Palliative procedures for malignant gastric outlet obstruction: A network meta-analysis.

Abstract

The optimal treatment for malignant gastric outlet obstruction (GOO) remains uncertain. The aim of this systematic review was to comprehensively investigate the efficacy and safety of four palliative treatments for malignant GOO: gastrojejunostomy (GJ), endoscopic ultrasound-guided gastroenterostomy (EGE), stomach-partitioning gastrojejunostomy (PGJ), and endoscopic stenting (ES). We searched the PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases; ClinicalTrials.gov; and the World Health Organization International Clinical Trials Registry Platform for randomized controlled trials (RCTs) and cohort studies comparing the aforementioned treatments for malignant GOO. We included studies that reported at least one of the following clinical outcomes: clinical success, 30-day mortality, reintervention rate, or length of hospital stay. Evidence from RCTs and non-RCTs was naïve combined to perform network meta-analysis through the frequentist approach using an inverse variance model. Treatments were ranked by P-score. This network meta-analysis included 3417 patients from 4 RCTs, 4 prospective cohort studies, and 32 retrospective cohort studies. PGJ was the optimal approach in terms of clinical success and reintervention (P-scores: 0.95 and 0.90, respectively). EGE had the highest probability of being the optimal treatment in terms of 30-day mortality and complications (P-scores: 0.82 and 0.99, respectively). Cluster ranking to combine the P-scores for 30-day mortality and reintervention indicated the benefits of PGJ and EGE (cophenetic correlation coefficient: 0.94; PGJ and EGE were in the same cluster). PGJ and EGE are recommended for malignant GOO. PGJ could be the alternative choice in centers with limited resources or cases unsuitable for EGE.