Laparoscopic gatrojejunostomy for palliation of gastric outlet obstruction in unresectable gastric cancer

Abstract

Background: Gastric bypass through laparotomy is required traditionally when gastric outlet obstruction occurs secondary to a disease process (e.g., unresectable cancer). The recent trend toward minimally invasive procedures has led us to apply laparoscopic bypass surgery for gastric obstruction caused by unresectable advanced gastric cancer.

Methods: From March 1998 to February 2000, 78 gastrojejunostomies (GJ) (45 open [OGJ] and 33 laparoscopic [LGJ] procedures) were performed for palliation of gastric outlet obstruction caused by advanced gastric, duodenal, papilla of vater, and pancreatic cancers at the Asan Medical Center. In 68 patients with advanced gastric cancer, OGJ (n = 38) and LGJ (n = 30) were performed. Of these, 10 OGJ patients were compared with 10 diagnosis-matched LGJ control subjects who underwent surgery during the same period in terms of age, gender, American Society of Anesthesiology (ASA) grading, previous abdominal surgery, operating time, time to oral food intake, pain-killer consumption, postoperative hospital stay, immune response, morbidity, and mortality. Immune parameters including serum white blood cells (WBC) count, tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), cortisol, and erythrocyte sedimentation rate (ESR) levels were assessed preoperatively and on postoperative days 1 and 3 between the two groups. With the patients under the general endotracheal anesthesia, we applied an upper midline incision in OGJ and inserted four trocars in LGJ. Side-to-side gastrojejunostomy was performed in a standard fashion. In LGJ, intracorporeal suture using 2-0 vicryl was performed to repair the gastrotomy and jejunotomy site after gastrojejunostomy using a 30-mm or 45-mm Endo-GIA stapler.

Results: There were no significant differences between OGJ and LGJ in terms of gender, age, ASA grading, and previous abdominal surgery. In OGJ, antecolic isoperistaltic GJ was performed in 10 cases, but 8 antecolic and 2 retrocolic approaches were performed in LGJ with no conversion to open surgery. Operating time (113.5 +/- 11.2 vs 100.5 +/- 9.8 min), pain-killer consumption (540 +/- 123.2 vs 430 +/- 58.2 mg), and postoperative hospital stay (12.5 +/- 3.9 vs 8.5 +/- 2.9 days) were reported, respectively. Serum WBC and cortisol levels were slightly increased in both groups preoperatively and on postoperative days 1 and 3. Serum ESR, TNF-alpha, and IL-6 levels were significantly increased in the OGJ patients. Postoperative complications (9 with OGJ and 2 with LGJ) and postoperative death (1 in each group) occurred. During the follow-up period (3-23 months), there was one case of readmission in each group because of anemia and generalized pain.

Conclusions: Laparoscopic GJ for the palliation of unresectable advanced gastric cancer can achieve excellent results with less suppression of immune function, lower morbidity, greater improvement of hemodynamic activities, and earlier recovery of bowel movements than OGJ.