Matched study of three methods for palliation of malignant pyloroduodenal obstruction

Background: The traditional management of pyloroduodenal obstruction is open gastrojejunostomy (OGJ). More recently laparoscopic gastrojejunostomy (LGJ) and endoscopic stenting (ES) have been introduced. The aim of this study was to evaluate the three approaches to the palliation of malignant pyloroduodenal obstruction. Methods: All patients who underwent surgery (open and laparoscopic) for malignant pyloroduodenal obstruction at Auckland City Hospital between 1989 and 2002 inclusive were identified from International Classification of Diseases (ICD) 10 codes and from the Otago Surgical Audit Database. Patients who had an endoscopic stent were identified from the Endoscribe database. A review of medical records was conducted and data recorded in a structured pro forma. There were 181 patients with malignant pyloroduodenal obstruction of whom 56 patients had OQJ, 14 had LQJ and 16 had ES. Patients in the LQJ and ES groups were matched with those who underwent OQJ with respect to American Society of Anesthesiologists (ASA) grade (I-V), age (within 10 years) and level of obstruction (pylorus, first part of duodenum D1, D2, D3 and D4). The primary outcomes compared between the groups were time to starting free oral fluids and light diet, length of stay and survival. Results: There were no significant differences in age, sex, ASA grade and level of obstruction between the matched OQJ (n = 16), LQJ (n = 14) and ES (n = 16) groups. There was a significant reduction in time to starting free oral fluids and light diet, and length of stay after the procedure, in the ES group. Patients who underwent surgical palliation of the obstruction had significantly more complications than those who underwent stenting (P = 0.016). There were no significant differences in requirement for biliary drainage either before or after the procedure between the three groups. Survival was shortest in the ES group. Conclusion: This matched study showed significant advantages for ES compared with OGJ and LQJ in the palliation of malignant pyloroduodenal obstruction.