Kd. Lillemoe et al., Is prophylactic gastrojejunostomy indicated for unresectable periampullarycancer? A prospective randomized trial, ANN SURG, 230(3), 1999, pp. 322-328
Objective
This prospective, randomized, single-institution trial was designed to eval
uate the role of prophylactic gastrojejunostomy in patients found at explor
atory laparotomy to have unresectable periampullary carcinoma.
Summary Background Data
Between 25% and 75% of patients with periampullary cancer who undergo explo
ratory surgery with intent to perform a pancreaticoduodenectomy are found t
o have unresectable disease. Most will undergo a biliary-enteric bypass. Wh
ether or not to perform a prophylactic gastrojejunostomy remains unresolved
. Retrospective reviews of surgical series and prospective randomized trial
s of endoscopic palliation have demonstrated that late gastric outlet obstr
uction, requiring a gastrojejunostomy, develops in 10% to 20% of patients w
ith unresectable periampullary cancer.
Methods
Between May 1994 and October 1998, 194 patients with a periampullary malign
ancy underwent exploratory surgery with the purpose of performing a pancrea
ticoduodenectomy and were found to have unresectable disease. On the basis
of preoperative symptoms, radiologic studies, or surgical findings, the sur
geon determined that gastric outlet obstruction was a significant risk in 1
07 and performed a gastrojejunostomy. The remaining 87 patients were though
t by the surgeon not to be at significant risk for duodenal obstruction and
were randomized to receive either a prophylactic retrocolic gastrojejunost
omy or no gastrojejunostomy. Short- and long-term outcomes were determined
in all patients.
Results
Of the 87 patients randomized, 44 patients underwent a retrocolic gastrojej
unostomy and 43 did not undergo a gastric bypass. The two groups were simil
ar with respect to age, gender, procedure performed (excluding gastrojejuno
stomy), and surgical findings. There were no postoperative deaths in either
group, and the postoperative morbidity rates were comparable (gastrojejuno
stomy 32%, no gastrojejunostomy 33%). The postoperative length of stay was
8.5 +/- 0.5 days for the gastrojejunostomy group and 8.0 +/- 0.5 days for t
he no gastrojejunostomy group. Mean survival among those who received a pro
phylactic gastrojejunostomy was 8.3 months, and during that interval gastri
c outlet obstruction developed in none of the 44 patients. Mean survival am
ong those who did not have a prophylactic gastrojejunostomy was 8.3 months.
In 8 of those 43 patients (19%), late gastric outlet obstruction developed
, requiring therapeutic intervention (gastrojejunostomy 7 patients, endosco
pic duodenal stent 1 patient; p < 0.01). The median time between initial ex
ploration and therapeutic intervention was 2 months.
Conclusion
The results from this prospective, randomized trial demonstrate that prophy
lactic gastrojejunostomy significantly decreases the incidence of late gast
ric outlet obstruction. The performance of a prophylactic retrocolic gastro
jejunostomy at the initial surgical procedure does not increase the inciden
ce of postoperative complications or extend the length of stay. A retrocoli
c gastrojejunostomy should be performed routinely when a patient is undergo
ing surgical palliation for unresectable periampullary carcinoma.