Gastric Outlet Obstruction: Current Status and Future Directions

Peptic ulcer disease

Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.

Effect of different preoperative nutritional treatments on postoperative recovery and clinical outcomes in patients with gastric cancer and early gastric outlet obstruction

Patients with gastric cancer and early gastric outlet obstruction often experience malnutrition and require various nutritional support strategies. This study aimed to evaluate the impact of different preoperative nutritional treatments on their postoperative recovery and prognosis. The present retrospective study collected data from 467 patients with gastric cancer and early gastric outlet obstruction who underwent surgery at Harbin Medical University Cancer Hospital (Harbin, China) between January 2016 and December 2018. All patients received preoperative nutritional treatment, with a mean treatment duration of 8.23±2.33 days. The present study analyzed associations and survival in different groups using χ2, independent-samples t-test, ANOVA and log-rank tests. Furthermore, single- and multi-factor survival analyses were conducted and nomograms and calibration curves constructed to investigate factors influencing patient survival. In this study, 230 patients (49.3%) received only parenteral nutrition (PN; Group 1), 162 patients (34.7%) received PN combined with enteral nutrition (EN; Group 2) and 75 patients (16.0%) received PN combined with a full- or semi-liquid diet (Group 3). No significant differences in clinical and pathological parameters were observed among the groups. However, Group 2 showed significant advantages in postoperative recovery, including faster time to first postoperative bowel sounds, flatus and bowel movement. Survival analysis indicated that Group 3 had shorter progression-free survival (χ2=30.485) and overall survival (χ2=31.249). Preoperative nutritional treatment was identified as an independent prognostic factor. Preoperative PN combined with EN proved advantageous for postoperative recovery of patients with gastric cancer and early gastric outlet obstruction. Furthermore, PN combined with full- or semi-liquid diets may not have fully met the nutritional needs of these patients, resulting in less favorable clinical outcomes.

Propensity score-matched retrospective cohort study of endoscopic ultrasound-guided gastroenterostomy and enteral stenting for malignant gastric outlet

BACKGROUND

Symptomatic malignant gastric outlet obstruction (GOO) significantly reduce patients' quality of life. Endoscopic treatment involves enteral stenting or endoscopic ultrasonography to perform gastroenterostomy (EUS-GE). Aim was to compare enteral stenting with EUS-GE for endoscopic treatment of malignant GOO.

METHODS

We retrospectively compared enteral stenting with EUS-GE for the treatment of malignant GOO. Patients treated at our institution were identified and a propensity score matching analysis was performed. Treatment failure was the primary outcome, while the secondary endpoints were time until treatment failure, technical and clinical success rates, and adverse event rates.

RESULTS

Eighty-eight patients were included in the final analysis. Of whom, 44 were included in each of the two treatment groups. Treatment failure occurred significantly more frequently in the enteral stenting group (13/44) compared with the EUS-GE group (4/44; hazard ratio: 4,9; 95% CI 1.6-15.1). A Kaplan-Meier analysis revealed a median time until treatment failure of 22.0 weeks (95% CI 4.6-39.4) in the enteral stenting group compared with 76.0 weeks (95% CI 55.9-96.1) in the EUS-GE group (P = .002). No difference in technical success and clinical success was detected. Technical success was achieved in 43/44 patients (97.7%) in the enteral stenting group compared with 41/44 patients (93.2%) in the EUS-GE group, while clinical success was achieved in 32/44 (72.7%) and 35/44 (79.5%) patients, respectively. Nine adverse events were observed (9/44, 10.2%). There were no differences in 30-day adverse event rate and 30-day mortality rate.

CONCLUSION

EUS-GE was superior to enteral stenting in the treatment of malignant GOO in terms of treatment failure and time until treatment failure in a propensity score-matched cohort.

Case Report of Overlapping Pyloric Obstruction Due to Dichlorvos Poisoning and Cholelithiasis with Choledocholithiasis

BACKGROUND Pyloric obstruction after dichlorvos poisoning causes repeated vomiting and inability to eat. Choledocholithiasis and cholelithiasis are the common digestive diseases, with high morbidity and relapse in elderly patients. However, the complex situation of these diseases' coexistence is a clinically intractable problem, and literature on selecting optimal surgical planning is scarce. CASE REPORT A thin 79-year-old woman took dichlorvos due to family conflicts. She improved after being urgently sent to local hospital for gastric lavage and detoxification. Over the next 3 months, she presented with intermittent nausea, vomiting, epigastric pain, and mental apathy, and was readmitted. Gastroscopy showed extensive scarring in the antrum, pyloric obstruction, and gastric retention. Magnetic resonance cholangiopancreatography revealed gallstones and choledocholithiasis. Also, she presented with gastric retention, hypertension, moderate anemia, hypoproteinemia, and electrolyte disturbances. After hospitalization, conservative treatment was performed, without improving vomiting, followed by surgical treatment. Gastrojejunostomy, Braun anastomosis, and nasojejunal feeding tube placement were performed for pyloric stenosis; cholecystectomy for cholelithiasis; and choledochotomy, intraoperative choledochoscopy examination, basket stone extraction, and primary suture of common bile duct without indwelling T tube for choledocholithiasis. Patient recovered and was discharged 9 days after surgery. She was recovered well, without vomiting, at 2-month follow-up. CONCLUSIONS Gastrojejunostomy plus Braun anastomosis is effective treatment of elderly patients with pyloric obstruction formed after pesticide-induced corrosion. Careful selection of choledocholithotomy with primary suture without indwelling T tube reduced postoperative pain and accelerated recovery. This complex case of pyloric obstruction with gallbladder and bile duct stones provides useful considerations for clinical treatment.

Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction: A case report and review of literature

BACKGROUND

Mycobacterium tuberculosis (TB) is the causative agent of TB, a chronic granulomatous illness. This disease is prevalent in low-income countries, posing a significant global health challenge. Gastrointestinal TB is one of the three forms. The disease can mimic other intra-abdominal conditions, leading to delayed diagnosis owing to the absence of specific symptoms. While gastric outlet obstruction (GOO) remains a frequent complication, its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy. Gastroduodenal TB can cause upper gastrointestinal hemorrhage, obstruction, and malignancy-like tumors.

CASE SUMMARY

A 23-year-old male presented with recurrent epigastric pain, distension, nausea, vomiting, and weight loss, prompting a referral to a gastroenterologist clinic. Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation. However, treatment was interrupted, possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes. Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall. Resection revealed gastric wall effacement with TB.

CONCLUSION

Primary gastric TB is rare, frequently leading to GOO. Given its rarity, suspicions should be promptly raised when encountering relevant symptoms, often requiring surgical intervention for diagnosis and treatment.

Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

Gastric outlet obstruction due to an intragastric balloon in a patient returning from the Caribbean

Key Clinical Message

Gastric outlet obstruction can be a dangerous complication of intragastric balloons, as it can result in severe metabolic alkalosis. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers.

Abstract

Intragastric balloons for weight loss have decreased in frequency in the United States. However, they are still frequent in low- and middle-income countries. Severe complications occur in less than 3% of patients who undergo this procedure. Herein, we present a case of gastric outlet obstruction, severe metabolic alkalosis, and refeeding syndrome in a patient returning from the Dominican Republic. She presented with 2 weeks of emesis and obstipation, followed by a pre-syncope and altered mental status. An intragastric mass was observed on computerized tomography, which was characterized as an intragastric balloon and retrieved endoscopically. All metabolic derangements were corrected, and the patient improved without sequelae. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers.

Clinical Practice Guideline for Percutaneous Endoscopic Gastrostomy

With an aging population, the number of patients with difficulty swallowing due to medical conditions is gradually increasing. In such cases, enteral nutrition is administered through a temporary nasogastric tube. Long-term use of a nasogastric tube leads to various complications and a decreased quality of life. Percutaneous endoscopic gastrostomy (PEG) is the percutaneous placement of a tube into the stomach, aided endoscopically, which may be an alternative to a nasogastric tube when enteral nutritional is required for 4 weeks or more. This paper is the first Korean clinical guideline for PEG. It was developed jointly by the Korean College of Helicobacter and Upper Gastrointestinal Research and led by the Korean Society of Gastrointestinal Endoscopy. These guidelines aimed to provide physicians, including endoscopists, with the indications, use of prophylactic antibiotics, timing of enteric nutrition, tube placement methods, complications, replacement, and tubes removal for PEG based on the currently available clinical evidence.

Gastric Outlet Obstruction Secondary to Severe Thoracolumbar Scoliosis

A 78-year-old woman with a history of idiopathic thoracolumbar scoliosis presented with signs, symptoms, and imaging findings consistent with a gastric outlet obstruction secondary to the rib cage impinging on the pylorus of the stomach. She underwent an operative intervention and intra-operative findings were consistent with severe scoliosis with the right rib cage impinging on the pylorus, causing gastric outlet obstruction. A laparoscopic procedure was performed to pexy the greater curvature of the stomach to the left upper quadrant and a percutaneous endoscopic trans-gastric jejunostomy was inserted at the end. Thoracolumbar idiopathic scoliosis is a relatively benign common condition. However, with the increasing aging population and resultant higher incidence of progression to degenerative scoliosis, more patients are presenting with severe spinal and rib cage deformities that can cause rare intra-abdominal sequelae. We report the first case of a gastric outlet obstruction caused by the rib cage impinging on the pylorus in a patient with severe thoracolumbar scoliosis.

Endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for palliation of malignant gastric outlet obstruction (ENDURO): study protocol for a randomized controlled trial

BACKGROUND

Malignant gastric outlet obstruction (GOO) is a debilitating condition that frequently occurs in patients with malignancies of the distal stomach and (peri)ampullary region. The standard palliative treatment for patients with a reasonable life expectancy and adequate performance status is a laparoscopic surgical gastrojejunostomy (SGJ). Recently, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) emerged as a promising alternative to the surgical approach. The present study aims to compare these treatment modalities in terms of efficacy, safety, and costs.

METHODS

The ENDURO-study is a multicentre, open-label, parallel-group randomized controlled trial. In total, ninety-six patients with gastric outlet obstruction caused by an irresectable or metastasized malignancy will be 1:1 randomized to either SGJ or EUS-GE. The primary endpoint is time to tolerate at least soft solids. The co-primary endpoint is the proportion of patients with persisting or recurring symptoms of gastric outlet obstruction for which a reintervention is required. Secondary endpoints are technical and clinical success, quality of life, gastroenterostomy dysfunction, reinterventions, time to reintervention, adverse events, quality of life, time to start chemotherapy, length of hospital stay, readmissions, weight, survival, and costs.

DISCUSSION

The ENDURO-study assesses whether EUS-GE, as compared to SGJ, results in a faster resumption of solid oral intake and is non-inferior regarding reinterventions for persistent or recurrent obstructive symptoms in patients with malignant GOO. This trial aims to guide future treatment strategies and to improve quality of life in a palliative setting.

TRIAL REGISTRATION

International Clinical Trials Registry Platform (ICTRP): NL9592. Registered on 07 July 2021.

Benefits of EUS-guided gastroenterostomy over surgical gastrojejunostomy in the palliation of malignant gastric outlet obstruction: a large multicenter experience

BACKGROUND AND AIMS

Palliation of malignant gastric outlet obstruction (mGOO) allows resumption of peroral intake. Although surgical gastrojejunostomy (SGJ) provides durable relief, it may be associated with a higher morbidity, interfere with chemotherapy, and require an optimum nutritional status. EUS-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative. We aimed to conduct the largest comparative series to date between EUS-GE and SGJ for mGOO.

METHODS

This multicenter retrospective study included consecutive patients undergoing SGJ or EUS-GE at 6 centers. Primary outcomes included time to resumption of oral intake, length of stay (LOS), and mortality. Secondary outcomes included technical and clinical success, reintervention rates, adverse events (AEs), and resumption of chemotherapy.

RESULTS

A total of 310 patients were included (EUS-GE, n = 187; SGJ, n = 123). EUS-GE exhibited significantly lower time to resumption of oral intake (1.40 vs 4.06 days, P < .001), at lower albumin levels (2.95 vs 3.33 g/dL, P < .001), and a shorter LOS (5.31 vs 8.54 days, P < .001) compared with SGJ; there was no difference in mortality (48.1% vs 50.4%, P = .78). Technical (97.9% and 100%) and clinical (94.1% vs 94.3%) success was similar in the EUS-GE and SGJ groups, respectively. EUS-GE had lower rates of AEs (13.4% vs 33.3%, P < .001) but higher reintervention rates (15.5% vs 1.63%, P < .001). EUS-GE patients exhibited significantly lower interval time to resumption of chemotherapy (16.6 vs 37.8 days, P < .001). Outcomes between the EUS-GE and laparoscopic (n = 46) surgical approach showed that EUS-GE had shorter interval time to initiation/resumption of oral intake (3.49 vs 1.46 days, P < .001), decreased LOS (9 vs 5.31 days, P < .001), and a lower rate of AEs (11.9% vs 17.9%, P = .003).

CONCLUSIONS

This is the largest study to date showing that EUS-GE can be performed among nutritionally deficient patients without affecting the technical and clinical success compared with SGJ. EUS-GE is associated with fewer AEs while allowing earlier resumption of diet and chemotherapy.

Novel treatment of gastric outlet obstruction secondary to incarcerated inguinal hernia: percutaneous endoscopic gastrostomy tube

A 93-year-old man presented with gastric outlet obstruction (GOO) secondary to a massive left inguinal hernia with incarcerated antrum. He reported a desire to avoid operative intervention, and given his comorbidities, such an operation carried high risk for perioperative complications. As such, we offered percutaneous endoscopic gastrostomy (PEG) tube placement, as this would allow intermittent decompression of the stomach to reduce the risk of obstruction and strangulation. He tolerated the procedure well and was discharged after several days of observation. He continues to do well at regular outpatient appointments. Although rare, GOO secondary to an incarcerated inguinal hernia is most likely to occur in a patient such as ours: elderly, comorbid and at high risk for perioperative complications. To our knowledge, this is the first documented case to be treated with a PEG tube, which can be a desirable and effective option in this subset of patients.

Laparoscopic distal gastrectomy demonstrates acceptable outcomes regarding complications compared to open surgery for gastric cancer patients with pylorus outlet obstruction

Background

For gastric cancer (GC) patients with pylorus outlet obstruction (POO), whether laparoscopic surgery has advantages over open surgery remains unclear. This study aims to investigate the differences between patients with and without POO in open and laparoscopic groups and to determine the differences between laparoscopic distal gastrectomy (LDG) and open distal gastrectomy (ODG) in GC patients with POO.

Methods

A total of 241 GC patients with POO who underwent distal gastrectomy at the Department of Gastric Surgery of the First Affiliated Hospital of Nanjing Medical University between 2016 and 2021 were included in this study. A total of 1,121 non-POO patients who underwent laparoscopic surgery and 948 non-POO patients who underwent open surgery from 2016 to 2021 were also enrolled in the study. We compared complication rates and hospital stays between open and laparoscopic groups.

Results

There was no significant difference for LDG between GC patients with and without POO regarding the overall complication rates (P = 0.063), the Grade III-V complication rate (P = 0.673), and the anastomotic complication rate (P = 0.497) from 2016 to 2021. The patients with POO had longer preoperative hospital stay (P = 0.001) and postoperative hospital stay (P=0.007) compared to patients without POO. No significant difference was observed for open patients between POO and non-POO patients regarding the overall complication rate (P = 0.357), grade III-V complication rate (P = 1.000), and anastomosis-related complication rate (P = 0.766). Compared with open surgery in GC patients with POO (n = 111), the total complication rate of the LDG group was 16.2%, which was significantly lower than that of the open group (26.1%, P = 0.041). No significant differences in the Grade III-V complication rate (P = 0.574) and anastomotic complication rate (P = 0.587) were observed between laparoscopic and open groups. Patients receiving laparoscopic surgery had shorter postoperative hospital stay than open surgery (P = 0.001). More resected lymph nodes (LNs) were also observed in the laparoscopic group (P = 0.0145).

Conclusion

The comorbidity of GC with POO does not increase the complication rate after laparoscopic or open distal gastrectomy. In GC patients with POO, laparoscopic surgery shows advantages over open surgery with a lower overall complication rate, shorter postoperative hospital stay, and more harvested lymph nodes. Laparoscopic surgery is a safe, feasible, and effective treatment for GC with POO.

Managing inoperable pancreatic cancer: the role of the pancreaticobiliary physician

Despite our understanding of pancreatic cancer (PC), the majority of patients with this disease are incurable. Both the incidence and mortality rates for PC have increased over the last decade. At diagnosis, the majority of patients have locally advanced PC, less than 20% of patients are eligible for potentially curative resection and approximately one-third have metastatic disease. The combination of frequent advanced presentation, low resection rates and poor responses to chemotherapy make PC one of the most lethal tumours. The treatment goals are to maintain local control, manage tumour-related morbidities and improve quality of life. Patients with inoperable PC are likely to experience significant symptoms associated with their tumour, including pancreatic insufficiency, nutritional deficiencies, pain, biliary obstruction, gastric outlet obstruction and diabetes. As a result, guidance on the management of patients with inoperable PC is critical. PC is commonly referred centrally to specialist centres particularly for surgery; however, the majority do not undergo surgical intervention and thus the importance of pancreaticobiliary physicians and endoscopists. This review will focus on the non-operative management of patients with unresectable pancreatic adenocarcinoma and review some of the issues that centralisation has contributed to.