Stomach-partitioning gastrojejunostomy is better than conventional gastrojejunostomy in palliative care of gastric outlet obstruction for gastric or pancreatic cancer: a meta-analysis

Unresectable distal gastric or pancreatic malignancies are the most common cause of gastric outlet obstruction (GOO). Fourteen-point-nine percent of patients with antral gastric cancer develop signs and symptoms of GOO (1) and 10–25% of patients with pancreatic cancer require intervention for GOO (2-4). The traditional surgical procedure for GOO is a side-to-side gastrojejunal anastomosis approximately 20 to 30 cm distal to the ligament of Treitz (5) (Figure 1). Even though nowadays the palliative care of GOO can also be performed endoscopically by positioning a self-expanding stent (2,6), the gastrojejunal bypass still retains its role in the following situations: (I) surgeons working in hospitals without an advanced interventional endoscopy service; (II) diagnosis of unresectability made during the surgical intervention, considering that up to 10% of patients are still found to have unresectable disease at the time of surgery (2,7). The limit of the conventional gastrojejunostomy (CGJ) is the high postoperative incidence of delayed gastric emptying (DGE) so that 30–50% of these patients continue to have preoperative symptoms: nausea, vomiting, difficulty eating (8-10). Some surgeons added the gastric partitioning to the gastrojejunostomy (GPGJ) to prevent the DGE by ensuring a complete passage of food into the jejunum (11-13). Gastric partitioning was originally described by Devine in 1925 as a method of antral exclusion and complete division of the stomach accompanied by a gastro-entero anastomosis in the proximal gastric pouch (Figure 2) for the management of difficult duodenal ulcers (14). Subsequently, in 1936 Maingot adapted the procedure for the treatment of unresectable antral cancers (15). The risks of Devine’s classic technique are antral stump leak, hemorrhage and rupture. A further limit of this technique is the inability to perform an endoscopic cancer surveillance (8). For the above-mentioned reasons, a modified Devine technique was introduced, which divides partially the stomach, maintaining a passage that is 2 to 3 cm in diameter in the lesser curvature, and connects the jejunum to the proximal part of the stomach (8,16) (Figure 3). Although several authors reported better outcomes in patients submitted to GPGJ compared to CGJ (9,10,17), clinical experience with GPGJ is poor, studies comparing the two techniques are few and no randomized trials were performed