GASTRIC OUTLET OBSTRUCTION

1. Gastric Outlet Obstruction
Rajeshwar .K
Final yr PG

2. Overview
Background
• Gastric outlet obstruction (GOO, also known
as pyloric obstruction) is not a single entity; it
is the clinical and pathophysiological
consequence of any disease process that
produces a mechanical impediment to gastric
emptying.

3. Upper endoscopy showing multiple gastric
polyps. Such polyps are a major cause of
gastric outlet obstruction.

4. Background
Clinical entities that can result in GOO generally are
categorized into 2 well-defined groups of causes—benign
and malignant.
This classification facilitates discussion of management
and treatment.
When peptic ulcer disease (PUD) was more prevalent,
benign causes were the most common; however, one
review shows that only 37% of patients with GOO have
benign disease and the remaining patients have
obstruction secondary to malignancy.

5. Problem :
• Gastric outlet obstruction can be a diagnostic and
treatment dilemma. As part of the initial workup,
exclude the possibility of functional nonmechanical
causes of obstruction, such as diabetic gastroparesis.
• Once a mechanical obstruction is confirmed,
differentiate between benign and malignant processes
because definitive treatment is based on recognition of
the specific underlying cause.
• Carry out diagnosis and treatment expeditiously,
because delay may result in further compromise of the
patient's nutritional status. Delay will also further
compromise edematous tissue and complicate surgical
intervention.

6. Epidemiology :
Frequency
• The incidence of gastric outlet obstruction (GOO)
has been reported to be less than 5% in patients
with PUD, which is the leading benign cause of the
problem.
• Five percent to 8% of ulcer-related complications
result in an estimated 2000 operations per year in
the United States.
• The incidence of GOO in patients with
peripancreatic malignancy, the most common
malignant etiology, has been reported as 15-20%.

7. Etiology :
• The major benign causes of gastric outlet obstruction
(GOO) are
1. PUD,
2. Gastric polyps,
3. Ingestion of caustics,
4. Pyloric stenosis,
5. Congenital duodenal webs,
6. Gallstone obstruction (Bouveret syndrome),
7. Pancreatic pseudocysts,
8. Bezoars.
• PUD manifests in approximately 5% of all patients with
GOO.
• Ulcers within the pyloric channel and first portion of the
duodenum usually are responsible for outlet obstruction.

8. Etiology …
• Obstruction can occur in an acute setting
secondary to acute inflammation and edema
or, more commonly, in a chronic setting
secondary to scarring and fibrosis.
• Helicobacter pylori has been implicated as a
frequent associated finding in patients with
GOO, but its exact incidence has not been
defined precisely.

9. Etiology…
• Within the pediatric population, pyloric
stenosis constitutes the most important cause
of GOO.
• Pyloric stenosis occurs in 1 per 750 births. It is
more common in boys than in girls and also is
more common in first-born children.
• Pyloric stenosis is the result of gradual
hypertrophy of the circular smooth muscle of
the pylorus.

10. Anatomic changes associated with pyloric stenosis.

11. Malignant causes
• Pancreatic cancer is the most common
malignancy causing GOO.
• Outlet obstruction may occur in 10-20% of
patients with pancreatic carcinoma.
• Other tumors that may obstruct the gastric
outlet include
a) Duodenal cancer
b) ampullary cancer,
c) cholangiocarcinomas
d) gastric cancer.
• Metastases to the gastric outlet also may be
caused by other primary tumors.

12. Pathophysiology :
• Intrinsic or extrinsic obstruction of the pyloric
channel or duodenum is the usual
pathophysiology of gastric outlet obstruction;
as previously noted, the mechanism of
obstruction depends upon the underlying
etiology.
• Patients present with intermittent symptoms
that progress until obstruction is complete.
Vomiting is the cardinal symptom.
• Initially, patients may demonstrate better
tolerance to liquids than solid food.

13. Pathophysiology :
• In a later stage, patients may develop significant
weight loss due to poor caloric intake.
Malnutrition is a late sign, but it may be very
profound in patients with concomitant
malignancy.
• In the acute or chronic phase of obstruction,
continuous vomiting may lead to dehydration and
electrolyte abnormalities.
• When obstruction persists, patients may develop
significant and progressive gastric dilatation. The
stomach eventually loses its contractility.
• Undigested food accumulates and may represent
a constant risk for aspiration pneumonia.

14. Presentation :
• Nausea and vomiting are the cardinal
symptoms of gastric outlet obstruction.
• Vomiting usually is described as nonbilious,
and it characteristically contains undigested
food particles.
• In the early stages of obstruction, vomiting
may be intermittent and usually occurs within
1 hour of a meal.

15. Presentation:
• Patients with gastric outlet obstruction resulting
from a duodenal ulcer or incomplete obstruction
typically present with symptoms of gastric
retention, including early satiety, bloating or
epigastric fullness, indigestion, anorexia, nausea,
vomiting, epigastric pain, and weight loss.
• They are frequently malnourished and
dehydrated and have a metabolic insufficiency.
• Weight loss is frequent when the condition
approaches chronicity and is most significant in
patients with malignant disease.

16. Metabolic effects
• Dehydration and electrolyte abnormalities-- Increase in BUN and
creatinine are late features of dehydration.
 Prolonged vomiting causes loss of hydrochloric acid &
produces an increase of bicarbonate in the plasma to compensate
for the lost chloride-------hypokalemic hypochloremic metabolic
alkalosis.
 Alkalosis shifts the intracellular potassium to the extracellular
compartment, and the serum potassium is increased factitiously.
• With continued vomiting, the renal excretion of potassium
increases in order to preserve sodium.
• The adrenocortical response to hypovolemia intensifies the
exchange of potassium for sodium at the distal tubule, with
subsequent aggravation of the hypokalemia.

17. Paradoxically acidic urine
 Initially, the urine has a low chloride and high bicarbonate
content, reflecting the primary metabolic abnormality
 This bicarbonate is excreted along with sodium and so, with
time, the patient becomes progressively hyponatraemic and more
profoundly dehydrated.
 Because of the dehydration, a phase of sodium retention
follows and potassium and hydrogen are excreted in preference.
 This results in the urine becoming paradoxically acidic.
 Alkalosis leads to a lowering of the circulating ionised calcium,
and tetany can occur.

18. Presentation…
• Abdominal pain is not frequent and usually
relates to the underlying cause, eg, PUD,
pancreatic cancer.
• Physical examination often demonstrates the
presence of chronic dehydration and malnutrition
• A dilated stomach may be appreciated as a
tympanitic mass in the epigastric area and/or left
upper quadrant.

19. Indications:
• Patients with gastric outlet obstruction (GOO)
due to benign ulcer disease may be treated
medically if results of imaging studies or
endoscopy determine that acute inflammation
and edema are the principle causes of the outlet
obstruction (as opposed to scarring and fibrosis,
which may be fixed).
• If medical therapy conducted for a reasonable
period fails to alleviate the obstruction, then
surgical intervention becomes appropriate.
• Typically, if resolution or improvement is not seen
within 48-72 hours, surgical intervention is
necessary.

20. Indications…
• The choice of surgical procedure depends
upon the patient's particular circumstances;
however, vagotomy and antrectomy should be
considered the criterion standard against
which the efficacy of other procedures is
measured.
• In cases of malignant obstruction, weigh the
extent of surgical intervention for the relief of
GOO against the malignancy's type and
extent, as well as the patient's anticipated
long-term prognosis.

21. Indications..
• As a guiding principle, undertake major tumor
resections in the absence of metastatic
disease in a patient who can withstand such a
procedure from a nutritional standpoint.
• In patients with largely metastatic disease,
determine the degree of surgical intervention
for palliation in light of the patient's realistic
prognosis and personal wishes.

22. Relevant Anatomy:
• SAC-LIKE ORGAN LOCATED MOSTLY IN THE LEFT UPPER
PART OF THE ABDOMEN
• It is located beneath the diaphragm and is attached
superiorly to the esophagus and distally to the duodenum.
• The stomach is divided into 4 portions, the cardia, the body,
the antrum, and the pylorus.
• HAS 2 SURFACES (ANTERIOR & POSTERIOR), 2 CURVATURES
(GREATER & LESSER), & 4 REGIONS (CARDIA, FUNDUS,
PYLORUS,& ANTRUM
• The gastric wall is made up of 4 layers: mucosa, submucosa,
muscularis propria, and serosa
• Inflammation, scarring, or infiltration of the antrum and
pylorus are associated with the development of gastric
outlet obstruction.

23. STOMACH

24. STOMACH
• It functions primarily as a reservoir to store
large quantities of recently ingested food
• Its volume ranges from about 30ml in a
neonate to 1.5 to 2L in adulthood.
• The gastroesophageal junction generally lies
to the left of the 10th thoracic vertebral body,
1-2cm below the diaphragmatic hiatus.
• The gastroduodenal junction lies at L1 and
generally to the right of the midline, but may
be lower

25. STOMACH
• ANTERIOR RELATIONS – DIAPHRAGM,
ANTERIOR ABDOMINAL WALL, LEFT COSTAL
MARGIN, & THE LEFT LOBE OF THE LIVER
• POSTERIOR RELATIONS – LESSER SAC,
PANCREAS, LEFT SUPRARENAL GLAND, LEFT
KIDNEY, SPLEEN, SPLENIC ARTERY, & THE
TRANVERSE COLON
• SUPERIOR RELATIONS – LEFT DOME OF THE
DIAPHRAGM

26. STOMACH

27. STOMACH
• BLOOD SUPPLY: FROM THE COELIAC AXIS –
LEFT GASTRIC,
• SPLENIC (SHORT GASTRIC & LEFT
GASTROEPIPLOIC),
• HEPATIC (GASTRODUODENAL[SUPERIOR
PANCREATICODUODENAL & RIGHT EPIPLOIC],
CYSTIC, & RIGHT GASTRIC)

28. STOMACH

29. STOMACH
• NERVE SUPPLY: VAGUS (ANTR & POSTR) The vagus constitutes the
motor and secretory nerve supply for the stomach.
• When divided, in the operation of vagotomy, the neurogenic (reflex)
gastric acid secretion is abolished but the stomach is, at the same
time, rendered atonic so that it empties only with great difficuty.
• Because of this, total vagotomy must always be accompanied by
some sort of drainage procedure, either a pyloroplasty (to enlarge
the pyloric exit and render the pyloric sphincter incompetent) or by a
gastrojejunostomy (to drain the stomach into the proximal small
intestine).
• Drainage can be avoided if the nerve of Latarjet is preserved, thus
maintaining the innervation and function of the pyloric antrum
(highly selective vagotomy).

31. STOMACH
• The sympathetic innervation is derived from
preganglionic fibers arising predominantly
from T6 to T8 spinal nerves.

32. STOMACH

33. BARIUM MEAL TRACING

34. Relevant Anatomy..
DUODENUM
• 25cm LONG, C-SHAPED CURVE AROUND THE HEAD OF THE PANCREAS, DIVIDED INTO 4 PARTS
• 1ST PART
 5cm LONG, ASCENDS FROM THE GASTRODUODENAL JUNCTION, OVERLAPPED BY THE LIVER &
GALL BLADDER
 IMMEDIATELY POSTR ARE THE PORTAL VEIN, COMMON BILE DUCT & GASTRODUODENAL ARTERY
SEPARATING IT FROM THE INFERIOR VENA CAVA
• 2nd PART
 7.5CM LONG, DESCENDS IN A CURVE AROUND THE HEAD OF PANCREAS, CROSSED BY THE
TRANSVERSE COLON & LIES ON THE RIGHT KIDNEY AND URETER.
• 3rd PART
 10cm LONG, RUNS TRANSVERSELY TO THE LEFT CROSSING THE INFERIOR VENA CAVA, AORTA & L3
VERT
• 4th PART
 ASCENDS UPWARDS & TO THE LEFT TO END AT THE DUODENOJEJUNAL JUNCTION
• BLOOD SUPPLY – THE SUPERIOR & INFERIOR PANCREATICODUODENAL ARTERIES
• It is intimately related to the gallbladder, liver, and pancreas; therefore, a malignant process of any
adjacent structure may cause outlet obstruction due to extrinsic compression.

35. DUODENUM

36. Contraindications for Surgical therapy
• Contraindications for surgery relate to the
underlying medical condition.
• Most patients benefit from an initial period of
gastric decompression, hydration, and correction of
electrolyte imbalances.
• In patients who are severely malnourished,
postponing surgical intervention until the
nutritional status has been optimized may be wise.
• In selective cases, some patients may benefit from
total parenteral nutrition (TPN) or distal tube
feeding (eg, placed via a percutaneous
jejunostomy).

37. Contraindications..
• One of the relative contraindications for surgery
is the presence of advanced malignancy; in these
cases, in which life expectancy may be limited to
a few months, palliation via endoscopically
placed stents should be considered.
• Overall, every patient with gastric outlet
obstruction deserves evaluation by a surgeon.
• Even if the patient has unresectable disease,
palliative surgical measures may improve the
quality of life.

38. WORKUP
Laboratory Studies
• Obtain a CBC. Check the hemoglobin and
hematocrit to. rule out the possibility of anemia.
• Obtain an electrolyte panel. As noted previously,
identifying and correcting electrolyte
abnormalities that tend to occur is essential.
• Liver function tests may be helpful, particularly
when a malignant etiology is suspected.
• A test for H pylori is helpful when the diagnosis
of PUD is suspected.

39. Imaging studies
Plain abdominal radiographs, contrast upper GI studies
(Gastrografin or barium), and CT scans with oral
contrast are helpful.
Plain radiograph of the abdomen. Enlarged stomach with calcified
content

40. Contrast study demonstrating an enlarged stomach. The point of
obstruction is visualized at the pyloric-duodenal junction (string sign).
Plain radiographs, including the obstruction series (ie, supine abdomen, upright
abdomen, chest posteroanterior), can demonstrate the presence of gastric
dilatation and may be helpful in distinguishing the differential diagnosis.

41. Diagnostic Procedures
• Upper endoscopy can help visualize the gastric
outlet and may provide a tissue diagnosis when
the obstruction is intraluminal.
• The sodium chloride load test is a traditional
clinical nonimaging study that may be helpful.
• The traditional sodium chloride load test is
performed by infusing 750 cc of sodium chloride
solution into the stomach via a nasogastric tube
(NGT).
• A diagnosis of gastric outlet obstruction (GOO) is
made if more than 400 cc remain in the stomach
after 30 minutes.

42. Diagnostic procedures..
• Nuclear gastric emptying studies measure the
passage of orally administered radionuclide over
time.
• Unfortunately, both the nuclear test and the
saline load test may produce abnormal results in
functional states.
• Barium upper GI studies are very helpful because
they can delineate the gastric silhouette and
demonstrate the site of obstruction.
• An enlarged stomach with a narrowing of the
pyloric channel or first portion of the duodenum
helps differentiate GOO from gastroparesis.

43. Diagnostic procedures..
• The specific cause may be identified as an
ulcer mass or intrinsic tumor.
• In the presence of PUD, perform endoscopic
biopsy to rule out the presence of malignancy.
• In the case of peripancreatic malignancy, CT
scan–guided biopsy may be helpful in
establishing a preoperative diagnosis.
• Needle-guided biopsy also may be helpful in
establishing the presence of metastatic
disease. This knowledge may impact the
magnitude of the procedure planned to
alleviate the GOO.

44. Histologic Findings
Histologic findings relate to the
individual underlying cause.

45. Medical Therapy
• Initial management of gastric outlet obstruction
(GOO) should be the same regardless of the
primary cause.
• After a diagnosis is made, admit patients for
hydration and correction of electrolyte
abnormalities.
• Remembering that the metabolic alkalosis of
GOO responds to the administration of chloride
is important; therefore, sodium chloride
solution should be the initial IV fluid of choice.
• Potassium deficits are corrected after repletion
of volume status and after replacement of
chloride.

46. Medical therapy
• Place a NGT to decompress the stomach.
Occasionally, a large tube is required because
the undigested food blocks tubes with small
diameters.
• When acute PUD has been identified as a
primary cause of gastric outlet obstruction
(GOO), focus treatment on the reduction of acid
production.
• Histamine-2 (H2) blockers and proton pump
inhibitors are the mainstay of treatment.

47. Medical therapy..
• Treat H pylori infection, when identified,
according to current recommendations.
• Although most patients improve temporarily
with treatment, scarring and fibrosis may
worsen over time.
• Pneumatic balloon dilatation of a chronic,
benign stricture can be performed via
endoscopy.
• Patients who are candidates for balloon
dilatation are likely to present with recurrent
GOO.

48. Medical therapy..
• Published series using this technique report
success rates of over 76% after multiple
dilatations, although the rate of failure and
recurrent obstruction is higher in patients treated
with balloon dilatation who have not also been
treated for H pylori infection.
• Patients who are negative for H pylori do not
respond favorably to balloon dilatation and should
be considered for surgical treatment early in the
process.
• Further treatment is tailored to the underlying
cause; this is where the distinction between
benign and malignant disease becomes important.

49. MEDICAL THERAPY :
INTERVENTION
• If the GOO is irreversible, or is caused by fibrotic scarring,
rather than edema and spasm, it requires a definitive
treatment.
• The advent of endoscopic balloon dilation (EBD), surgery
was the only treatment for these patients.
• Recent data suggest that EBD is an effective alternative to
surgery in a majority of patients with ulcer-related and
caustic induced GOO.
• Patients with a possibility of malignancy would not be
candidates for EBD.
• In inflammatory conditions like Crohn’s disease or infection
like tuberculosis causing GOO, specific treatment for the
antecedent disease is mandatory and may obviate the
need for surgery or EBD.

50. EBD
• The advent of through-the-scope (TTS) balloon
dilating catheters, EBD has become the first line of
therapy in a majority of patients with benign GOO.
EQUIPMENT
• The balloons are available in lengths of 5.5-8.0 cm
and are inflated using a hydrostatic device that is
attached to a pressure gauge.
• Two types of balloons are currently available, one
which can be dilated to a single diameter (Olympus
SWIFT Balloon Dilators, Microvasive Rigiflex balloon)
and the other ones that can be dilated to pre-fixed
increasing diameters depending on the pressure
with which they are inflated, e.g. CRE® dilators from
Boston Scientific Inc and Quantum TTC® Balloon
Dilators from Wilson Cook.

51. GUIDELINES FOR BALLOON DILATION
Patient selection
• Only localized stricture of the stomach should
be chosen.
• The site of gastric cicatrisation is not
important.
• CT scan to assess antral wall thickness may be
a good modality to identify the “right
patients” and to exclude malignancy.
• Endosonography may also emerge as a useful
adjunct in this regard, especially in helping
direct intralesional steroid injections.

52. Patient preparation
• Prior to the procedure, the patient should be kept
fasting for 8-12 h.
• Gastric decompression should be carried on using a
wide bore Ryles’ tube in patients who have gastric
residue.
• Aspiration of gastric contents should be done to
ensure a clearer view and to prevent regurgitation of
contents into the air-passages.
• Patient’s diet should be restricted to liquids only, in
those with severe stenosis.
• Patients are given pharyngeal anesthesia and
conscious sedation administered along with hyoscine
butylbromide injection prior to the procedure.

53. When should dilation be started?
• Patients with peptic-GOO can be dilated any time
after gastric decompression is done as most have
chronic cicatrisation.
• In those with active ulceration one can wait for
response to proton pump inhibitors. As stated
previously, it is best to wait for 8 wk after caustic
ingestion to allow for natural healing.

54. How frequently should dilation be done?
• Although different workers have dilated at 1-3 wk
intervals, weekly dilation in sub-acute phase of
caustic ingestion to facilitate:
(a) reaching the end point of 15 mm, in a short
period of time.
(b) maintaining nutritional status of the patient.
• In patients in the chronic phase of caustic ingestion
and peptic-GOO, dilation can be done once a week
or once in 3 wk.
• Once adequate nutrition is ensured, the interval
between dilations can be varied, taking into account
the social circumstances; e.g. the distance the
patient travels, etc.

55. Panel showing barium study in a patient with peptic pyloric
stenosis with trifoliate deformity of duodenal bulb (A), and
endoscopic pictures at the beginning (B), after 2 dilations (C)
and after 4 dilations (D).

56. Surgical Therapy
Management of benign disease
• More than 75% of patients presenting with
GOO eventually require surgical intervention.
• Surgical intervention usually provides
definitive treatment of GOO, but it may result
in its own comorbid consequences.
• Operative management should offer relief of
obstruction and correction of the acid
problem.

57. Surgical therapy..
The most common surgical procedures performed for GOO
related to PUD are
• Vagotomy and antrectomy,
• Vagotomy and pyloroplasty,
• Truncal vagotomy and gastrojejunostomy,
• Pyloroplasty,
• Laparoscopic variants of the aforementioned procedures.
• Vagotomy and antrectomy with Billroth II reconstruction
(gastrojejunostomy) seem to offer the best results.
• Vagotomy and pyloroplasty and pyloroplasty alone,
although used with some success, can be technically
difficult to perform due to scarring at the gastric outlet.

58. VAGOTOMY

59. VAGOTOMY

61. • A combination of balloon dilatation and highly
selective vagotomy has been described, but it is
associated with gastroparesis and a high
recurrence rate.
• Placement of a jejunostomy tube at the time of
surgery should be considered.
• This provides temporary feeding access in
already malnourished patients. Also, in
chronically dilated partial obstructions, the
stomach may be slow to recover a normal rate of
emptying

63. Surgical therapy….
• The role of the laparoscopic approach in the
treatment of GOO is under investigation and may
represent a valid form of therapy with low
morbidity.
• One group in China performed laparoscopic
truncal vagotomy and gastrojejunostomy for GOO
related to PUD, with nearly complete resolution
of symptomatology.
• The investigators reported no conversions to
open procedure or mortalities.
• Twenty-seven percent of patients did experience
transiently delayed gastric emptying, which
resolved with conservative measures.

64. Surgical therapy…
• Kim et al also reported good results from the use of
laparoscopic truncal vagotomy with gastrojejunostomy,
including shorter operating times and hospital stays in
comparison with the open procedure.
• Hall et al performed a double-blind, multicenter,
randomized, controlled trial comparing patient recovery
following laparoscopic pyloromyotomy to that after open
pyloromyotomy in infants with pyloric stenosis.
• The investigators found that among the 87 infants who
underwent the laparoscopic procedure, the median
(interquartile range) postoperative time needed to
achieve full enteral feeding was 18.5 hours, compared
with 23.9 hours in the 93 infants who underwent open
pyloromyotomy.

65. • The study also found that the incidence of
postoperative vomiting was similar in the open
and laparoscopic groups, as was the frequency of
intraoperative and postoperative complications.
• The authors suggested that open and
laparoscopic pyloromyotomy are safe means of
treating infantile pyloric stenosis.
• Because of its apparent advantages, however,
they recommended that in centers with suitable
laparoscopic experience, the laparoscopic form of
the procedure be used.

67. Completed myotomy in open pyloromyotomy for
hypertropic pylotic stenosis.

68. Management of malignant disease
• The management of GOO secondary to
malignancy is controversial.
• Of patients with periampullary cancer, 30-50%
present with nausea and vomiting at the time of
diagnosis.
• Most of these tumors are unresectable
(approximately 40% of gastric cancers and 80-
90% of periampullary cancers.)
• When tumors are found to be unresectable, 13-
20% of patients eventually develop GOO before
they succumb to their disease.

70. Management of malignant disease(GOO)
• Gastrojejunostomy remains the surgical
treatment of choice for GOO secondary to
malignancy.
• Although surgeons traditionally have preferred
an antecolic anastomosis to prevent further
obstruction by advancing tumor growth, a
publication evaluating the retrocolic anastomosis
in this setting challenges conventional wisdom.
• Results demonstrate that a retrocolic
anastomosis may be associated with decreased
incidences of delayed gastric emptying (6% vs
17%) and late GOO (2% vs 9%).

71. Roux-en-Y GJ

72. Management of malignant disease(GOO)
• Other groups have illustrated that partial
stomach-partitioning gastrojejunostomy
decreases the rates of delayed gastric
emptying as compared with traditional
gastrojejunostomy.
• Feeding jejunostomy should again be
considered to combat malnutrition and slow
recovery of gastric emptying.

73. Management of malignant disease(GOO)
• Internationally, studies are underway using
laparoscopic gastrojejunostomy instead of the
open procedure.
• In the United States, critics cite a nearly 20%
conversion rate and a delay in the return of gut
function as reasons to not perform the procedure
laparoscopically.
• Comparisons of laparoscopic GI anastomosis
versus the open procedure have revealed less
morbidity and mortality, shorter hospital stays,
fewer blood transfusions, and faster GI transit
recovery time.

74. Management of malignant disease(GOO)
• Researchers at Johns Hopkins Hospital have attempted
endoscopic transgastric approaches to create a
gastrojejunostomy in a porcine model.
• As natural orifice transluminal surgery gains more
widespread interest, these novel approaches may
become more popular.
• Chopita and colleagues reported on the use of magnetic
endoscopic gastroenteric anastomosis in 15 patients
with malignant gastroenteric obstruction. The procedure
had an 86.7% success rate, with the authors noting the
additional benefits of shorter duration of hospital stay
and good quality of life in patients.
• Although still experimental, this procedure may one day
be a surgical option.

75. Management of malignant disease(GOO)
• No and colleagues reported that gastrojejunostomy was preferable to
metal stent placement in providing palliation of GOO caused by
unresectable or metastatic cancer in patients with a good performance
status.
• Self-expandable metallic stents also have been used for the treatment
of GOO in a malignant setting.
• Metallic stents have previously been used successfully to treat stenosis
of such areas as the blood vessels, bile duct, esophagus, and trachea.
• With the development of newer stents and delivery systems, metallic
stents may have a role in the nonsurgical treatment of gastroduodenal
obstruction.
• Stents may allow the physician to avoid complicated surgical
procedures. Currently, only the Wallstent has FDA approval for
palliation in malignant gastroduodenal obstruction.
• Significant complications include the following: malposition,
misdeployment, tumor ingrowth or overgrowth, migration, bleeding,
and perforation.

76. Management of malignant disease(GOO)
• A review of 19 studies published in 2004 quoted
clinical success rates of 80-90%.
• Subsequent multicenter trials using the enteral
Wallstent in 176 patients with malignant GOO
resulted in 89% of patients tolerating oral intake for
a median of 219 days postprocedure.
• Of the 84% in whom the stent was successful after
the initial procedure, 22% required restenting to
tolerate an oral diet.
• In addition, as other studies have demonstrated,
chemotherapy was independently associated with
an increased tolerance in oral intake.

77. Figure 1. Stents used . a,
Duodenal stent; b, pylorus
stent

78. Figure 2. Stent delivery system. (a), stent delivery system; (b), the front tip of
the delivery system; (c), the handler of the delivery system.

79. Management of malignant disease(GOO)
• One proposed solution uses covered metallic stents that
have a lower incidence of tumor ingrowth.
• A 60% rate of tumor ingrowth in uncovered stents versus
a 10% rate of tumor ingrowth in covered stents has been
reported. Furthermore, with the double stent technique,
that is, simultaneous placement of both covered stents
and uncovered stents, lower early restenosis rates have
been achieved.
• A stent patency of 21.5 days for uncovered stents versus
150 days for double stents has been achieved.
• Of the 62 patients studied by Maetani et al, half received
uncovered stents and half covered stents. The authors
found no statistical difference in patency, but the triple-covered
stent resulted in less frequent dysfunction four
weeks after stenting.

80. Management of malignant disease(GOO)
• Several retrospective studies have been performed to
compare the results of stenting versus surgical
intervention.
• Survival rates are equivalent; however, costs, length
of stay, and number of subsequent procedures are all
decreased following stenting.
• In addition, a delay of gastric emptying and morbidity
decrease with the use of metallic stents.
• These promising results suggest that stents may
eventually replace surgery as palliative intervention
for unresectable periampullary malignancies.

81. Management of malignant disease(GOO)
• A 2011 study from the Netherlands discusses the
use of a D-Weave Niti-S nitinol stent specifically
for the duodenum.
• A key outcome in this palliative procedure was a
significant improvement in global health status
and median 82-day survival.
• This study reports a marvelous technical and
robust clinical success rate with patency up to 190
days, and a 25% complication rate.

84. Expandable metallic stent placement for malignant gastric outlet
obstruction under endoscopy in a patient

85. Postoperative Details
 Admit patients to a monitor unit after the procedure.
 Pay special attention to fluid and electrolyte status.
 Most surgeons agree that perioperative antibiotics are advisable but may be
limited to use during the immediate perioperative period in the absence of
intervening infection.
 If a gastric reconstruction is performed, an NGT is recommended.
 The length of time that the NGT should remain in place is controversial;
however, it is important to remember that a previously dilated stomach, the
performance of a vagotomy, and the presence of metastatic cancer may all
contribute to decreased gastric motility.
 An anatomically patent gastrojejunostomy may fail to empty for days. This
syndrome of delayed gastric emptying is a well-known entity and requires
surgical patience. Again, preoperative planning for feeding access becomes
important during this immediate postoperative period.
 Aggressive pulmonary toilet, prophylaxis for gastritis and deep venous
thrombosis (DVT), and early ambulation are advisable.

86. Follow-up
• Closely monitor patients after surgery and upon
discharge. After relief of gastric outlet obstruction,
patients may continue to experience gastric
dysmotility and may require medication to
stimulate gastric emptying and motility.
• In patients with malignancy, the potential for
progressive and recurrent disease always remains.
These patients should be monitored by a surgeon or
an oncologist.
• Closely monitor patients whose treatment consisted
of balloon dilatation because most of these patients
require subsequent dilatations to achieve
satisfactory results.

87. Complications
• Although the risk is small, patients undergoing endoscopic treatment
with either balloon dilatation or stenting are at risk for perforation.
• Migration of the stents and reocclusion requiring further intervention.
• Operative complications in patients undergoing surgery for gastric outlet
obstruction (GOO) often are related to the nutritional status of the
patients. Commencing nutritional support upon recognition of the
presence of GOO is important.
• If surgery is anticipated, delaying the surgery or any intervention until
TPN has been instituted for at least 1 week is often prudent.
• Acute intervention may be technically difficult because of significant
gastric dilatation and gastric wall edema. This circumstance may increase
the rate of anastomotic leak. On occasion, delaying surgical intervention
for several days while the stomach is decompressed by nasogastric
suction may be prudent.
• Alert patients undergoing gastric resection for benign or malignant
disease to the possibility of well-known postgastrectomy syndromes,
such as dumping, alkaline gastritis, and afferent loop syndrome.

88. Outcome and Prognosis
• Gastric outlet obstruction (GOO) is a clinical condition
that may result from a number of underlying causes, both
benign and malignant.
• Despite medical advances in the acid suppression
mechanism, the incidence of GOO remains a prevalent
clinical problem in benign PUD.
• Also, an increase in the number of cases of GOO seems to
be noted secondary to malignancy; this is possibly due to
improvements in cancer therapy, which allow patients to
live long enough to develop this complication.
• Orient initial management to identification of the primary
underlying cause and to the correction of volume and
electrolyte abnormalities.
• Barium swallow studies and upper endoscopy are the
main tests used to help make the diagnosis. Tailor
treatment to the specific cause.

89. Future and Controversies
• The role of prophylactic gastrojejunostomy in cases of
malignant gastric outlet obstruction (GOO) is a question that
has not been answered. Some surgeons argue that
prophylactic gastrojejunostomy may increase postoperative
morbidity, primarily due to delayed gastric emptying.
• Lillemoe and Cameron addressed this issue in a publication.
Of patients with unresectable periampullary cancer, 87 were
randomized to receive or not receive a prophylactic
gastrojejunostomy. Although results demonstrated that no
significant differences exist in morbidity, length of hospital
stay, and survival rates, the group in which prophylactic
gastrojejunostomies were performed had a 0% (0/44)
incidence of GOO versus 19% (8/43) in the other group.
• The authors concluded that prophylactic gastrojejunostomy
significantly decreased the incidence of late GOO and should
be performed routinely when a patient is undergoing
surgical palliation for periampullary cancer.

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