Periampullary cancer is cancer that forms near the junction of the lower end of the common bile duct (the channel that transmits bile from the liver to the small bowel), pancreatic duct (the channel that drains the pancreatic juice into small bowel), and the upper part of the small bowel. One fifth of these tumours are amenable for surgical removal. The remaining four-fifths are not amenable for surgical removal (unresectable periampullary cancer). Because of its close proximity to the stomach outlet, these periampullary cancers can cause obstruction to the stomach outlet and prevent the flow of food from the stomach to the small bowel. While diversion of food by way of joining the stomach to the upper small bowel (gastrojejunostomy) or inserting a stent across the obstructed part of the small bowel (duodenal stent) is necessary for patients who have established stomach outlet obstruction, the role of gastrojejunostomy in patients without established stomach outlet obstruction (prophylactic gastrojejunostomy) is controversial. The aim of this review was to determine whether prophylactic gastrojejunostomy should be performed routinely in patients with unresectable periampullary cancer. We searched various medical databases for randomised controlled trials comparing prophylactic gastrojejunostomy versus no gastrojejunostomy in patients with unresectable periampullary cancer and obtained the relevant information. Quality control of the information obtained was achieved by two authors independently assessing the studies for inclusion and independently obtaining the necessary information and ensuring that the data matched with each other.
We identified two trials (of high risk of bias or systematic error) involving 152 patients randomised to gastrojejunostomy (80 patients) and no gastrojejunostomy (72 patients). In both studies, patients were found to be unresectable during operations aimed at surgical removal i.e. the tummy was opened to remove the cancer by operation but the cancer could not be removed. Most of the patients from both groups underwent bypass of the biliary tract to relieve their jaundice or prevent jaundice from developing. There was no evidence of any difference in the overall survival, surgical complications, quality of life, or hospital stay between the two groups. The proportion of patients who developed long term stomach outflow obstruction was significantly lower in the prophylactic gastrojejunostomy group (2.5%) compared with no gastrojejunostomy group (27.8%). The operating time was significantly longer in the gastrojejunostomy group compared with no gastrojejunostomy group by about 45 minutes. Routine prophylactic gastrojejunostomy is indicated in patients with unresectable periampullary cancer undergoing open operation of the tummy. There is no information available currently about the necessity for prophylactic gastrojejunostomy in patients with periampullary cancer diagnosed to be unresectable by investigations such as scans. Further trials of low risk of bias (systematic errors) are necessary to assess the role of prophylactic gastrojejunostomy in patients with unresectable periampullary cancer.