscopy: 8 HPB malignancy	ND	116 min	2 DGE	ND	7 d	8 d	ND
Navarra et al[67], 2006	24	RCT: 12 LGJ vs 12 OGJ	Laparoscopy: 5 HPB malignancy	ND	150 min	None	ND	4.08 d	11 d	ND
Mehta et al[39], 2006	27	RCT: 14 LGJ vs 13 SEMS	ND	6 patients (ES, PD)	ND	2 bleeding, 1 wound infection, 1 pneumonia, 3 DGE. 3 mortality (sepsis, pneumonia, carcinomatosis)	ND	ND	11.4 D	ND
Al-Rashedy et al[68], 2005	26	Cohort: LGJ and OGJ	Laparoscopy: 7 HPB malignancy	ND	ND	2 (13.3%)	ND	ND	3 (3-8)	ND
Khan et al[69], 2005	19	Case series: laparoscopic CCJ ± GJ (16 GJ, 1 CCJ, 2 both)	7 HPB malignancy	2 CCJ	164 min single bypass, 245 min double bypass	ND	3d	ND	ND	ND
Mittal et al[37], 2004	56	Cohort: 16 OGJ, 14 LGJ, 16 ES.	Laparoscopy: 9 HPB malignancy	None patient	ND	4 pneumonia, 1 ileus, 1 wound infection	ND	5 d (4-8)	13.5 d (6-36) (after procedure 7d)	ND
Bergamaschi et al[70], 2002	55	Case/control: antiperistaltic vs isoperistaltic LGJ	AP-LGJ: 29 HPB malignancy, IP-LGJ 14 HPB malignancy	ND	100min (AP) vs 99min (IP)	14 (II: 1, III: 9, IV: 3)	ND	5.1d (AP) vs 5.3 d (IP)	8.4 d (AP) vs 8.1 d (IP)	ND
Bergamaschi et al[71],1998	22	Case /control: OGJ (prophylactic and GOO treatment) vs LGJ (GOO treatment)	Laparoscopy: 9 HPB malignancy	1 ES, 3 PD	94 min	Pneumonia (1), SSI (1), delayed gastric emptying (1)	ND	8.4 (media)	18.4 (media)	ND
Brune et al[15], 1997	16	Case series: LGJ	13 HPB malignancy	ES/PD	126 min (70-210)	1 reintervention (hemorrhage), 3 delayed gastric emptying	ND	ND	4.7 (2-8)	16 patients untill death
Nagy et al[72], 1995	10	Case series: LGJ	9 HPB malignancy	8 ES/1 PD/ 2 simultaneous CJ	ND	2 reconversions, 1 CCF, 1 pneumonia, 1 CD infection	ND	10 d (4-15)	ND	All patients untill death

HPB: Hepatopancreatic-biliary; LOS: Length of stay; LGJ: Laparoscopic gastrojejunostomy; OGJ: Open gastrojejunostomy; ND: Not described; GOO: Gastric outlet obstruction; CCJ: Cholecystojejunostomy; CJ: Choledochojejunostomy; ES: Endoscopic stent; PD: Percutaneous drainage; AP: Antiperistaltic; IP: Isoperistaltic; CCF: Congestive cardiac failure; RCT: Randomized controlled trial; CD: Clostridium difficile; DGE: Delayed gastric emptying.

Table 3 Systematic review of laparoscopic gastrojejunostomy for gastrict obstruction due to advanced hepatobiliary cancer: Surgical technique

Ref.	Peristalsis	Location	Type
All HPB malignancy
Jeurnink et al[60], 2007	ND	Antecolic	Completely stapler
Hamade et al[4], 2005	IP	Antecolic	Stapler + manual suture
Denley et al[9], 2005	IP	Antecolic	Stapler + manual suture
Kazanjian et al[5], 2004	ND	Antecolic	Completely stapler
Alam et al[61], 2003	IP	ND	Completely stapler
Kuriansky et al[62], 2000	ND	Retrocolic	Completely stapler
Casaccia et al[63], 1999	ND	Antecolic	Completely stapler/stapler+ manual suture
Casaccia et al[64], 1998	ND	Antecolic	Completely stapler/stapler+ manual suture
Rhodes et al[65], 1995	ND	ND	Stapler + manual suture
Wilson et al[57], 1992	ND	Antecolic	Stapler + manual suture
Mixed malignancies
Zhang et al[66], 2011	ND	Antecolic (majority)	Stapler + manual suture
Guzman et al[3], 2009	ND	ND	Stapler + manual suture
Navarra et al[67], 2006	IP	Antecolic	Stapler + manual suture
Mehta et al[39], 2006	ND	Antecolic	Stapler + manual suture
Al-Rashedy et al[68], 2005	ND	Antecolic	Hand-sutured or stapler
Khan et al[69], 2005	ND	Antecolic	Stapler + manual suture
Mittal et al[37], 2004	ND	ND	ND
Bergamaschi et al[70], 2002	29 AP vs 14 IP	Antecolic	17 completely stapled/38 stapler+ manual suture
Bergamaschi et al[71],1998	ND	ND	7 completely stapled/2 stapler+ manual suture
Brune et al[15], 1997	IP	Antecolic	Stapler + manual suture
Nagy et al[72], 1995	ND	Antecolic	Stapler + manual suture

IP: Isoperistaltic; AP: Antiperistaltic; ND: Not described.

Table 4 Personal serie of laparoscopic gastrojejunostomy

Age/sex	Biliary obstruction	Surgical technique	Clinical success	Time to initiate intake	Surgery-discharge (d)	90-d morbidity	Duration of food intake	Survival (d)
87/F	No	IP antecolic, stapler + manual suture	Yes	4	12	CD infection	Until death	402
76/M	Biliary stent	IP antecolic, stapler + manual suture	Yes	3	12	No	Until death	228
91/F	No	IP antecolic, stapler + manual suture	Yes	1	5	No	Until death	278
78/F	No	IP antecolic, stapler + manual suture	Yes	3	10	Readmission: Sepsis due to hepatic abscess (death)	78	78
68/F	Biliary stent	IP antecolic, stapler + manual suture	Yes	3	12	Readmission: Intestinal obstruction due to carcinomatosis (death)	82	82
76/M	Biliary stent	IP antecolic, stapler + manual suture	Yes	3	13	Catheter-related bacteriemia. Readmission: Biliary stent due to jaundice.	Until death	220
76/F	No	IP antecolic, stapler + manual suture	Yes	3	5	No	Until death	ND

M: Male; F: Female; IP: Isoperistaltic; CD: Clostridium difficile; ND: Not described; LOS: Lenght of stay.

Table 5 Technical options for gastric outlet obstruction: advantages and disadvantages

Procedure	Advantages	Disadvantages
Open GJ	Bypass of tumor	Most invasive procedure
	Established surgical procedure	Longer LOS
	Lower re-intervention rate	Nutritional status
	Good long-term results	Critically ill patients
Laparoscopic GJ	Bypass of tumor	Invasive procedure
	Lower re-intervention rate	Longer LOS
	Established surgical procedure	Nutritional status
	Less invasive than open GJ	Critically ill patients
	Good long-term results
Endoscopic enteral stent	Short procedure time	Stent migration
	Established endoscopic procedure	Patency
	Broad indication regardless patient condition
	Short LOS
	Good short-term results
EUS-GJ	Bypass of tumor	Special device
	Short procedure time	Non-establish endoscopic procedure
	Short LOS	Serious adverse events
	Less invasive

EUS-GJ: Endoscopic ultrasound gastrojejunostomy; GJ: Gastrojejunostomy; LOS: Length of stay.