What is the best surgical approach for treating gastric outlet obstruction (GOO)?

Best Surgical Approach for Gastric Outlet Obstruction (GOO)

For patients with gastric outlet obstruction who have a life expectancy greater than 2 months, have good functional status, and who are surgically fit, laparoscopic gastrojejunostomy is the recommended surgical approach due to lower blood loss and shorter hospital stay compared to open procedures. 1

Treatment Algorithm for GOO

Patient Assessment Factors

• Life expectancy (>2 months vs. <2 months) 1
• Functional status (good vs. poor) 1
• Surgical fitness 1
• Nutritional status 1
• Presence of ascites 1

First-Line Treatment Options

• For patients with good prognosis (>2 months life expectancy) and good functional status:

  • Laparoscopic gastrojejunostomy is preferred over open surgical approach 1
  • Benefits include fewer limitations in food texture/consistency and better long-term relief of symptoms 1
  • Associated with lower blood loss and shorter hospital stay compared to open surgical approach 1

• For patients with poor prognosis (<2 months life expectancy) or poor surgical candidates:

  • Enteral stent placement should be considered 1
  • Provides earlier food intake but has higher rates of recurrent obstructions and re-interventions 1

Emerging Alternative

• Endoscopic ultrasound-guided gastrojejunostomy (EUS-GE):
  • Acceptable alternative to both surgical gastrojejunostomy and enteral stent placement 1
  • Combines benefits of laparoscopic approach with less invasiveness 2, 3
  • Technical success rates of approximately 92% and clinical success rates of 90% 1
  • Recent evidence shows similar long-lasting symptom relief as surgical gastrojejunostomy 4
  • Shorter procedure duration, lower post-procedure ileus rate, and shorter hospital stay compared to surgical approach 4
  • Requires expert experience and specialized facilities 5

Important Considerations and Caveats

• Surgical gastrojejunostomy considerations:

  • Poor nutritional status, ascites, and poor functional status are independent predictors of clinical failure 1
  • Up to 50% of patients may develop delayed gastric emptying after surgery due to food contents accumulating in the antrum 1

• Enteral stent contraindications:

  • Should not be used in patients with multiple luminal obstructions 1
  • Should not be used in patients with severely impaired gastric motility 1
  • Consider venting gastrostomy in these scenarios 1

• EUS-GE considerations:

  • Currently no dedicated FDA-approved devices for this procedure 1
  • Stent misdeployment is the most common adverse event (reported in 12% of patients) 1
  • May have higher initial clinical success rates than enteral stents 1
  • For benign GOO, surgical gastrojejunostomy may have better technical success than EUS-GE 4

Specific Answers to Options Presented

Among the options provided (Billroth I, Billroth II, Truncal vagotomy + gastrectomy, Truncal vagotomy + pyloroplasty):

• None of these procedures are specifically recommended as first-line treatments in the most recent guidelines for malignant GOO 1
• For malignant GOO, laparoscopic gastrojejunostomy is the preferred surgical approach 1
• For benign GOO (such as from peptic ulcer disease), treatment should focus on addressing the underlying cause, including proton pump inhibitors and H. pylori eradication when applicable 6