Endoscopic Management of Gastroduodenal Obstruction

Endoscopic Management of Gastroduodenal Obstruction

Vanessa M. Shami, MD, FASGE, reviewing Jue TL, et al. Gastrointest Endosc 2020 Nov 7.

Gastric outlet obstruction (GOO) can result in significant morbidity. Symptoms include early satiety, nausea, vomiting, and abdominal pain, which are frequently associated with weight loss. Etiologies may be malignant or benign. Malignant etiologies, the leading cause of GOO, include pancreatic, gastric, and duodenal cancers. The most common benign cause of GOO is peptic ulcer disease, but the use of acid suppression and widespread Helicobacter pylori treatment has decreased its overall incidence. This guideline from the American Society for Gastrointestinal Endoscopy used the Grading of Recommendations, Assessment, Development and Evaluation methodology to provide evidence-based recommendations for the endoscopic management of GOO. 

The recommendations include the following:

  • In patients presenting with incurable GOO, the authors suggest either placement of self-expandable metal stents (SEMS) or referral for gastrojejunotomy (GJ) placement. A decision about the approach should be multifactorial, including patient characteristics, preferences, and local expertise. (Conditional recommendation, low quality of evidence).
  • Based on shared decision-making, if a patient has incurable malignant GOO, the authors suggest SEMS placement (compared with surgical GJ) in patients with a life expectancy of <6 months and patients who want prompt resumption of oral intake and who wish to be discharged early.
  • If a patient has incurable malignant GOO, the authors suggest surgical GJ (compared with SEMS placement) in patients with a life expectancy of >6 months with good performance status.
  • In patients with advanced malignant GOO who need palliative stenting, there is insufficient evidence to make a recommendation about covered versus uncovered SEMS. The final decision should be based on stent availability, patient characteristics, and patient preferences. (Conditional recommendation, moderate quality of evidence).
  • In patients with benign GOO, there is insufficient evidence to support endoscopic management over surgical management. (Conditional recommendation, low quality of evidence).
  • Factors that should be considered include the length of the stricture, response to dilation, and health and comorbidities.

Vanessa M. Shami, MD, FASGE

COMMENT

More high-quality studies comparing endoscopic management versus surgical GJ to treat GOO are needed. When deciding treatment, endoscopists should consider the etiology of GOO, the clinical status of the patient, the availability of local expertise, and the preference of the patient.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

CITATION(S)

Jue TL, Storm AC, Naveed M, et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc 2020 Nov 7. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2020.07.063)

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