Endoscopic management of malignant gastric outlet obstruction

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Abstract

Gastric outlet obstruction (GOO) is a clinical entity characterized by postprandial vomiting, epigastric abdominal pain, bloating or discomfort, early satiety, and eventually weight loss. GOO may not be clinically evident until high-grade obstruction occurs due to the unique ability of the stomach to distend significantly to accommodate large volumes. GOO is caused by mechanical gastroduodenal obstruction or motility disorders and can be divided into 3 major categories: benign mechanical, malignant mechanical, and motility disorders. Treatment options include surgical interventions such as resection or bypass surgery, and endoscopic procedures such as enteral stenting and endoscopic ultrasound-guided gastroenterostomy.

Introduction

Gastric outlet obstruction (GOO) is a clinical entity characterized by postprandial vomiting, epigastric abdominal pain, bloating or discomfort, early satiety, and eventually weight loss. Because of shared clinical features, it is often difficult to distinguish motility disorders from mechanical obstruction or functional dyspepsia based on symptoms alone. GOO may not be clinically evident until high-grade obstruction occurs due to the unique ability of the stomach to distend significantly to accommodate large volumes. GOO is caused by mechanical gastroduodenal obstruction or motility disorders and can be divided into 3 major categories: benign mechanical, malignant mechanical, and motility disorders. This article will discuss the endoscopic treatments of GOO related to malignant mechanical obstructions.

GOO typically involves the distal stomach and/or the proximal small intestine. Malignant mechanical GOO usually results from cancer affecting the distal stomach or proximal duodenum. Gastric and pancreatic cancers are the most common malignant mechanical causes of GOO [1]. The most common cause is distal gastric cancer, which accounts for up to 35% of GOO cases [2], and pancreatic adenocarcinoma with extension to the duodenum or stomach [3]. Other less common causes of malignant GOO include gastric lymphomas, cystic neoplasm of the pancreas, gallbladder and bile duct cancer, carcinoid, retroperitoneal lymphadenopathy, retroperitoneal sarcoma, leiomyosarcoma, and gastrointestinal stromal tumors.

Treatment options include surgical interventions such as resection or bypass surgery, and endoscopic procedures such as enteral stenting and endoscopic ultrasound (EUS)-guided gastroenterostomy (GE). Surgical options provide definitive relief of obstruction at the cost of delay in treatment for wound healing and return of bowel function. However, resection can lead to cure in locally advanced cases, while palliative bypass options also allow for simultaneous biliary decompression when more distal obstruction is present. Endoscopic stents are typically reserved as palliative measures for unresectable lesions causing GOO and is a safe option only when there is no evidence of downstream disease. Issues with stent obstruction due to tumor overgrowth or food impaction can present significant problems, particularly in patients in whom treatment had significantly extended survival. The new EUS-guided options allow for a hybrid solution with creation of immediate anastomosis, thus eliminating need for recovery. However, limitations in tools and techniques necessitate caution when considering this option. Advances in endoscopic tools, such as magnets, may demonstrate promising options for select patients in the future.

Section snippets

Enteral SEMS

Duodenal Self-Expanding Metal Stent (SEMS) is a valuable treatment option for palliation in mechanical malignant GOO. Stent placement provides the ability to relieve obstructive symptoms as well as provide continued enteral nutrition, medication delivery, and to improve the patient's overall quality of life.

Enteral SEMS are all uncovered, and consist of a woven, knitted or laser-cut metal mesh that exerts self-expanding forces until they reach their maximum fixed width. They are cylindrical in

Covered vs uncovered SEMS

Uncovered SEMs are currently the only approved stents for treatment of malignant GOO and are generally the preferred stent choice due to them being less prone to migration and having increased flexibility. In addition, uncovered SEMs allow for bile flow through the stent apertures in patients with concomitant biliary stents. Unfortunately, tumor ingrowth and eventual obstruction is an important complication to remember, which is solely associated with uncovered stents. Covered enteral stents

Future developments

In 2010, Van Hooft et al., described the use of endoscopically placed magnets to create a gastroenteric anastomosis of malignant GOO [40]. While the procedure was technically successful it did require dilation of the stricture to 16 mm and placement of a metal stent. The study was halted due to a single death from the stent, and further use of this device was not described. However, today we are seeing development of endoscopically placed magnets for enteroenteric anastomosis as treatment for

Conclusion

Placement of SEMS is recommended for the treatment of malignant gastroduodenal obstruction in patients with a poor performance status and/or short life expectancy, according to safety, efficacy, and cots. Surgical gastrojejunostomy is an alternative approach with more durable results and lower rates of long-term complications. The choice of an uncovered versus covered SEMS should be based on patient-related characteristics, including the location of the stenosis, concomitant involvement of the

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    Funding: None.

    Conflict of interest: Anish Patel: None declared. Dr Sethi: Boston Scientific: consultant. Olympus: consultant.

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