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Palliative procedure for malignant gastric outlet obstruction: a systematic review and network meta-analysis
Type
thesis
Date Issued
2024-06-25
Author(s)
TRAN VAN KHOI
Advisor
譚家偉
Subjects
系所名稱：國際醫學研究博士學位學程
Publisher
國際醫學研究博士學位學程
Description
學位別：博士
關鍵字：gastric outlet obstruction; palliative treatment; gastrojejunostomy; stomach-partitioning; stent; lumen apposing metal stent
論文公開日期：2029-07-16
關鍵字：gastric outlet obstruction; palliative treatment; gastrojejunostomy; stomach-partitioning; stent; lumen apposing metal stent
論文公開日期：2029-07-16
Abstract
Background: Malignant gastric outlet obstruction (GOO) treatment options, including gastrojejunostomy (GJ), endoscopic ultrasound-guided gastroenterostomy (EGE), stomach partitioning gastrojejunostomy (PGJ), and endoscopic stenting (ES), are currently under debate regarding their optimal efficacy and safety. To address this, we performed a network meta-analysis (NMA) to compare these treatments.
Methods: We searched randomized controlled trials (RCTs) and cohort studies that compared palliative strategies for malignant GOO from Pubmed, Embase, Cochrane, Scopus, Web of Science, ClinicalTrial.gov, and WHO International Clinical Trials Registry Platform. We included studies that reported at least one clinical outcome (clinical success, complication, mortality, reintervention rate, length of hospital stay). The evidence from RCTs and non-RCTs was combined through the frequentist framework, inverse variance model, and naïve combination. We estimated the effective results using relative risk (RR) and mean differences (MD) with 95% CI. The probability of best treatment was ranked by P-score (0-1), with a higher score indicating better treatment.
Results: This NMA included 4 RCTs and 36 non-RCTs (4 prospective and 32 retrospective studies) with 3617 patients. The overall rates of clinical success rate, complication rate, 30-day mortality rate, and reintervention rate were 88.9% (95% CI 85.6-91.6), 20.7% (95% CI 17.2-24.6), 5.4% (95% CI 3.2-8.9), and 13.8% (95% CI 10.7-17.9), respectively. PGJ was ranked the best approach for clinical success and reintervention rates (P-score: 0.95, 0.90, respectively). EGE had the highest probability of being the best for 30-day mortality and complication rates (P-score: 0.82, 0.99, respectively). Cluster rank combined the probability of the best treatment for safety regarding mortality and efficacy regarding reintervention prevention showed the benefit of PGJ and EGE (cophenetic correlation coefficient: 0.94, PGJ and EGE in the same cluster).
Conclusions: For malignant GOO, stomach partitioning gastrojejunostomy and endoscopic ultrasound-guided gastroenterostomy should be considered for recommendation. Stomach partitioning gastrojejunostomy could be an alternative approach when endoscopic ultrasound-guided gastroenterostomy is unsuccessful or not feasible. Additional studies should directly compare EGE and PGJ and the effects of open and laparoscopic approaches.
Methods: We searched randomized controlled trials (RCTs) and cohort studies that compared palliative strategies for malignant GOO from Pubmed, Embase, Cochrane, Scopus, Web of Science, ClinicalTrial.gov, and WHO International Clinical Trials Registry Platform. We included studies that reported at least one clinical outcome (clinical success, complication, mortality, reintervention rate, length of hospital stay). The evidence from RCTs and non-RCTs was combined through the frequentist framework, inverse variance model, and naïve combination. We estimated the effective results using relative risk (RR) and mean differences (MD) with 95% CI. The probability of best treatment was ranked by P-score (0-1), with a higher score indicating better treatment.
Results: This NMA included 4 RCTs and 36 non-RCTs (4 prospective and 32 retrospective studies) with 3617 patients. The overall rates of clinical success rate, complication rate, 30-day mortality rate, and reintervention rate were 88.9% (95% CI 85.6-91.6), 20.7% (95% CI 17.2-24.6), 5.4% (95% CI 3.2-8.9), and 13.8% (95% CI 10.7-17.9), respectively. PGJ was ranked the best approach for clinical success and reintervention rates (P-score: 0.95, 0.90, respectively). EGE had the highest probability of being the best for 30-day mortality and complication rates (P-score: 0.82, 0.99, respectively). Cluster rank combined the probability of the best treatment for safety regarding mortality and efficacy regarding reintervention prevention showed the benefit of PGJ and EGE (cophenetic correlation coefficient: 0.94, PGJ and EGE in the same cluster).
Conclusions: For malignant GOO, stomach partitioning gastrojejunostomy and endoscopic ultrasound-guided gastroenterostomy should be considered for recommendation. Stomach partitioning gastrojejunostomy could be an alternative approach when endoscopic ultrasound-guided gastroenterostomy is unsuccessful or not feasible. Additional studies should directly compare EGE and PGJ and the effects of open and laparoscopic approaches.