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Review
. 2020 Apr 28;26(16):1847-1860.
doi: 10.3748/wjg.v26.i16.1847.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Edoardo Troncone  1 , Alessandro Fugazza  2 , Annalisa Cappello  2 , Giovanna Del Vecchio Blanco  1 , Giovanni Monteleone  1 , Alessandro Repici  2 , Anthony Yuen Bun Teoh  3 , Andrea Anderloni  4
Affiliations
Review

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Edoardo Troncone et al. World J Gastroenterol. .

Abstract

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Keywords: Duodenal stricture; Endoscopic ultrasound-guided gastroenterostomy; Enteral stent; Gastric cancer; Gastrojejunostomy; Interventional endoscopic ultrasonography; Pancreatic cancer; Self-expanding metal stent.

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Conflict of interest statement

Conflict-of-interest statement: Dr. Anderloni reports personal fees from Boston Scientific, during the conduct of the study; personal fees from Boston Scientific, outside the submitted work; Dr. Repici reports personal fees from Boston Scientific, personal fees from Fujifilm, during the conduct of the study; personal fees from Boston Scientific, personal fees from Fujifilm, outside the submitted work; Dr. Teoh reports personal fees from Microtech Medical Corporations, personal fees from Boston Scientific, personal fees from Cook, personal fees from Taewoong, during the conduct of the study; personal fees from Microtech Medical Corporations, personal fees from Boston Scientific, personal fees from Cook, personal fees from Taewoong, outside the submitted work; The other Authors declare no conflict of interests.

Figures

Figure 1
Figure 1
Computed tomography scan appearance of malignant duodenal stricture with gastric distension due to pancreatic cancer.
Figure 2
Figure 2
Graphic representation of the main approaches applied to manage malignant gastric outlet obstruction. A: Surgical gastrojejunostomy; B: Endoscopic enteral stenting with self-expanding metal stents; C: Endoscopic ultrasound-guided gastroenterostomy.
Figure 3
Figure 3
Final endoscopic appearance of a duodenal uncovered self-expanding metal stent deployed across duodenal stricture, in a patient with gastric outlet obstruction due to pancreatic cancer.
Figure 4
Figure 4
Intra-operative image of laparoscopic gastrojejunostomy.
Figure 5
Figure 5
Endoscopic ultrasound view of the distended jejunal loop.
Figure 6
Figure 6
Endoscopic ultrasound-guided gastroenterostomy with the double balloon occluder. A: The double balloon occluder in place distending the small bowel in between; B: Endoscopic ultrasound-guided placement of lumen-apposing metal stent between the stomach and jejunum; C: Final endoscopic appearance of lumen-apposing metal stent.
Figure 7
Figure 7
Computed tomography scan appearance of endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stent placed between the stomach and jejunum.
See this image and copyright information in PMC

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