Is prophylactic gastrojejunostomy indicated for unresectable periampullarycancer? A prospective randomized trial

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.