A Comparison of Endoscopic and Surgical Gastrojejunostomy in Patients with Malignant Gastric Outlet Obstruction: A National Cohort Analysis (2016-2020).

Abstract

Background and aims: Malignant gastric outlet obstruction (MGOO) is an unfortunate complication of advanced upper gastrointestinal malignancies. Historically, surgical gastrojejunostomy has been the procedure of choice to achieve enteral bypass. Recently, endoscopic techniques have gained popularity in the management of MGOO. We aimed to compare peri-procedural outcomes between surgical and endoscopic gastrojejunostomy in patients with MGOO.

Methods: The National Inpatient Sample (NIS) was queried for 2016 through 2020. The International Classification of Diseases, Tenth Revision (ICD-10) codes were used to identify adult admissions with a principal diagnosis of gastric, pancreatic, or duodenal cancer undergoing endoscopic gastrojejunostomy (EGJ) or surgical gastrojejunostomy (SGJ). The two cohorts were compared for peri-procedural adverse events.

Results: Twenty thousand nine hundred thirty (20,930) hospitalizations undergoing gastrojejunostomy (16,585 SGJ and 4,345 EGJ) for MGOO were identified. The SGJ cohort had a higher proportion of patients with pancreatic cancer (36.16% vs 19.56%) and a lower proportion of patients with gastric cancer (55.16% vs 71.99%). A higher percentage of endoscopic GJs were performed in the Northeast (20.33% vs 27.66%, P<0.001), while a smaller percentage of endoscopic GJs were performed in the South (30.56% vs. 39.52%, P <0.001). Between the two groups, the difference in mortality rates was not significantly different [0.62, 95% CI 0.35-1.10, P =0.106), but the EGJ group had lower odds of respiratory failure [4.7% vs. 7.4%, aOR (adjusted odds ratio) 0.68, 95% CI (confidence interval) 0.48 - 0.96, P =0.032], blood transfusion [9.25% vs. 13.74%, aOR 0.63, 95% CI 0.48 - 0.82, P =0.001], and peritonitis [2.19% vs 4.5%, aOR 0.55, 95% CI 0.33-0.91, P =0.022]. The EGJ group had lesser hospitalization charges [mean $164,794 vs. $183,519, adjusted difference on regression $16,495, 95% CI $29,204 - $3,786, P =0.011], and shorter hospital stays [mean 9.88 vs. 12.56 days, adjusted difference 2.24 days, 95% CI 1.53 - 2.96 days, P <0.001]. The use of EGJ increased over five years [16.86% in 2016 to 24.14% in 2020, P-value for trend=0.002], while the use of SGJ decreased [83.13% in 2016 to 75.85% in 2020, Trend P=0.002].

Conclusions: Compared to surgical GJ, endoscopic GJ is associated with lower rates of peri-procedural adverse events, hospitalization charges, and length of stay. For these reasons, endoscopic GJ should be strongly considered in managing malignant gastric outlet obstruction.