Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial
Received 25 January 2009; accepted 25 September 2009. published online 09 December 2009.
Background
Both gastrojejunostomy (GJJ) and stent placement are commonly used palliative treatments of obstructive symptoms caused by malignant gastric outlet obstruction (GOO).
Objective
Compare GJJ and stent placement.
Design
Multicenter, randomized trial.
Setting
Twenty-one centers in The Netherlands.
Patients
Patients with GOO.
Interventions
GJJ and stent placement.
Main Outcome Measurements
Outcomes were medical effects, quality of life, and costs. Analysis was by intent to treat.
Results
Eighteen patients were randomized to GJJ and 21 to stent placement. Food intake improved more rapidly after stent placement than after GJJ (GOO Scoring System score ≥2: median 5 vs 8 days, respectively; P < .01) but long-term relief was better after GJJ, with more patients living more days with a GOO Scoring System score of 2 or more than after stent placement (72 vs 50 days, respectively; P = .05). More major complications (stent: 6 in 4 patients vs GJJ: 0; P = .02), recurrent obstructive symptoms (stent: 8 in 5 patients vs GJJ: 1 in 1 patient; P = .02), and reinterventions (stent: 10 in 7 patients vs GJJ: 2 in 2 patients; P < .01) were observed after stent placement compared with GJJ. When stent obstruction was not regarded as a major complication, no differences in complications were found (P = .4). There were also no differences in median survival (stent: 56 days vs GJJ: 78 days) and quality of life. Mean total costs of GJJ were higher compared with stent placement ($16,535 vs $11,720, respectively; P = .049 [comparing medians]). Because of the small study population, only initial hospital costs would have been statistically significant if the Bonferroni correction for multiple testing had been applied.
Limitations
Relatively small patient population.
Conclusions
Despite slow initial symptom improvement, GJJ was associated with better long-term results and is therefore the treatment of choice in patients with a life expectancy of 2 months or longer. Because stent placement was associated with better short-term outcomes, this treatment is preferable for patients expected to live less than 2 months. (Clinical trial registration number: ISRCTN 06702358.)
Rotterdam, Amsterdam, Amersfoort, Utrecht, The Netherlands
Current affiliations: Departments of Gastroenterology and Hepatology (S.M.J., E.J.K., P.D.S.), Public Health (E.W.S.), Surgery (C.H.J.V.), and Internal Medicine (E.J.K.), Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands, Department of Gastroenterology and Hepatology (J.E.V.), Academic Medical Center Amsterdam, Amsterdam, The Netherlands, Department of Gastroenterology and Hepatology (M.P.S.), Meander Medical Center Amersfoort, Amersfoort, The Netherlands, Department of Gastroenterology and Hepatology (F.P.V., P.D.S.), University Medical Center Utrecht, Utrecht, The Netherlands
Reprint requests: Suzanne M. Jeurnink, MSc, Department of Gastroenterology and Hepatology, Erasmus MC/University Medical Center Rotterdam, ‘s Gravendijkwal 230, 3015 CE Rotterdam, The Netherlands.
See CME section; p. 596
DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: S.M. Jeurnink, P.D. Siersema, E.W. Steyerberg, and E.J. Kuipers were financially supported byZonMW(grant945-06-503). All other authors disclosed no financial relationships relevant to this publication.
ABSTRACT
Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial