title: Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial.
abstract: BACKGROUND
  Both gastrojejunostomy (GJJ) and stent placement are commonly used palliative treatments of obstructive symptoms caused by malignant gastric outlet obstruction (GOO).
  
  
  OBJECTIVE
  Compare GJJ and stent placement.
  
  
  METHODS
  Multicenter, randomized trial.
  
  
  METHODS
  Twenty-one centers in The Netherlands.
  
  
  METHODS
  Patients with GOO.
  
  
  METHODS
  GJJ and stent placement.
  
  
  METHODS
  Outcomes were medical effects, quality of life, and costs. Analysis was by intent to treat.
  
  
  RESULTS
  Eighteen patients were randomized to GJJ and 21 to stent placement. Food intake improved more rapidly after stent placement than after GJJ (GOO Scoring System score > or = 2: median 5 vs 8 days, respectively; P < .01) but long-term relief was better after GJJ, with more patients living more days with a GOO Scoring System score of 2 or more than after stent placement (72 vs 50 days, respectively; P = .05). More major complications (stent: 6 in 4 patients vs GJJ: 0; P = .02), recurrent obstructive symptoms (stent: 8 in 5 patients vs GJJ: 1 in 1 patient; P = .02), and reinterventions (stent: 10 in 7 patients vs GJJ: 2 in 2 patients; P < .01) were observed after stent placement compared with GJJ. When stent obstruction was not regarded as a major complication, no differences in complications were found (P = .4). There were also no differences in median survival (stent: 56 days vs GJJ: 78 days) and quality of life. Mean total costs of GJJ were higher compared with stent placement ($16,535 vs $11,720, respectively; P = .049 [comparing medians]). Because of the small study population, only initial hospital costs would have been statistically significant if the Bonferroni correction for multiple testing had been applied.
  
  
  CONCLUSIONS
  Relatively small patient population.
  
  
  CONCLUSIONS
  Despite slow initial symptom improvement, GJJ was associated with better long-term results and is therefore the treatment of choice in patients with a life expectancy of 2 months or longer. Because stent placement was associated with better short-term outcomes, this treatment is preferable for patients expected to live less than 2 months. (
  
  
  BACKGROUND
  ISRCTN 06702358.).
authors.affiliation: Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Jeurnink
authors.forename: Ewout W
authors.initials: EW
authors.lastname: Steyerberg
authors.forename: Jeanin E
authors.initials: JE
authors.lastname: van Hooft
authors.forename: Casper H J
authors.initials: CH
authors.lastname: van Eijck
authors.forename: Matthijs P
authors.initials: MP
authors.lastname: Schwartz
authors.forename: Frank P
authors.initials: FP
authors.lastname: Vleggaar
authors.forename: Ernst J
authors.initials: EJ
authors.lastname: Kuipers
authors.forename: Peter D
authors.initials: PD
authors.lastname: Siersema
mesh_terms: D000368:Aged; D016099:Endoscopy, Gastrointestinal / Q000191:economics; D005260:Female; D015390:Gastric Bypass; D017219:Gastric Outlet Obstruction / Q000209:etiology / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010166:Palliative Care; D019919:Prosthesis Implantation / Q000379:methods*; D011788:Quality of Life; D012008:Recurrence; D015607:Stents / Q000191:economics; D013274:Stomach Neoplasms / Q000150:complications / Q000401:mortality; D016896:Treatment Outcome