Comparative efficacy and safety of treatments for malignant gastric outlet obstruction: a systematic review and network meta-analysis

BACKGROUND AND AIMS: It is unclear which is the best treatment for palliation of malignant gastric outlet obstruction (GOO). We performed a network meta-analysis combining direct and indirect comparisons among the different techniques. METHODS: We identified 8 randomized controlled trials (430 patients) comparing surgical gastrojejunostomy (GJ), stomach-partitioning GJ, EUS-GJ, and enteral stent placement (ES) with each other. The clinical success was the primary outcome, whereas technical success, severe adverse events (SAEs), reintervention rate, and length of hospital stay were secondary outcomes. The results were expressed in terms of risk ratio (RR) or standardized mean difference with relevant 95% CIs. RESULTS: All the treatments resulted in being significantly inferior to EUS-GJ in terms of clinical success (GJ vs EUS-GJ: RR, 0.82; 95% CI, 0.75-0.90; partitioning GJ vs EUS-GJ: RR, 0.83; 95% CI, 0.75-0.93; ES vs EUS-GJ: RR, 0.91; 95% CI, 0.85-0.98). Surgery was also significantly inferior to ES (RR, 0.89; 95% CI, 0.81-0.98). No difference was observed for technical success and SAEs. ES was associated with a significantly increased risk of reintervention as compared with EUS-GJ (RR, 7.69; 95% CI, 1.81-33.3) and surgical GJ (RR, 6.66; 95% CI, 2.04-20). Again, EUS-GJ appeared as the best treatment in terms of reintervention rate (surface under the cumulative ranking curve, 0.81). Surgery and partitioning GJ determined a significant increase in the length of hospital stay. The quality of evidence was mainly deemed as moderate because of the risk of imprecision. CONCLUSIONS: EUS-GJ appears to be the best treatment for malignant GOO. ES represents a valuable, widely available, and less expensive alternative, but with a significantly higher need for reintervention.