Application of modified laparoscopic stomach-partitioning gastrojejunostomy for stage IV gastric cancer with gastric outlet obstruction

Introduction

Background

Gastric cancer remains a major public health burden in China, with approximately 358,672 new cases and 260,372 deaths reported in 2022, accounting for about 40% of global cases. It ranks fifth in cancer incidence and third in cancer-related mortality nationwide (1). Notably, 30–40% of patients are diagnosed at stage IV, and a significant proportion present with gastric outlet obstruction (GOO) (2,3). GOO, typically caused by tumor invasion of the distal stomach or proximal duodenum, occurs in approximately 30% of advanced gastric cancer cases. It is frequently associated with local invasion or distant metastases, resulting in unresectable disease at presentation and poor clinical outcomes (4,5).

Rationale

For patients with unresectable stage IV gastric cancer complicated by GOO, the primary therapeutic objectives are rapid symptom relief, nutritional improvement, and quality of life. Effective relief of obstruction enables timely initiation of systemic conversion therapy, potentially facilitating tumor downstaging and subsequent R0 resection, which is associated with improved prognosis (6). While endoscopic stenting (ES) is less invasive and provides faster symptom relief (7), it carries a relatively high risk of stent migration and recurrent obstruction, often requiring reintervention. For patients with an expected survival exceeding two months, surgical gastrojejunostomy (GJ) is considered a more durable and effective option (8,9). The stomach-partitioning gastrojejunostomy (SPGJ) has been shown to be more effective than CGJ in relieving GOO and reducing delayed gastric emptying (DGE) (10). With advancements in conversion therapy, an increasing number of patients may become candidates for radical surgery following initial palliation. However, D2 lymphadenectomy after CGJ is often technically challenging due to the need to dismantle the anastomosis and dense adhesions. To address this, we previously developed a modified laparoscopic stomach-partitioning gastrojejunostomy (M-LSPGJ) technique (11), which includes No. 4sb lymph node dissection, partial stomach transection, GJ to the proximal remnant, and Braun anastomosis. This design enables preservation of the original anastomoses during second-stage D2 gastrectomy, simplifies the procedure, and reduces operative time.

Objective

This study aimed to evaluate the safety, feasibility, and clinical effectiveness of M-LSPGJ for patients with stage IV gastric cancer complicated by GOO. Specifically, we assessed the ability of M-LSPGJ to relieve obstruction, enhance oral intake, thereby facilitating subsequent conversion therapy and radical resection within a structured two-modular treatment strategy. The findings provide a practical framework and theoretical basis for integrating surgical palliation with potentially curative interventions in advanced gastric cancer management. We present this article in accordance with the SUPER reporting checklist (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-346/rc) (12).

Preoperative preparations and requirements

This single-center retrospective study enrolled 22 patients diagnosed with stage IV gastric cancer complicated by GOO, who underwent M-LSPGJ at the Cancer Hospital, Chinese Academy of Medical Sciences, between January 2020 and January 2024. Patients met the following inclusion criteria: (I) laparoscopically confirmed unresectable gastric cancer due to adjacent organ invasion or distant metastasis; (II) symptomatic GOO, defining as a GOOSS score of 0 or 1 (0 = no oral intake, 1 = liquids only) (7); (III) Eastern Cooperative Oncology Group (ECOG) performance status of 0–2 after nutritional optimization; and (IV) expected survival greater than 6 months. Exclusion criteria included active gastrointestinal bleeding, intolerance to surgery, and severe comorbidities. All patients were evaluated by a multidisciplinary team (MDT) for treatment tolerance and long-term prognosis. After full informed discussions, M-LSPGJ was performed by the surgical team.

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (protocol No. NCC4843, ethics No. 24/543-4823). Written informed consent was obtained from the patients for the publication of this article and the video. A copy of the written consent is available for review by the editorial office of this journal.

The enrolled cohort comprised 13 males (59.1%) and 9 females (40.9%), with a mean age of 62.1±12.6 years and mean BMI of 22.0±2.6 kg/m². Preoperatively, 16 patients (72.7%) had a GOOSS score of 1 (liquid diet only), and 6 patients (27.3%) had a score of 0 (no oral intake). Clinically, 18 patients (81.8%) were staged T4b, 12 patients (54.5%) had distant metastasis, and overall staging was IVa in 10 patients (45.5%) and IVb in 12 patients (54.5%). Additional baseline characteristics are summarized in Table 1.

Step-by-step description

A two-modular laparoscopic strategy was adopted. The first modular involved a modified LSPGJ, aiming to relieve obstruction and optimize the anatomical field for future radical surgery. The second modular consisted of laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy, selectively performed in patients who responded to conversion therapy and met the criteria for R0 resection.

The first modular: M-LSPGJ

During the first modular M-LSPGJ, standard laparoscopic techniques were applied (Figure 1 and Video 1). Exploratory laparoscopy and peritoneal lavage cytology were routinely performed to confirm unresectability. The left gastroepiploic vessels were ligated at their origin near the splenic hilum, followed by No. 4sb lymph node dissection. The greater curvature was transected at least 5 cm proximal to the tumor, while a 2 cm wide gastric conduit on the lesser curvature was preserved. When dissecting No. 4sb lymph nodes, care must be taken to completely control bleeding at the vascular stump on the greater curvature of the stomach to prevent hemorrhage due to the stomach’s abundant blood supply. GJ was established approximately 25 cm distal to the Treitz ligament, followed by Braun jejunojejunostomy created 25 cm downstream from the GJ.

Figure 1 Schematic diagram of the M-LSPGJ and laparoscopic subtotal resection of distal gastric cancer plus D2 lymph node dissection. (A) M-LSPGJ includes partial gastric transaction, No. 4sb lymph node dissection, gastrojejunostomy, and braun anastomosis. (B) Laparoscopic subtotal resection of distal gastric cancer plus D2 lymph node dissection. M-LSPGJ, modified laparoscopic stomach-partitioning gastrojejunostomy.

All patients underwent the first-modular M-LSPGJ. Perioperative outcomes were summarized in Table 2. Indications for surgery included pancreatic invasion (7 patients, 31.8%), macroscopic peritoneal metastases (5 patients, 22.7%), bulky nodal involvement and retroperitoneal metastases (3 patients each, 13.6%), omental metastases (2 patients, 9.0%), as well as hepatic, and mesenteric metastases (1 patient each, 4.5%). Peritoneal lavage cytology was positive in 8 patients (36.4%), and metastatic involvement of No. 4sb lymph nodes was identified in 9 patients (40.9%).

Conversion therapy

After postoperative recovery of oral intake, patients were reassessed by a MDT. Conversion therapy was initiated using SOX (S-1 + oxaliplatin) or XELOX (capecitabine + oxaliplatin), combined with PD-1 inhibitors. Contrast-enhanced CT scans of the chest, abdomen, and pelvis were performed every 3 cycles to assess tumor response as Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 (13). Adverse events were graded according to NCI-CTCAE v5.0 (14). The decision to proceed to second-stage surgery was based on radiological response and overall clinical status.

Second modular: laparoscopic radical surgery

For patients demonstrating tumor regression and clinical fitness after conversion therapy, second-stage laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy was performed. After confirming resectability through intra-abdominal exploration and repeat peritoneal lavage cytology, the duodenum was transected at the pancreatic level using a 60-mm linear stapler. The remnant stomach was transected along with the lesser curvature, and a standard D2 lymphadenectomy was completed. The original GJ was preserved without revision.

Postoperative considerations and tasks

The first modular: M-LSPGJ

Table 2 summarizes the detailed information on the first-modular procedure. The median operative time was 85.5 minutes, and the median estimated blood loss was 30 mL. The mean duration of nasogastric tube placement was 3.6 days, and the average time to achieve GOOSS score 2 was 4.5 days. The mean postoperative hospital stay was 8.1 days, and the average interval from surgery to the initiation of first-line adjunctive therapy was 27.4 days. Intraoperative complications were rare, with only one case (4.5%) of bleeding attributed to tissue edema. Postoperative complications occurred in 3 patients (13.6%): anastomotic bleeding (Clavien-Dindo grade III, 1 case), DGE (grade II, 1 case), and DGE (grade III) complicated by aspiration pneumonia (IV, 1 case). By postoperative day 30, oral intake had significantly improved across the cohort.

As shown in Figure 2, 19 patients (86.4%) achieved a GOOSS score of 3, indicating normal oral intake, while the remaining 3 patients (13.6%) reached a score of 2, consistent with the ability to tolerate a soft or liquid diet. The mean time to achieve a GOOSS score of 2 was 4.5 (2.1) days.

Figure 2 Paired preoperative and postoperative day-30 GOOSS scores. GOOSS, Gastric Outlet Obstruction Scoring System.

Conversion therapy

Table 3 presents the details of the conversion therapy. All patients received conversion therapy postoperatively. The majority (86.4%, 19/22) were treated with SOX plus PD-1 inhibitors, and 3 patients (13.6%) received XELOX plus PD-1. Treatment-related adverse events (TRAEs) were generally tolerable; 63.6% (14/22) experienced no grade ≥2 toxicity. The most frequent TRAE was grade 2 myelosuppression (18.2%). One patient discontinued therapy due to grade 4 gastrointestinal bleeding. Among the 21 patients completing ≥3 treatment cycles, partial response (PR) was observed in 10 (47.6%), stable disease (SD) in 8 (38.1%), and progressive disease (PD) in 3 (14.3%), indicating favorable tolerability and conversion potential.

Second modular: laparoscopic radical surgery

Table 4 presents the details of the radical surgery. Nine patients (40.9%) proceeded to the second-stage laparoscopic distal subtotal gastrectomy with D2 lymphadenectomy, and 8 (36.4%) achieved R0 resection. One patient remained cytology-positive on intraoperative peritoneal lavage. The mean operative time was 111.6±13.4 minutes, and the average blood loss was 66.3±28.4 mL (Table 4). The primary GJ from first-modular was preserved without dismantling or revision. There were no major intraoperative events. Postoperatively, only 1 patient developed grade III pleural effusion; the remaining 8 had an uneventful recovery.

Follow up

At the last follow-up on April 15, 2025, the median follow-up duration was 36.8 months. The median PFS and OS were 8.7 and 15.0 months, respectively. Among patients who did not achieve R0 resection, the median PFS was 7.9 months, whereas it had not been reached in those who underwent R0 resection. The median OS was 10.4 months in the non-R0 group and 30.5 months in the R0 group. Patients who achieved R0 resection (n=8) had significantly improved survival outcomes compared to those without resection (n=14), with a HR of 0.19 for OS (95% CI: 0.05–0.68, P=0.01; Figure 3A) and 0.18 for PFS (95% CI: 0.05–0.65, P=0.008; Figure 3B), highlighting the prognostic benefit of curative surgery following successful conversion therapy.

Figure 3 Kaplan-Meier survival curves comparing patients with and without R0 resection. (A) OS was significantly improved in patients who achieved R0 resection compared to those who did not (HR =0.19, 95% CI: 0.05–0.68, P=0.01). (B) PFS was also significantly longer in the R0-Y group (HR =0.18, 95% CI: 0.05–0.65, P=0.008). R0, curative resection; N, no resection (n=8); Y, R0 resection (n=14). CI, confidence interval; HR, hazard ratio; OS, overall survival; PFS, progression-free survival.

Among the eight patients who achieved R0 resection, three experienced disease progression: one patient (No. 20) developed peritoneal metastasis at 8 months, one patient (No. 21) developed pulmonary metastasis at 12 months, and one patient (No. 5) developed bone metastasis at 8 months. The remaining five patients have shown no signs of recurrence to date, including patient No. 1, who remains disease-free at 55 months (Table S1).

Tips and pearls

The M-LSPGJ not only effectively relieves GOO but also optimizes the surgical field for subsequent radical resection by reducing postoperative adhesions and preserving the anastomosis created during the initial procedure. The systematic dissection of No. 4sb lymph nodes and preservation of the GJ facilitate later reconstruction, minimizing surgical complexity and intraoperative risk. However, successful conversion depends critically on appropriate patient selection and timely initiation of conversion therapy. In our cohort, 12 patients had distant metastases (M1), including 8 with positive peritoneal cytology. Among them, only 3 underwent second-stage radical resection, and one failed to achieve R0 due to persistent cytological positivity. By contrast, 6 of the 10 patients without distant metastasis (M0) successfully completed curative surgery. Our findings suggest that patients with locally advanced, non-metastatic disease (e.g., cT4a–bN + M0) may derive the greatest benefit, underscoring the need for further studies to refine surgical indications and improve outcomes.

Although the primary goal of M-LSPGJ is rapid and durable symptom relief, the incorporation of No. 4sb lymphadenectomy did not increase operative complexity or postoperative morbidity. Instead, it conferred technical advantages during second-stage surgery by pre-emptively clearing the greater curvature near the splenic hilum. By transferring part of the dissection typically required during radical gastrectomy to the initial procedure, this approach not only reduced adhesion formation in the surgical field but also obviated the need to dismantle the original GJ, thereby simplifying the subsequent resection and shortening operative time.

Discussion

Patients with advanced gastric cancer complicated by GOO frequently experience profound nutritional deficits due to impaired oral intake, which markedly compromises quality of life and limits eligibility for subsequent systemic oncologic therapies. In recent years, advancements in minimally invasive surgery and systemic treatment modalities have increasingly supported the feasibility of combining bypass procedures with conversion therapy to enable curative resection in selected patients (11,15,16). In this study, we employed M-LSPGJ, consisting of partial stomach partitioning, No. 4sb lymph node dissection, GJ, and Braun anastomosis, which not only effectively alleviated gastric obstruction but also optimized the anatomical field for future radical surgery. Among the 22 patients with stage IV gastric cancer and GOO, the mean time to achieve a GOOSS score of 2 was 4.5±2.1 days. By postoperative day 30, 86.4% (19/22) had resumed normal oral intake (GOOSS =3), indicating substantial improvement in gastrointestinal function. Only two patients (9.1%) developed DGE, a rate consistent with prior studies (17). Ultimately, 40.9% (9/22) underwent radical gastrectomy, and 36.4% (8/22) achieved R0 resection.

Among available interventions for GOO, GJ and ES remain the most adopted palliative strategies. In contrast, ES provides a minimally invasive alternative with rapid symptom relief and faster recovery, and is often recommended for patients with limited life expectancy (<2 months) or those deemed unfit for surgery (8,18,19). However, recent meta-analyses have revealed significant limitations in the long-term efficacy of ES. Although ES is associated with shorter hospital stays, quicker resumption of oral intake, and lower rates of procedure-related infections (RR =0.30, 95% CI: 0.12–0.75, P=0.01), its durability remains suboptimal. Specifically, ES carries a substantially higher risk of reintervention (RR =2.60, 95% CI: 1.87–3.63, P<0.001), reflecting a limited ability to maintain long-term luminal patency (19). In a Bayesian network meta-analysis conducted by Wang et al., GJ was associated with significantly improved overall survival (HR =0.61, 95% CI: 0.49–0.74) compared with non-resective strategies such as chemotherapy, ES, or jejunostomy. Notably, GJ also significantly increased the likelihood of patients receiving subsequent conversion therapy (20). These findings underscore the importance of structural surgical reconstruction as a cornerstone of integrated treatment for GOO, especially in patients with potential for conversion surgery.

SPGJ has been increasingly recognized for its anatomical and functional advantages in reconstructing gastric flow in patients with GOO. Since its initial description by Kaminishi et al. in 1997, SPGJ has demonstrated promising outcomes, with 88% of patients resuming normal oral intake within 2 weeks postoperatively and a significantly prolonged median survival compared to CGJ (13.4 vs. 5.8 months) (21). Building on this foundation, Ernberg et al. conducted comparative studies that further substantiated the clinical advantages of SPGJ over CGJ. SPGJ was associated with a markedly reduced incidence of DGE (0% vs. 42.9%, P=0.02), improved postoperative nutritional status (GOOSS score: 3 vs. 1, P=0.02), and shorter median hospital stays (11.5 vs. 22.5 days, P=0.02) (22). Anatomically, SPGJ preserves a narrow gastric conduit along the lesser curvature, thereby lowering intragastric pressure and reducing the risk of gastric atony, while also maintaining endoscopic accessibility. Further validation was provided by Zhang et al., who combined clinical observations with computational modeling. Their results confirmed that SPGJ significantly enhanced gastrointestinal function postoperatively, reduced DGE incidence (2.1% vs. 36%, P<0.001), accelerated gastric emptying, and decreased the pressure gradient across the gastrojejunal anastomosis compared to CGJ (23). Complementary biomechanical simulations by Xu et al. demonstrated that the gastric partition effectively diverted luminal flow from the pylorus toward the anastomosis, thereby improving flow dynamics and reducing gastric retention (24). Our present study builds upon this foundation by integrating No. 4sb lymph node dissection into the SPGJ technique. This not only preserved low DGE incidence (2/22, 9.1%) but also minimized postoperative adhesions, facilitating future D2 lymphadenectomy. Importantly, the No. 4sb lymph nodes, located at the junction of the greater curvature and the gastrocolic ligament, represent a second-tier metastatic site in distal gastric cancer. Omission of this dissection during the initial procedure often results in dense postoperative adhesions, complicating the subsequent separation of the gastrocolic ligament and the gastro-pancreatic fold during radical resection. In such cases, adequate clearance of the greater curvature—including No. 4sb lymph nodes—may necessitate takedown of the previously constructed GJ, thereby increasing surgical complexity, prolonging operative time, and heightening the risk of intraoperative complications (25). Recognizing this, our surgical design proactively incorporates No. 4sb dissection in the first-modular bypass to anatomically prepare for conversion surgery. In contrast, aggressive dissection during this phase, such as No. 6 nodes, has been cautioned against by Zhang et al. due to the increased technical difficulty during secondary surgery (15).

Recent clinical studies have increasingly supported the proactive use of conversion therapy in advanced gastric cancer. Morgagni et al. reported outcomes from 73 patients initially diagnosed with unresectable gastric cancer, of whom 57 received conversion therapy. Among these, 22 ultimately underwent R0 resection. In contrast, 35 patients received chemotherapy alone. The median OS was significantly longer in the R0 resection group (50 months) compared to the chemotherapy-only group (14 months), leading the authors to conclude that achieving R0 resection following conversion therapy is the most critical prognostic factor in this setting (26). Similarly, Huang et al. analyzed 182 patients with advanced gastric cancer who received different treatment modalities. Of these, 24 underwent surgery after conversion therapy, 100 received palliative chemotherapy following surgery, and 49 underwent surgery alone. The corresponding median OS was 23.4, 13.7, and 5.6 months, respectively (P<0.0001), and the 5-year OS rates were 31.4%, 13.1%, and 0% (P<0.01), further underscoring the prognostic value of conversion surgery (27). Nevertheless, whether patients with GOO can derive similar survival benefits from subsequent curative resection remains uncertain. In this exploratory study, we compared survival outcomes between patients who achieved R0 resection and those who received non-curative and non-surgical treatments. Although the R0 group demonstrated a clear trend toward improved survival, the sample size limits definitive conclusions. Further prospective, large-scale studies are warranted to validate these observations and refine patient selection criteria.

The selection of appropriate candidates for conversion therapy in advanced gastric cancer remains a pivotal clinical challenge. In our cohort, the conversion success rate was relatively low (36.4%, 8/22), largely due to the high prevalence of distant metastases or positive peritoneal cytology at diagnosis (54.5%, 12/22). Among these patients, only one with an initial M1 disease (retroperitoneal lymph node metastasis) ultimately underwent curative resection following conversion therapy. These findings highlight the substantial difficulty of achieving R0 resection in truly unresectable stage IVb gastric cancer. Accordingly, patients with GOO and borderline resectable disease—particularly those with cT4bNxM0 status—may represent the subgroup most likely to benefit from a two-modular approach combining obstruction relief with systemic conversion therapy.

The CheckMate-649 trial established the clinical benefit of first-line PD-1 blockade (nivolumab) combined with chemotherapy in advanced gastric cancer. Among Chinese patients, nivolumab plus chemotherapy significantly improved OS compared to chemotherapy alone. In patients with PD-L1 CPS ≥5, the risk of death was reduced by 44% (median OS: 15.5 vs. 9.6 months; HR =0.56), and in the overall population (regardless of CPS score), the risk reduction was 38% (median OS: 14.3 vs. 10.3 months; HR =0.62) (28). In our cohort, most patients received SOX plus PD-1 inhibitors as a conversion regimen. Among 22 patients, 21 completed at least three cycles of treatment, with only one discontinuation due to grade 4 gastrointestinal bleeding. According to RECIST 1.1 (13), 10 patients (47.6%) achieved PR, while 8 (38.1%) had SD, indicating good disease control and tolerability. Further support comes from the G208 (DRAGON-IV/CAP-05) trial, where the addition of low-dose apatinib and camrelizumab to SOX chemotherapy (SOXRC) achieved a pathological complete response rate of 18.3%, compared to 5.0% in the SOX-only group, without increasing postoperative complications (29).

Nevertheless, this study has limitations. It is a single-center retrospective analysis with a relatively small sample size and substantial inter-patient heterogeneity, including the presence of distant metastases in over half of the cohort (12/22, 54.5%), which may impact the assessment of conversion success rates. Moreover, the lack of a control arm and long-term follow-up data limits the strength of the conclusions. Despite these limitations, our findings offer preliminary evidence supporting a multimodal treatment strategy that integrates functional reconstruction and conversion therapy, warranting further validation in larger, prospective cohorts. Based on these findings, we are currently conducting a prospective cohort study (ChiCTR2500102365) to evaluate the safety and efficacy of the SOXRC regimen in patients with initially unresectable advanced gastric adenocarcinoma complicated by GOO, including those with cT4bNanyM0 or cTanyNanyM1 disease with limited distant metastasis.

Conclusions

Modified LSPGJ provides effective obstruction relief and facilitates radical surgery in selected patients with GOO advanced gastric cancer. It offers a promising approach for individualized treatment and warrants further prospective validation.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-346/rc

Peer Review File: Available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-346/prf

Funding: This study was supported by the Special Fund for the Beijing Hope Run of Cancer Foundation of China (No. LC2019L05) and the Capital Health Development Research Special Fund Project (No. 2024-2-4026).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jgo.amegroups.com/article/view/10.21037/jgo-2025-346/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (protocol No. NCC4843, Ethics No. 24/543-4823). Written informed consent was obtained from the patients for the publication of this article and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Bray F, Laversanne M, Sung H, et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024;74:229-63. [Crossref] [PubMed]
2. Zhao F, Yang D, Lan Y, et al. Different trends of gastric cancer in China, Japan, Republic of Korea and United States of America. iScience 2024;27:110074. [Crossref] [PubMed]
3. Pinnam BSM, Ojemolon PE, Mohammed A, et al. Comparison of endoscopic and surgical gastrojejunostomy in patients with malignant gastric outlet obstruction: a national cohort analysis (2016-2020). Gastrointest Endosc 2025;102:205-213.e1. [Crossref] [PubMed]
4. Maharshi S, Sharma D, Sharma SS, et al. Aetiology and clinical spectrum of gastric outlet obstruction in North West India. Trop Doct 2023;53:433-6. [Crossref] [PubMed]
5. Troncone E, Fugazza A, Cappello A, et al. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2020;26:1847-60. [Crossref] [PubMed]
6. Yamaguchi K, Yoshida K, Tanahashi T, et al. The long-term survival of stage IV gastric cancer patients with conversion therapy. Gastric Cancer 2018;21:315-23. [Crossref] [PubMed]
7. Adler DG, Baron TH. Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients. Am J Gastroenterol 2002;97:72-8. [Crossref] [PubMed]
8. Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9. [Crossref] [PubMed]
9. Manuel-Vázquez A, Latorre-Fragua R, Ramiro-Pérez C, et al. Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature. World J Gastroenterol 2018;24:1978-88. [Crossref] [PubMed]
10. Lorusso D, Giliberti A, Bianco M, et al. Stomach-partitioning gastrojejunostomy is better than conventional gastrojejunostomy in palliative care of gastric outlet obstruction for gastric or pancreatic cancer: a meta-analysis. J Gastrointest Oncol 2019;10:283-91. [Crossref] [PubMed]
11. Shao XX, Xu Q, Wang BZ, et al. Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report. World J Gastrointest Surg 2023;15:1247-55. [Crossref] [PubMed]
12. Zhang K, Ma Y, Wu J, et al. The SUPER reporting guideline suggested for reporting of surgical technique. Hepatobiliary Surg Nutr 2023;12:534-44. [Crossref] [PubMed]
13. Schwartz LH, Litière S, de Vries E, et al. RECIST 1.1-Update and clarification: From the RECIST committee. Eur J Cancer 2016;62:132-7. [Crossref] [PubMed]
14. Freites-Martinez A, Santana N, Arias-Santiago S, et al. Using the Common Terminology Criteria for Adverse Events (CTCAE - Version 5.0) to Evaluate the Severity of Adverse Events of Anticancer Therapies. Actas Dermosifiliogr (Engl Ed) 2021;112:90-2. [Crossref] [PubMed]
15. Zhang LY, Ma JJ, Zang L, et al. Staged laparoscopic management of locally advanced gastric cancer with outlet obstruction. J Surg Oncol 2021;123:S8-S14. [Crossref] [PubMed]
16. Tanaka T, Suda K, Satoh S, et al. Effectiveness of laparoscopic stomach-partitioning gastrojejunostomy for patients with gastric outlet obstruction caused by advanced gastric cancer. Surg Endosc 2017;31:359-67. [Crossref] [PubMed]
17. Ramos MFKP, Pereira MA, Dias AR, et al. Gastric partitioning versus gastrojejunostomy for gastric outlet obstruction due to unresectable gastric cancer: randomized clinical trial. BJS Open 2024;9:zrae152. [Crossref] [PubMed]
18. Del Nero L, Sheijani AD, De Ceglie A, et al. A Meta-Analysis of Endoscopic Stenting Versus Surgical Treatment for Malignant Gastric Outlet Obstruction. World J Surg 2023;47:1519-29. [Crossref] [PubMed]
19. Khamar J, Lee Y, Sachdeva A, et al. Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis. Surg Endosc 2023;37:4834-68. [Crossref] [PubMed]
20. Wang C, Zhang X, Liu Y, et al. Efficacy and long-term prognosis of gastrojejunostomy for malignant gastric outlet obstruction: A systematic review and Bayesian network meta-analysis. Eur J Surg Oncol 2023;49:106967. [Crossref] [PubMed]
21. Kaminishi M, Yamaguchi H, Shimizu N, et al. Stomach-partitioning gastrojejunostomy for unresectable gastric carcinoma. Arch Surg 1997;132:184-7. [Crossref] [PubMed]
22. Ernberg A, Kumagai K, Analatos A, et al. The Added Value of Partial Stomach-partitioning to a Conventional Gastrojejunostomy in the Treatment of Gastric Outlet Obstruction. J Gastrointest Surg 2015;19:1029-35. [Crossref] [PubMed]
23. Zhang H, Xu F, Zheng Z, et al. Gastric emptying performance of stomach-partitioning gastrojejunostomy versus conventional gastrojejunostomy for treating gastric outlet obstruction: A retrospective clinical and numerical simulation study. Front Bioeng Biotechnol 2023;11:1109295. [Crossref] [PubMed]
24. Xu F, Zhang H, Fan Z, et al. Investigating biomechanical alterations and emptying patterns after various gastrojejunostomy strategy. Food Res Int 2024;176:113815. [Crossref] [PubMed]
25. Liu H, Xu Q, Ma FH, et al. The clinical value of totally laparoscopic stomach-partitioning gastrojejunostomy for malignant gastric outlet obstruction]. Zhonghua Zhong Liu Za Zhi 2020;42:445-8. [PubMed]
26. Morgagni P, Solaini L, Framarini M, et al. Conversion surgery for gastric cancer: A cohort study from a western center. Int J Surg 2018;53:360-5. [Crossref] [PubMed]
27. Huang RY, Kou HW, Le PH, et al. Outcomes of Conversion Surgery for Metastatic Gastric Cancer Compared with In-Front Surgery Plus Palliative Chemotherapy or In-Front Surgery Alone. J Pers Med 2022;12:555. [Crossref] [PubMed]
28. Moehler M, Xiao H, Blum SI, et al. Health-Related Quality of Life With Nivolumab Plus Chemotherapy Versus Chemotherapy in Patients With Advanced Gastric/Gastroesophageal Junction Cancer or Esophageal Adenocarcinoma From CheckMate 649. J Clin Oncol 2023;41:5388-99. [Crossref] [PubMed]
29. Li C, Tian Y, Zheng Y, et al. Pathologic Response of Phase III Study: Perioperative Camrelizumab Plus Rivoceranib and Chemotherapy Versus Chemotherapy for Locally Advanced Gastric Cancer (DRAGON IV/CAP 05). J Clin Oncol 2025;43:464-74. [Crossref] [PubMed]