Skip to main content

Maximizing Oral Intake Tolerance in Malignant Gastric Outlet Obstruction – A Markov Decision Tree Analysis Comparing Duodenal Stenting, Endoscopic Ultrasound-Guided Gastroenterostomy and Surgical Gastrojejunostomy

Authors
CHUE Koy Min1,2, Benjamin Robert DOUGLASS1,3, Lester ONG Wei Lin1,2, Jeremy TAN Tian Hui1,2,4, WONG Wai Keong1,2,4, Baldwin YEUNG Po Man1,2

Affiliations

  1. Upper Gastrointestinal and Bariatric Surgery Service, Department of General Surgery, Sengkang General Hospital, Singapore
  2. Duke-NUS Academic Medical Centre, Singapore
  3. Department of Upper Gastrointestinal Surgery, Glasgow Royal Infirmary, Glasgow, UK
  4. Department of Upper Gastrointestinal and Bariatric Surgery, Singapore General Hospital, Singapore

Introduction
Malignant gastric outlet obstruction (GOO) has a significant impact on quality of life. The advent of endoscopic ultrasound-guided gastroenterostomy (EGE) showed promising results in GOO palliation. Traditional isolated outcome measures like mortality or complications, do not sufficiently address critical considerations for end-of-life patients like oral intake tolerance. This study aimed to determine via a probabilistic approach, the optimal management strategy for GOO patients that maximises their oral intake tolerance.

Methods
A Markov decision analytical model was developed, with input variables based on a systematic review of randomized controlled trials (RCT) comparing duodenal stenting (DS), EGE and surgical gastrojejunostomy (GJ). Prospective cohort studies with a comparator group were also included for the EGE model given the scarcity of RCTs. Model assumption was a patient with GOO, with equal probabilities of being allocated to 1 of 3 treatment options. Each data point was evaluated using mean and highest plausible values representing worst-case scenarios. Primary outcome was oral intake tolerance. Secondary outcome was crossover to another intervention arm.

Results
The systematic review identified 15 studies for inclusion into the Markov model. Eight compared between DS techniques, 4 compared DS and GJ, 2 compared between GJ techniques, and 2 compared DS and EGE. Based on 10000 simulations in each arm, model based on mean plausible probabilities revealed GJ as the optimal approach with 88.6% oral intake tolerance (EGE 79.3%; DS 70.1%). Model based on worst-case outcomes revealed EGE as the optimal approach with 64.2% oral intake tolerance (GJ 56.4%; DS 38.7%). Crossover probabilities were highest in DS group both in mean (14.7%) and worst-case (26.5%) scenarios.

Conclusion
Even after accounting for differing periprocedural risks, recurrences and outcomes, a gastric bypass option, either through a GJ or EGE, appeared to be the preferred approach in maximising oral intake tolerance in GOO palliation.