Endoscopic management of gastric outlet obstruction disease

Abstract

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient's prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.

Keywords: Gastric outlet obstruction disease; endoscopic balloon dilation; endoscopic ultrasound-guided gastroenterostomy; metal stents.

Figure 1

Duodenal balloon dilation over the wire. The sequence of images shows (A) the identification of the anatomy of the stricture with water-soluble contrast medium, (B) the balloon placed over a guidewire positioned under fluoroscopic guidance, and (C) its dilation until the desired diameter is reached

Figure 2

Algorithm for treatment of benign gastric outlet obstruction disease NSAID, non steroidal anti-inflammatory drugs; H. pylori, Helicobacter pylori; FC-SEMS, fully coated self-expanding metal stent; LAMS, lumen-apposing stent; EUS-GE, endoscopic ultrasound-guided gastroenterostomy.

Figure 3

Enteral self-expanding metal stent

Figure 4

Bilio-duodenal self-expanding metal stent

Figure 5

Stent in stent

Figure 6

Endoscopic ultrasound-guided balloon-assisted gastroenterostomy. Radiological and endoscopic image of the positioning of a lumen-apposing metal stent after a contrast-filled balloon was used to identify the jejunal loop

Figure 7

Algorithm for treatment of malignant gastric outlet obstruction disease SEMS, self-expanding metal stent; EUS-GE, endoscopic ultrasound-guided gastroenterostomy; PEG, percutaneous endoscopic gastrostomy.