33 - Palliation of Gastric Outlet Obstruction

Abstract

Malignant gastric outlet obstruction (MGOO) is a syndrome caused by intestinal obstruction due to peripyloric or duodenal tumor growth. Patients with MGOO usually have unresectable disease with a poor prognosis. Treatment should therefore focus on comfort and resolution of obstructive symptoms. Endoscopic self-expandable metal stent (SEMS) placement is a minimally invasive alternative to the traditional surgical gastrojejunostomy for the palliation of MGOO. Gastroduodenal SEMS placement is a feasible procedure with technical success rates of 90%–100%. Improvement in oral food intake or relief of obstructive symptoms is achieved in 63%–99% of patients. Clinical failure of SEMSs mainly depends on the patient's performance status and the presence and extent of peritoneal carcinomatosis. SEMSs remain patent for a median period of 73–91 days. Stent dysfunction occurs in approximately 20% of patients, and mainly involves reobstruction by tumor growth (13%) or stent migration (4%). The latest randomized controlled trials (RCTs) have shown lower reobstruction rates and superior stent patency for partially covered SEMSs in comparison with uncovered SEMSs. Patients treated with SEMSs have better short-term outcomes compared with surgical gastrojejunostomy, including a faster recovery of food intake and shorter hospitalization. Gastrojejunostomy is superior in the long term, with lower recurrent obstruction and reintervention rates. Endoscopic SEMS placement is a valid alternative to surgical gastrojejunostomy for the palliation of MGOO. Because of the better short-term outcomes, SEMS placement is generally recommended to patients in poor clinical condition who have a short life expectancy of weeks to months.