From the Guidelines
Treatment for gastric outlet obstruction should prioritize endoscopic stent placement as the primary intervention for malignant obstructions, as it is a safe and effective minimally invasive palliative treatment. This approach is supported by the most recent guidelines, including those from the National Comprehensive Cancer Network (NCCN) 1. The primary goals of palliation for patients with malignant gastric obstruction are to reduce nausea and vomiting and, when possible, allow resumption of an oral diet.
Key considerations in the management of gastric outlet obstruction include:
- Alleviating or bypassing the obstruction using endoscopic placement of an enteral stent for relief of outlet obstruction or esophageal stent for EGJ/gastric cardia obstruction 1.
- Surgical options such as gastrojejunostomy or gastrectomy in select patients 1.
- External beam radiation therapy (EBRT) and chemotherapy as part of a multimodal approach 1.
- When obstruction cannot be alleviated or bypassed, the primary goal is to reduce symptoms via venting gastrostomy, with options including percutaneous, endoscopic, surgical, or interventional radiology gastrostomy tube placement for gastric decompression 1.
The decision on the specific intervention should be made in a multidisciplinary setting, taking into account the characteristics of the obstruction, patient’s expectations, prognosis, expected subsequent therapies, and functional status 1. For patients who are not candidates for gastrojejunostomy, consideration should be given to the insertion of an enteral stent 1.
In terms of specific management strategies:
- Initial management may involve decompression using a nasogastric tube, correction of fluid and electrolyte imbalances, and administration of proton pump inhibitors to reduce gastric acid secretion.
- For obstructions caused by peptic ulcer disease, Helicobacter pylori eradication therapy may be indicated.
- Definitive treatment depends on the cause, with options including endoscopic balloon dilation for benign strictures and surgical intervention for more severe cases.
- Nutritional support is essential, often requiring parenteral nutrition initially, followed by enteral feeding once partial obstruction is relieved.
Overall, the choice of treatment approach depends on the severity of obstruction, underlying etiology, and the patient's overall health status, with a focus on minimizing morbidity, mortality, and improving quality of life 1.
From the Research
Treatment Options for Gastric Outlet Obstruction
The treatment of gastric outlet obstruction (GOO) depends on the underlying cause, which can be benign or malignant. The following are some of the treatment options:
- Proton pump inhibitors and H. pylori eradication for benign causes such as peptic ulcer disease 2
- Endoscopic treatments, including:
- Surgery, which remains the last resort for some cases 3, 5
Endoscopic Management
Endoscopic management of GOO is a cost-effective method and can be used as an alternative to palliative surgery. The choice of endoscopic treatment depends on patient-related variables, such as the stricture site, concomitant involvement of the bile duct, and the patient's prognosis 3. EUS-GE is a promising technique that has shown better clinical outcomes compared to other endoscopic procedures 5, 6.
Specific Treatments for Malignant GOO
For unresectable malignant GOO, the following treatments can be considered:
- Endoscopic stenting (SEMS) 5
- Laparoscopic gastrojejunostomy (LGJ) 5
- Endoscopic ultrasound-guided balloon-occluded gastrojejunostomy bypass (EPASS) 5 These treatments have shown varying degrees of technical and clinical success, with EPASS being associated with better clinical outcomes in some studies 5.
Treatment in Children
In children, the most common causes of gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease, and ingestion of caustic substances. Endoscopic balloon dilatation (EBD) and surgical intervention are the most common treatments, with EBD being used in exceptional cases 4. Local steroid injection and electrocauterization can augment the effect of EBD, and the future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations 4.