Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction

Emma Upchurch; Mark Ragusa; Roberto Cirocchi

doi:10.1002/14651858.CD012506.pub2

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 1 Re‐establishment of oral intake (technical success of the intervention).

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Analysis 1.2

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 2 Time to re‐establishment of oral intake (days).

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Analysis 1.3

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 3 All‐cause mortality.

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Analysis 1.4

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 4 Median survival postintervention (days).

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Analysis 1.5

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 5 Time to recurrence of obstructive symptoms.

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Analysis 1.6

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 6 Serious adverse events.

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Analysis 1.7

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 7 Serious adverse events: need for reintervention.

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Analysis 1.8

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 8 Minor adverse events.

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Analysis 1.9

Comparison 1 Surgical palliation versus duodenal stenting, Outcome 9 Length of hospital stay (days).

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Summary of findings for the main comparison. Duodenal stenting compared with surgical palliation for malignant gastric outlet obstruction

Duodenal stenting compared with surgical palliation for malignant gastric outlet obstruction
Patient or population: people with malignant gastric outlet obstruction Setting: hospital Intervention: duodenal stent placement Comparison: surgical palliation
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
	Assumed risk	Corresponding risk
	Surgical palliation	Duodenal stent
Re‐establishment of oral intake (technical success of the intervention) Follow‐up: 1 to 30 days	975 per 1000	956 per 1000 (858 to 1000)	RR 0.98 (0.88 to 1.09)	82 (3)	⊕⊕⊝⊝ Low¹
Time to re‐establishment of oral intake Follow‐up: 1 to 30 days	7.6 days	The mean time to oral intake in the duodenal stent group was 3.07 days shorter	MD ‐3.07 days (‐4.76 to ‐1.39)	57 (2)	⊕⊕⊝⊝ Low¹
All‐cause mortality Follow‐up: 1 to 30 days	214 per 1000	154 per 1000 (30 to 780)	RR 0.72 (0.14 to 3.64)	27 (1)	⊕⊝⊝⊝ Very low²
Median survival postintervention Follow‐up: 1 to 975 days	78 days	The median survival in the duodenal stent group was 22 days shorter	MD ‐22.00 days (‐53.45 to 9.45)	39 (1)	⊕⊝⊝⊝ Very low^1,3
Time to recurrence of obstructive symptoms Follow‐up: 1 to 975 days	37 per 1000	188 per 1000 (36 to 990)	RR 5.08 (0.96 to 26.74)	57 (2)	⊕⊕⊕⊝ Moderate³
Adverse events Follow‐up: 1 to 30 days	Serious adverse events		RR 1.15 (0.33 to 3.98)	84 (3)	⊕⊝⊝⊝ Very low^1,3
	98 per 1000	112 per 1000 (32 to 388)
	Serious adverse events (need for reintervention)		RR 4.71 (1.36 to 16.30)	84 (3)	⊕⊝⊝⊝ Very low^3,4
	49 per 1000	230 per 1000 (66 to 795)
	Minor adverse events		RR 0.35 (0.07 to 1.61)	84 (3)	⊕⊝⊝⊝ Very low^1,5
	341 per 1000	120 per 1000 (24 to 550)
Length of hospital stay Follow‐up: 1 to 30 days	12.9 days	The mean length of hospital stay in the duodenal stent group was 6.70 days shorter	MD ‐6.70 days (9.41 lower to 3.98 lower)	84 (3)	⊕⊕⊕⊝ Moderate³
Health‐related quality of life	Studies used different methods to assess quality of life in the included studies so the data could not be combined.
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; MD: mean difference; RR: risk ratio.
GRADE Working Group grades of evidence High‐quality: further research is very unlikely to change our confidence in the estimate of effect. Moderate‐quality: further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low‐quality: further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low‐quality: we are very uncertain about the estimate.
¹Unclear or high risk bias within the studies (very serious concerns) (downgraded by two levels). ²Unclear or high risk of bias within the studies (downgraded by two levels) in addition to very serious inconsistencies between the studies (downgraded by two levels). ³Some imprecision in the results as exemplified by the large confidence intervals (downgraded by one level). ⁴Confidence intervals were wide (overlapped no effect and clinically significant effect) and the sample size was small (downgraded by two levels). ⁵Serious inconsistencies between the studies (downgraded by one level).

Summary of findings for the main comparison. Duodenal stenting compared with surgical palliation for malignant gastric outlet obstruction

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Comparison 1. Surgical palliation versus duodenal stenting

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Re‐establishment of oral intake (technical success of the intervention) Show forest plot	3	82	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.88, 1.09]

2 Time to re‐establishment of oral intake (days) Show forest plot	2	57	Mean Difference (IV, Random, 95% CI)	‐3.07 [‐4.76, ‐1.39]

3 All‐cause mortality Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

4 Median survival postintervention (days) Show forest plot	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

5 Time to recurrence of obstructive symptoms Show forest plot	2	57	Risk Ratio (M‐H, Random, 95% CI)	5.08 [0.96, 26.74]

6 Serious adverse events Show forest plot	3	84	Risk Ratio (M‐H, Random, 95% CI)	1.15 [0.33, 3.98]

7 Serious adverse events: need for reintervention Show forest plot	3	84	Risk Ratio (M‐H, Random, 95% CI)	4.71 [1.36, 16.30]

8 Minor adverse events Show forest plot	3	84	Risk Ratio (M‐H, Random, 95% CI)	0.35 [0.07, 1.61]

9 Length of hospital stay (days) Show forest plot	3	84	Mean Difference (IV, Random, 95% CI)	‐6.70 [‐9.41, ‐3.98]

Comparison 1. Surgical palliation versus duodenal stenting

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