Malignant gastric outlet obstruction: Which is the best therapeutic option?

Abstract

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Keywords: Gastrojejunostomy, Self-expanding metal stent, Enteral stent, Interventional endoscopic ultrasonography, Endoscopic ultrasound-guided gastroenterostomy, Pancreatic cancer, Gastric cancer, Duodenal stricture

Core tip: In the last decades, surgical gastrojejunostomy and enteral stenting have represented the main palliative strategies for patient with malignant gastric outlet obstruction. Although they showed good clinical efficacy, these approaches suffer from limits secondary to the high procedure-related risks and longer hospital stay (surgery) or the need subsequent re-interventions due to stent dysfunction (endoscopic stenting). The recently proposed endoscopic ultrasonography-guided gastroenterostomy may include both advantages of a minimally invasive endoscopic procedure and the long-lasting benefits of the gastrojejunostomy. However, such procedure is not standardized and prospective comparative studies are needed to define the best strategy for these patients.