The prognosis of gastric outlet obstruction

Endoscopic balloon dilation management for benign duodenal stenosis

BACKGROUND AND AIMS

Benign duodenal stenosis (BDS) is most commonly caused by peptic ulcer disease (PUD). Endoscopic balloon dilation (EBD) is the recommended initial management despite limited supporting literature. Our study investigated the etiologic spectrum of BDS and its response to endoscopic dilation.

METHODS

We performed a cohort study of a prospectively maintained database of BDS at our large tertiary academic center between 2002 and 2018. All patients who underwent EBD were analyzed. Dilation was performed using through-the-scope balloons. Technical and clinical successes of initial and repeat EBD were compared. Descriptive statistics, univariate, and multivariate analysis were performed.

RESULTS

The study included 86 patients with 54.7% female gender. Etiologies included 39 patients with PUD (45.3%), 19 patients with Crohn's disease (22.1%), 23 patients had idiopathic etiologies (26.7%), and 5 patients were listed as other etiologies (5.8%). Proximal stricture location (1st part of duodenum) occurred in 66% of females, whereas distal duodenal involvement was seen in 63.6% of males (p value 0.007). Usage of PPI was associated with 3.6 times higher clinical success rate (p value 0.04). Technical (97.4%) and clinical (77.8%) successes for index dilations in PUD were not significantly better than those of non-PUD patients (p values 0.99, 0.52).

CONCLUSION

EBD has both a high technical and clinical success for BDS regardless of etiology and should be considered over initial surgical intervention due to low risk profile. Males tend to have more distal duodenal involvement, and PPI usage is an independent predictor for clinical success.

Can computed tomography-antral wall thickness predict response to endoscopic balloon dilation in patients with caustic-induced gastric outlet obstruction?

BACKGROUND

Caustic-induced gastric outlet obstruction (GOO) remains one of the important causes of long-term morbidity in patients with caustic ingestion. Though endoscopic balloon dilation is an effective modality, response to caustic GOO is poorer as compared to peptic stricture. Computed tomography (CT)-antral wall thickness (AWT) has not been previously explored to predict the procedural success in patients with caustic GOO.

METHODS

In a retrospective single-center study of prospectively maintained database, all patients with symptomatic caustic GOO who underwent CT scan prior to endoscopic balloon dilation were included. Gastric AWT was measured at the site of maximum visible thickness on CT scan. Details regarding caustic ingestion and endoscopic dilation were retrieved. Patients were divided into two groups, based on CT-AWT (< or ≥9 mm) and compared for outcome measures.

RESULTS

Mean age of included patients (n=35) was 33.51 ± 13.65 years and 22 were male. Procedural success was achieved in 29 (82.85%) patients. Number of mean dilation sessions required were 5.28 ± 2.96 for achieving procedural success. The mean CT-AWT was 10.73 ± 2.80 mm (range 4-18 mm). There was no significant association between the CT-AWT and the number of dilations and procedural success. On univariate analysis, size of the first balloon used was a predictor of refractory stricture (p=0.011). However, no other factors predicted either refractory stricture or procedural success.

CONCLUSION

There is no additional role of CT-AWT in predicting response to endoscopic balloon dilation or to predict refractory stricture in patients with caustic GOO.

Trans-Biliary Gastric Outlet Recanalization and Stenting: A Case Report

Gastric ischemia is a condition of hypo-perfusion associated with hypotension, vasculitis, and thromboembolism. We report a case of a gastric outflow obstruction due to sizeable visceral artery thrombo-embolism leading to the ischemic conclusion, the frailty, multiple comorbidities deeming general anesthesia (GA) risky, and the patient’s decision not to have an open surgery under GA. Invasive procedures in patients with similar profiles like our patient are usually not risk-free, this leads the intervention radiology team to believe a minimally invasive procedure while avoiding GA might be optimal. A 63-year-old female with multiple comorbidities came eight weeks after significant surgery complaining of severe acute epigastric pain, abdominal distention and rigidity, and persistent vomiting. Further investigations showed obstruction in the gastric antrum and pyloric canal. Three separate endoscopic attempts to find and cross the stricture failed. Firstly, gastrostomy access was established, but due to the stomach being massively distended, passing a guidewire through the pylorus failed despite using multiple hydrophilic wires and pre-shaped catheters, this is due to the collapsed pylorus. Subsequently, two attempts under ultrasound guidance to puncture the duodenal bulb and pass a wire and catheter through the antrum stricture were unsuccessful, and another attempt was considered of high risk. An alternative approach through the gallbladder was established, and cholangiography was performed to delineate the anatomy. Then an approach through the right hepatic duct and ampulla of Vater was successfully performed. The attempted passage through the stricture was successful. The dilation was successful, and the patient tolerated both fluid and solids orally. Due to having such a frail patient, interventions of minimal invasiveness and favorable outcome are welcomed. This case report suggests that this technique showed satisfactory results and achieved the goal to improve the overall quality of life where the patient had a good oral intake with no post-operation complications.

Palliative Gastrectomy vs. Gastrojejunostomy for Advanced Gastric Cancer: A Systematic Review and Meta-Analysis

Background: Advanced gastric cancer is the fifth leading cause of cancer-related deaths. Patients with metastatic advanced gastric cancer commonly develop a gastric outlet obstruction that considerably worsens their quality of life. Surgical interventions such as gastrojejunostomy and palliative gastrectomy are commonly administered to alleviate this obstruction. However, whether one intervention is better than another at improving morbidity- and mortality-related outcomes is unclear. Thus, in this meta-analysis, we compare outcomes of palliative gastrectomy and gastrojejunostomy (overall hospital stay length, time to oral intake, survival, and complication rates) in patients with metastatic advanced gastric cancer to identify the best procedure.

Objective: To compare morbidity and mortality outcomes of palliative gastrectomy and gastrojejunostomy in patients with metastatic advanced gastric cancer.

Methods: We followed the PRISMA guidelines to systematically search Web of Science, EMBASE, CENTRAL, Scopus, and MEDLINE for relevant studies. We conducted a random-effects meta-analysis to find differential outcomes between palliative gastrectomy and gastrojejunostomy among variables such as time to oral intake, overall hospital stay length, complication rates, and survival in patients with metastatic advanced gastric cancer.

Results: From 963 studies, we found 7 eligible studies with 642 patients (70.3 ± 4.7 years) who had undergone palliative gastrectomy or gastrojejunostomy. Our meta-analysis revealed an insignificant (p > 0.05) differences in terms of overall survival duration (Hedge's g, 1.22), complication risks (odds ratio, 1.35), and time to oral intake (g, 0.62) and hospital stay length (g, 0.12) between patients undergoing gastrojejunostomy and palliative gastrectomy.

Conclusion: In this present study we observed no statistically significant differences in terms of morbidity and mortality outcomes after palliative gastrectomy and gastrojejunostomy in patients with metastatic advanced gastric cancer. Therefore, no conclusions can be drawn for the variables evaluated. This study provides a preliminary overview of the risks associated with gastrojejunostomy and palliative gastrectomy to help gastroenterologists manage patients with metastatic advanced-stage gastric cancer.

Update on endoscopic management of gastric outlet obstruction in children

Endoscopic balloon dilatation (EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.

Pyloroplasty for Benign Gastric Outlet Obstruction — Indications and Techniques

The understanding of peptic ulcer disease (PUD) etiology, and improvements in treatment during the last two decades, has dramatically decreased the once so frequently performed procedures for PUD and its complications. Benign gastric outlet obstruction may, however, still require operative intervention when non-operative treatment fails. Today, surgeons in training, and even practicing surgeons, may have limited operative experience with procedures required to alleviate an obstructed pylorus. Our aim of this paper is to review the techniques (the Heineke-Mikulicz and Finney pyloroplasties, and modifications) and indications for pyloroplasty in the modern surgical era.

Gradual sucrose gastric loading test: A method for the prediction of nonsuccess gastric enteral feeding in critically ill surgical patients

Background and Aims:

Intolerance of gastric enteral feeding (GEN) commonly occurs in surgical Intensive Care Unit (SICU). A liquid containing sugar could prolong gastric emptying time. This study was to propose a method for prediction of nonsuccess GEN using gastric volume after loading (GVAL) following gradual sucrose gastric loading.

Materials and Methods:

Mechanical ventilator supported and hemodynamically stable patients in SICU were enrolled. About 180-240 min before the GEN starting, a sucrose solution (12.5%; 450 mosmole/kg, 800 mL) was administered via gastric feeding tube over 30 min with 45° head upright position. GVAL was measured at 30, 60, 90, and 120 min after loading. GEN success status using clinical criteria was assessed at 72 h after the starting GEN protocol. The receiving operating characteristic (ROC) and c statistic were used for discrimination at each time point of GVAL.

Results:

A total of 32 patients were enrolled and completed the protocol. 14 patients (43.7%) were nonsuccessful GEN. The nonsuccess group was found to have significantly more GVAL than the other group at all-time points during the test (P < 0.05). The most discriminating point of GVAL for the prediction of nonsuccess was 150 mL at 120 min after loading with a sensitivity of 92.3%, specificity of 88.9%, positive predictive value of 85.7%, negative predictive value of 94.1%, and ROC area 0.97 (95% confidence interval 0.91–1.00).

Conclusion:

A high GVAL following sucrose gastric loading test might be a method to predict nonsuccess GEN in critically ill surgical patients.

Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction

AIM: To evaluate the safety and efficacy of partially covered self-expandable metallic stents (SEMSs) in benign pyloric obstruction.

METHODS: We retrospectively analyzed data from 10 consecutive patients with peptic ulcer-related pyloric obstructive symptoms (gastric outlet obstruction scoring system (GOOSS) score of 1) between March 2012 and September 2013. The patients were referred to and managed by partially covered SEMS insertion in our tertiary academic center. We assessed the technical success, symptom improvement, and adverse events after stenting.

RESULTS: Early symptoms were improved just 3 d after SEMS placement in all 10 patients. The GOOSS score of all patients improved from 1 to 3. There were no serious immediate adverse events. The overall rate of being symptom free was 90% at a median of 11 mo of follow-up (range: 4-43 mo). Five patients were managed by a rescue SEMS because of failure of previous endoscopic balloon dilatation. Among them, four patients had sustained symptom improvement after the SEMS procedure. During the follow-up period, migration of the SEMS was observed in two patients (20.0%), both of whom had previous endoscopic balloon dilatation before SEMS insertion.

CONCLUSION: Despite the small number in this study, partially covered SEMSs showed a favorable and safe outcome in the treatment of naïve benign pyloric obstruction and in salvage treatment after balloon dilatation failure.

Peptic ulcer disease

Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.

Laparoscopic gastrojejunostomy for the treatment of gastric outlet obstruction

These authors found that laparoscopic gastrojejunostomy for the management of gastric outlet obstruction can be performed with good outcomes and acceptable complication rates.

Background and Objectives:

Laparoscopic gastrojejunostomy (LGJ) has been proposed as the technique preferred over open gastrojejunostomy for relieving gastric outlet obstruction (GOO) due to malignant and benign disease. This study investigates the feasibility and safety of LGJ for GOO.

Methods:

A retrospective review was performed of patients who underwent LGJ at Mount Sinai Medical Center from 2004 to 2008. Patient's operative course and long-term outcomes were collected.

Results:

Twenty-eight patients were reviewed (16 had malignancy, 7 had PUD, 3 had Crohn's disease, and one had obstruction of unclear cause). Average operative time was 170 minutes, and estimated blood loss was 80cc. One case was converted to open; another had stapler misfiring. Patients regained bowel function at a median of 3 days and remained in the hospital for a median of 8 days. There were 4 major postoperative complications (14%): 1 anastomotic leak and 1 trocar-site hemorrhage requiring reoperation and 2 gastrointestinal bleeds requiring endoscopic intervention. There were 5 minor complications (18%), including a partial small bowel obstruction, 1 patient developed bacteremia, and 3 patients had delayed gastric emptying. One patient had persistent GOO requiring reoperation 3 months later.

Conclusion:

LGJ can be performed for GOO with improved outcome and an acceptable complication rate compared to the open GJ reported in the literature.

Endoscopic balloon dilation for benign gastric outlet obstruction in adults

Gastric outlet obstruction (GOO) includes obstruction in the antropyloric area or in the bulbar or post bulbar duodenal segments. Though malignancy remains the most common cause of GOO in adults, a significant number of patients have benign disease. The latter include peptic ulcer disease, caustic ingestion, post-operative anastomotic state and inflammatory causes like Crohn’s disease and tuberculosis. Peptic ulcer remains the most common benign cause of GOO. Management of benign GOO revolves around confirmation of the etiology, removing the offending agent Helicobacter pylori (H. pylori), non-steroidal anti-inflammatory drugs, etc. and definitive therapy. Traditionally, surgery has been the standard mode of treatment for benign GOO. However, after the advent of through-the-scope balloon dilators, endoscopic balloon dilation (EBD) has emerged as an effective alternative to surgery in selected groups of patients. So far, this form of therapy has been shown to be effective in caustic-induced GOO with short segment cicatrization and ulcer related GOO. In the latter, EBD must be combined with eradication of H. pylori. Dilation is preferably done with wire-guided balloon catheters of incremental diameter with the aim to reach the end-point of 15 mm. While it is recommended that fluoroscopic control be used for EBD, this is not used by most endoscopists. Frequency of dilation has varied from once a week to once in three weeks. Complications are uncommon with perforation occurring more often with balloons larger than 15 mm. Attempts to augment efficacy of EBD include intralesional steroids and endoscopic incision.

An unusual cause of gastric outlet obstruction: a pancreaticoduodenal artery aneurysm

We present a rare case of gastric outlet obstruction due to compression of the duodenum by a pancreaticoduodenal artery (PDA) aneurysm 2.5 cm in diameter, in a 43-year-old man from Saudi Arabia who presented with persistent vomiting and epigastric pain. The initial investigations and blood works were negative, and esophagogastroduodenoscopy (EGD) was unremarkable. A CT abdomen demonstrated a mass around the duodenum and dilatation of the stomach, and CT angiography showed the PDA aneurysm. The patient was stabilized and then referred to a tertiary center for embolization. Our case demonstrates a diagnostic challenge that physicians may encounter in patients who present with vomiting and epigastric pain.

Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction

PURPOSE OF REVIEW

To examine the short and long-term success rates of balloon dilation of pyloric stenosis.

RECENT FINDINGS

Several large studies have demonstrated high rates of success for the relief of symptoms from pyloric stenosis using through-the-scope balloons. These dilating balloons readily increase the diameter of the stenotic pylorus on average from 6 to 16 mm. Patients who require more than two dilations are at high risk of endoscopic failure and the need for surgical intervention. Rapid re-stenosis rates are observed in patients with malignant pyloric obstruction. Since many patients with benign pyloric stenosis have underlying ulcer disease, helicobacter infection is a relatively common finding. Eradication of this infection at the time of balloon dilation will ensure higher long-term success rates.

SUMMARY

In summary, benign pyloric stenosis can be readily treated with endoscopic balloon dilation and should be the first-line therapy.

Vagotomy and Gastrojejunostomy for Benign Gastric Outlet Obstruction

OBJECTIVE

Peptic-ulcer-induced gastric outlet obstruction is an indication for operative intervention. The advent of minimal access surgery allows the conventional open procedure to be performed via laparoscopy.

PATIENTS AND METHODS

From 1996 to 2000, 15 consecutive patients, aged 29 to 75 years, underwent laparoscopic truncal vagotomy and gastrojejunostomy for gastric outlet obstruction. Perioperative data and longterm followup results were analyzed.

RESULTS

There were no conversions or perioperative mortality. The mean operative time was 114 minutes. Patients required on average 1 dose of intramuscular pethidine for analgesia. Eleven patients were discharge by postoperative day 10; the remaining 4 patients had delayed gastric emptying which settled with conservative treatment. With an average followup period of 80 months, patients were classified as Visick I (n = 7), II (n = 5), III (n = 1), and IV (n = 2).

CONCLUSION

Laparoscopic truncal vagotomy and gastrojejunostomy is technically feasible for patients with benign gastric outlet obstruction and is associated with satisfactory perioperative and longterm outcome.

Antral hyperplastic polyp causing intermittent gastric outlet obstruction: case report

BACKGROUND

Hyperplastic polyps are the most common polypoid lesions of the stomach. Rarely, they cause gastric outlet obstruction by prolapsing through the pyloric channel, when they arise in the prepyloric antrum.

CASE PRESENTATION

A 62-year-old woman presented with intermittent nausea and vomiting of 4 months duration. Upper gastrointestinal endoscopy revealed a 30 mm prepyloric sessile polyp causing intermittent gastric outlet obstruction. Following submucosal injection of diluted adrenaline solution, the polyp was removed with a snare. Multiple biopsies were taken from the greater curvature of the antrum and the corpus. Rapid urease test for Helicobacter pylori yielded a negative result. Histopathologic examination showed a hyperplastic polyp without any evidence of malignancy. Biopsies of the antrum and the corpus revealed gastritis with neither atrophic changes nor Helicobacter pylori infection. Follow-up endoscopy after a 12-week course of proton pomp inhibitor therapy showed a complete healing without any remnant tissue at the polypectomy site. The patient has been symptom-free during 8 months of follow-up.

CONCLUSIONS

Symptomatic gastric polyps should be removed preferentially when they are detected at the initial diagnostic endoscopy. Polypectomy not only provides tissue to determine the exact histopathologic type of the polyp, but also achieves radical treatment.

Review article: Helicobacter pylori infection and gastric outlet obstruction - prevalence of the infection and role of antimicrobial treatment

The prevalence of Helicobacter pylori infection in peptic ulcer disease complicated by gastric outlet obstruction seems to be, overall, lower than that reported in non-complicated ulcer disease, with a mean value of 69%. However, H. pylori infection rates in various studies range from 33% to 91%, suggesting that differences in variables, such as the number and type of diagnostic methods used or the frequency of non-steroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. The resolution of gastric outlet obstruction after the eradication of H. pylori has been demonstrated by several studies. It seems that the beneficial effect of H. pylori eradication on gastric outlet obstruction is observed early, just a few weeks after the administration of antimicrobial treatment. Furthermore, this favourable effect seems to remain during long-term follow-up. Nevertheless, gastric outlet obstruction does not always resolve after H. pylori eradication treatment and an explanation for the failures is not completely clear, non-steroidal anti-inflammatory drug intake perhaps playing a major role in these cases. Treatment should start pharmacologically with the eradication of H. pylori even when stenosis is considered to be fibrotic, or when there is some gastric stasis. In summary, H. pylori eradication therapy should be considered as the first step in the treatment of duodenal or pyloric H. pylori-positive stenosis, whereas dilation or surgery should be reserved for patients who do not respond to such medical therapy.

Helicobacter pylori-related gastric outlet obstruction: is there a role for medical treatment?

The role of Helicobacter pylori in the pathogenesis of duodenal and gastric ulcer and ulcer recurrence is widely known. Bleeding, perforation, and gastric outlet obstruction represent the most serious, potentially life-threatening complications of ulcer disease. At present, the effect of H. pylori eradication on complicated ulcer disease has not been fully established. Case reports exist on the resolution of gastric outlet obstruction after eradication of H. pylori. We report the first case of H. pylori-related gastric outlet obstruction successfully treated with parenteral antibiotics.

Endoscopic balloon dilatation of peptic pyloroduodenal strictures

A through-the-scope endoscopic balloon dilatation technique and acid-reducing medication was used in 46 consecutive patients (median age, 55; range, 21-88 years) with benign gastric outlet obstruction. In five patients, dilatation was not technically possible. In 41 patients, 122 dilatations (median, 2; range, 1-9 per patient) were performed without morbidity. Ninety-four procedures were successful (77%) at the initial attempt (able to pass a 12-mm endoscope into the duodenum at the end of the procedure). Median follow-up in the 41 patients was 19 (range, 1-78) months. Thirteen patients (32%) required subsequent surgery; 8 had delayed operation for persistent symptoms (1-28 months after the first dilatation), 1 had surgery during the initial hospital admission, and 4 required emergency surgery for other ulcer complications (3 perforation, 1 bleeding). Of the 28 patients who had only balloon dilatation and medical therapy, 11 are asymptomatic (4 with active ulceration), 9 have mild symptoms (Visick 2), and 3 have persistent symptoms (Visick 3). One patient was lost to follow-up and four patients have died (one from an ulcer-related complication). Balloon dilatation and sustained acid-reducing therapy with regular endoscopic surveillance should be first-line treatment of peptic pyloroduodenal strictures, because the procedure is safe and is likely to be successful in half of the patients in whom dilatation is technically possible.

Gastric outlet obstruction caused by microperforation of Helicobacter pylori-related antral ulcer

We report a Helicobacter pylori-related antral gastric ulcer that continued to cause symptoms despite H. pylori eradication. The patient had progressive gastric outlet obstruction, raising the possibility of a malignancy. On exploratory laparotomy, he was found to have a large inflammatory mass surrounding a contained microperforation.

Gastric outlet obstruction

Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.

Gastroduodenal disease in the elderly patient

Benign and malignant diseases of the stomach and duodenum are common in the elderly. Atypical presentations frequently are seen, making early diagnosis difficult. Aggressive surgical and medical management regimens are usually possible, giving cure rates comparable to those seen in the younger population.

The course of peptic ulcer disease

Peptic ulcer disease usually has periodic exacerbations and remissions. Pain can disappear without total healing of the ulcer crater and can be absent when an ulcer is present. Changes in the incidence of ulcer disease have been noted in recent years. Genetic predisposition, infection with H. pylori, and the use of anti-inflammatory drugs are involved in causation. Stress; the use of alcohol, tobacco and caffeine; and other diseases have been implicated as etiologic factors. Ulcer pain has a recognizable pattern, but the symptoms can be variable, particularly in older people and in patients taking ulcerogenic medications. The familiar complications of hemorrhage, perforation, and obstruction still occur, and nonulcer dyspepsia has not been fully explained. Duodenal ulcers have a disturbing tendency to return; new therapeutic approaches offer hope.

Pyloric deformation from peptic disease. Radiographic evidence for incompetence rather than obstruction

We have used double-contrast radiographic techniques to clarify what changes in the configuration and movements of the gastroduodenal junction result when peptic lesions involve the distal gastric segment between the proximal (PPL) and the distal pyloric muscle loop (DPL). Among 50 cases of pyloric ulceration diagnosed during a four-year study period, 18 cases fulfilled all study criteria. Ulcers maintained a consistent location with regard to the muscular structures of the pylorus, and by affecting these structures, led to many strange deformations of the gastric outlet including permanent pseudodiverticula and reversal of pyloric angulation. The most common site for peptic lesions in the pyloric segment was the protuberance of the lesser curvature called the pyloric torus; many torus lesions extended into and destroyed the DPL. This led to widening of the gastric outlet and radiographic evidence of increased duodenogastric reflux. Pyloric closure was further impaired in this setting because the mucosa no longer prolapsed into the gastric outlet and did not occlude the pyloric lumen as it normally does. Less common lesions involved the greater curvature and the PPL. In one patient, scarring of the PPL led to an antral web and gastric hyperperistalsis. This was the only patient who required operation for chronic gastric outlet obstruction. One-third of the 18 patients had reflux esophagitis in addition to peptic pyloric disease. In most patients without additional ulcerogenic risk factors, treatment with antisecretory agents led to the healing of ulcer craters. We conclude that the morphologic and functional changes of the gastric outlet caused by peptic lesions depend, in part, on the effect the ulcer has on the underlying pyloric musculature.(ABSTRACT TRUNCATED AT 250 WORDS)

Through the endoscope balloon dilatation of benign gastric outlet obstruction

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Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.