What surgical palliative procedures are recommended for patients with advanced gastrointestinal (GI) tract disease?

Surgical Palliative Procedures for Advanced GI Tract Disease

For patients with advanced GI malignancies requiring surgical palliation, the primary procedures are gastrojejunostomy for gastric outlet obstruction, biliary-enteric bypass for biliary obstruction, and celiac plexus neurolysis for severe abdominal pain, with procedure selection based on symptom burden, life expectancy, and surgical fitness. 1

Gastric Outlet Obstruction

Patient Selection Algorithm

For medically fit patients with life expectancy >2-3 months and good functional status, laparoscopic gastrojejunostomy is the preferred surgical approach because it provides more durable long-term symptom relief, lower reintervention rates, reduced blood loss, and shorter hospital stays compared to open surgery. 1, 2, 3

For patients with life expectancy <2 months or poor surgical candidates, endoscopic self-expanding metal stent (SEMS) placement is preferred over surgery due to faster oral intake resumption, shorter hospital stays, and immediate symptom relief. 2, 4, 3

Surgical Technique Considerations

• Prophylactic gastrojejunostomy should be performed in patients found to have unresectable disease at laparotomy who are at risk of developing symptomatic gastric outlet obstruction, as randomized trials show this significantly decreases late obstruction (occurring in ~20% without prophylaxis) without increasing hospital stay or complication rates. 1

• Stomach-partitioning gastrojejunostomy provides superior function compared to simple gastrojejunostomy and should be the preferred technique when performing this procedure. 1

• Retrocolic gastrojejunostomy is the recommended approach based on evidence from randomized controlled trials in periampullary cancer. 1

Critical Contraindications

Do not place enteral stents in patients with multiple luminal obstructions, severely impaired gastric motility, or significant ascites - instead, consider venting gastrostomy placement after draining ascites to reduce infectious complications. 2, 4, 3

Biliary Obstruction

Surgical Approach

For patients with potentially resectable disease found to have unresectable tumors at laparotomy, perform open biliary-enteric bypass which provides durable palliation and can be combined with gastrojejunostomy and celiac plexus neurolysis. 1

Choledochojejunostomy or hepaticojejunostomy to the jejunum is strongly preferred over cholecystojejunostomy because it provides more durable and reliable palliation of biliary obstruction. 1

When Surgery is Not Indicated

• Endoscopic metallic biliary stents are appropriate for patients not undergoing laparotomy, with expandable metallic endoprostheses providing durable palliation. 1

• Percutaneous biliary drainage with subsequent internalization is reserved for cases where endoscopic stent placement fails. 1

Severe Tumor-Associated Abdominal Pain

Celiac plexus neurolysis should be performed in patients with advanced pancreatic or gastric cancer experiencing severe abdominal pain, as randomized controlled trials demonstrate significant improvement in pain relief. 1

Approach Options

• Open celiac plexus neurolysis can be performed at the time of staging laparoscopy if unresectable disease is discovered, depending on life expectancy and surgical expertise. 1

• Laparoscopic, thoracoscopic, EUS-guided, and percutaneous fluoroscopic/CT-guided approaches are all acceptable alternatives to open technique. 1

• For severe localized back pain in metastatic disease, external beam radiation therapy should be considered as an adjunct to pain management. 1, 4

Reduction Surgery (Cytoreductive Gastrectomy)

Reduction surgery (gastrectomy for metastatic disease without urgent symptoms) is NOT recommended outside of clinical trials, as the REGATTA trial demonstrated no survival benefit and actually showed worse 2-year survival (25.1% with gastrectomy plus chemotherapy vs. 31.7% with chemotherapy alone). 1

Exception to Avoid Reduction Surgery

Palliative gastrectomy is only indicated for urgent symptoms of bleeding or obstruction in stage IV disease, provided the patient is medically fit. 1

Nutritional Support Considerations

If oral intake cannot be resumed within 5-7 days post-intervention, place jejunal feeding tubes distal to the obstruction for nutritional support, but avoid overly aggressive nutrition in patients with very limited life expectancy as this increases suffering. 2, 3

Never place feeding tubes distal to obstruction in cases requiring anatomic surgical correction (such as malrotation or diaphragmatic herniation) - these require definitive surgical repair, not nutritional bypass. 2, 3

Common Pitfalls to Avoid

• Do not perform prophylactic duodenal bypass routinely - this is category 2B evidence and should be individualized based on risk assessment at laparotomy. 1

• Drain significant ascites before any venting gastrostomy placement to reduce infectious complications. 2, 4, 3

• If severe uncontrolled pain develops after gastric stent placement, immediately remove the stent endoscopically rather than attempting conservative management. 2, 4

• Avoid surgical intervention in patients with multiple failed endoscopic attempts (>4-6 sessions) without reassessing goals of care, as surgical morbidity may outweigh benefits in advanced disease. 2