Ng Ayesha P, Hadaya Joseph E, Sanaiha Yas, Chervu Nikhil L, Girgis Mark D, Benharash Peyman
Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States.
Department of Surgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States.
J Gastrointest Surg. 2025 Feb;29(2):101884. doi: 10.1016/j.gassur.2024.101884. Epub 2024 Nov 14.
Of note, 15% to 20% of patients with duodenal or periampullary malignancies develop gastric outlet obstruction (GOO). Although small randomized trials have reported more rapid recovery and shorter hospital stay with endoscopic stenting (ES), limited studies have evaluated outcomes at a national level. The current study characterized short-term clinical and financial outcomes associated with gastrojejunostomy (GJ) vs ES in malignant GOO.
Adults with malignant GOO treated with ES or GJ were identified in the 2016-2020 Nationwide Readmissions Database. Entropy balancing was used to balance covariates between groups, and multivariate regression was used to evaluate the association between GJ or ES and in-hospital mortality, total parenteral nutrition (TPN) use, complications, length of stay (LOS), costs, and 90-day readmission.
Of 8186 patients with GOO, 5603 (68.4%) underwent ES, and 2583 (31.6%) underwent GJ. The cohorts were similar in age, female/male sex, and comorbidities. However, patients who underwent GJ were more commonly frail. After risk adjustment, mortality, composite complications, and 90-day readmission were comparable between patients who underwent GJ and those who underwent ES. GJ was associated with greater odds of blood transfusion (adjusted odds ratio [AOR], 1.74; 95% CI, 1.37-2.21) and postoperative TPN use (AOR, 3.76; 95% CI, 2.64-5.35). Furthermore, patients who underwent GJ experienced a significant increment of >$15,800 in costs and >6.9 days in LOS. In subgroup analysis of patients with metastatic disease, mortality, complications, and readmission remained comparable among palliation strategies.
ES seems to yield comparable short-term morbidity and mortality relative to GJ with significant cost reduction. Increasing access to endoscopic technology and regionalizing care to high-volume centers may help improve outcomes for patients with malignant GOO.
值得注意的是，15%至20%的十二指肠或壶腹周围恶性肿瘤患者会发生胃出口梗阻（GOO）。尽管小型随机试验报告称内镜支架置入术（ES）能使患者恢复更快且住院时间更短，但在国家层面评估其结局的研究有限。本研究对恶性GOO患者行胃空肠吻合术（GJ）与ES相关的短期临床和经济结局进行了特征分析。
在2016 - 2020年全国再入院数据库中识别接受ES或GJ治疗的成年恶性GOO患者。采用熵平衡法平衡组间协变量，并使用多因素回归评估GJ或ES与住院死亡率、全胃肠外营养（TPN）使用、并发症、住院时间（LOS）、费用及90天再入院之间的关联。
在8186例GOO患者中，5603例（68.4%）接受了ES，2583例（31.6%）接受了GJ。两组在年龄、性别及合并症方面相似。然而，接受GJ的患者更常见身体虚弱。风险调整后，接受GJ的患者与接受ES的患者在死亡率、复合并发症及90天再入院率方面相当。GJ与输血几率增加（调整优势比[AOR]，1.74；95%可信区间[CI]，1.37 - 2.21）及术后TPN使用几率增加（AOR，3.76；95%CI，2.64 - 5.35）相关。此外，接受GJ的患者费用显著增加超过15,800美元，住院时间延长超过6.9天。在转移性疾病患者的亚组分析中，姑息治疗策略之间的死亡率、并发症及再入院率仍相当。
与GJ相比，ES似乎能产生相当的短期发病率和死亡率，且成本显著降低。增加内镜技术的可及性并将医疗服务集中于高容量中心可能有助于改善恶性GOO患者的结局。
