eMedicine Specialties > General Surgery > Abdomen
Gastric Outlet Obstruction: Treatment
Updated: Oct 29, 2009
Treatment
Medical Therapy
Initial management of gastric outlet obstruction (GOO) should be the same regardless of the primary cause. After a diagnosis is made, admit patients for hydration and correction of electrolyte abnormalities. Remembering that the metabolic alkalosis of GOO responds to the administration of chloride is important; therefore, sodium chloride solution should be the initial IV fluid of choice. Potassium deficits are corrected after repletion of volume status and after replacement of chloride.
Place a NGT to decompress the stomach. Occasionally, a large tube is required because the undigested food blocks tubes with small diameters.
Further treatment is tailored to the underlying cause; this is where the distinction between benign and malignant disease becomes important.
Surgical Therapy
Management of benign disease
When acute PUD has been identified as a primary cause of gastric outlet obstruction (GOO), focus treatment on the reduction of acid production. Histamine-2 (H2) blockers and proton pump inhibitors are the mainstay of treatment.
Treat H pylori infection, when identified, according to current recommendations. Although most patients improve temporarily with treatment, scarring and fibrosis may worsen over time. Pneumatic balloon dilatation of a chronic, benign stricture can be performed via endoscopy. Patients who are candidates for balloon dilatation are likely to present with recurrent GOO. Published series using this technique report success rates of over 76% after multiple dilatations,3 although the rate of failure and recurrent obstruction is higher in patients treated with balloon dilatation who have not also been treated for H pylori infection.4
Patients who are negative for H pylori do not respond favorably to balloon dilatation and should be considered for surgical treatment early in the process.5 More than 75% of patients presenting with GOO eventually require surgical intervention.6
Surgical intervention usually provides definitive treatment of GOO, but it may result in its own comorbid consequences. Operative management should offer relief of obstruction and correction of the acid problem.
The most common surgical procedures performed for GOO related to PUD are vagotomy and antrectomy, vagotomy and pyloroplasty, truncal vagotomy and gastrojejunostomy, pyloroplasty, and laparoscopic variants7 of the aforementioned procedures. Of these, vagotomy and antrectomy with Billroth II reconstruction (gastrojejunostomy) seem to offer the best results. Vagotomy and pyloroplasty and pyloroplasty alone, although used with some success, can be technically difficult to perform due to scarring at the gastric outlet. A combination of balloon dilatation and highly selective vagotomy has been described, but it is associated with gastroparesis and a high recurrence rate.
Placement of a jejunostomy tube at the time of surgery should be considered. This provides temporary feeding access in already malnourished patients. Also, in chronically dilated partial obstructions, the stomach may be slow to recover a normal rate of emptying.
The role of the laparoscopic approach in the treatment of GOO is under investigation and may represent a valid form of therapy with low morbidity. The experience of several international centers has been published. One group in China performed laparoscopic truncal vagotomy and gastrojejunostomy for GOO related to PUD, with nearly complete resolution of symptomatology. The investigators reported no conversions to open procedure or mortalities. Twenty-seven percent of patients did experience transiently delayed gastric emptying, which resolved with conservative measures.8
Kim et al also reported good results from the use of laparoscopic truncal vagotomy with gastrojejunostomy, including shorter operating times and hospital stays in comparison with the open procedure.9
Hall et al performed a double-blind, multicenter, randomized, controlled trial comparing patient recovery following laparoscopic pyloromyotomy to that after open pyloromyotomy in infants with pyloric stenosis.10 (See image below and Image 5.) The investigators found that among the 87 infants who underwent the laparoscopic procedure, the median (interquartile range) postoperative time needed to achieve full enteral feeding was 18.5 hours, compared with 23.9 hours in the 93 infants who underwent open pyloromyotomy. The median postoperative length of stay in the laparoscopic and open pyloromyotomy groups were 33.6 hours and 43.8 hours, respectively.
Open pyloromyotomy.
The study also found that the incidence of postoperative vomiting was similar in the open and laparoscopic groups, as was the frequency of intraoperative and postoperative complications. The authors suggested that open and laparoscopic pyloromyotomy are safe means of treating infantile pyloric stenosis. Because of its apparent advantages, however, they recommended that in centers with suitable laparoscopic experience, the laparoscopic form of the procedure be used.
Management of malignant disease
The management of GOO secondary to malignancy is controversial. Of patients with periampullary cancer, 30-50% present with nausea and vomiting at the time of diagnosis.11,12 Most of these tumors are unresectable (approximately 40% of gastric cancers and 80-90% of periampullary cancers).13,14 When tumors are found to be unresectable, 13-20% of patients eventually develop GOO before they succumb to their disease. The 1-year survival rate is poor.
Gastrojejunostomy remains the surgical treatment of choice for GOO secondary to malignancy. Although surgeons traditionally have preferred an antecolic anastomosis to prevent further obstruction by advancing tumor growth, a publication evaluating the retrocolic anastomosis in this setting challenges conventional wisdom.15 Results demonstrate that a retrocolic anastomosis may be associated with decreased incidences of delayed gastric emptying (6% vs 17%) and late GOO (2% vs 9%). Other groups have illustrated that partial stomach-partitioning gastrojejunostomy decreases the rates of delayed gastric emptying as compared with traditional gastrojejunostomy.16 Feeding jejunostomy should again be considered to combat malnutrition and slow recovery of gastric emptying.
Internationally, studies are underway using laparoscopic gastrojejunostomy instead of the open procedure. In the United States, critics cite a nearly 20% conversion rate and a delay in the return of gut function as reasons to not perform the procedure laparoscopically. Comparisons of laparoscopic GI anastomosis versus the open procedure have revealed less morbidity and mortality, shorter hospital stays, fewer blood transfusions, and faster GI transit recovery time.17,18
Researchers at Johns Hopkins Hospital have attempted endoscopic transgastric approaches to create a gastrojejunostomy in a porcine model.19 As natural orifice transluminal surgery gains more widespread interest, these novel approaches may become more popular.
Chopita and colleagues reported on the use of magnetic endoscopic gastroenteric anastomosis in 15 patients with malignant gastroenteric obstruction. The procedure had an 86.7% success rate, with the authors noting the additional benefits of shorter duration of hospital stay and good quality of life in patients.20 Although still experimental, this procedure may one day be a surgical option.
Self-expandable metallic stents also have been used for the treatment of GOO in a malignant setting. Metallic stents have previously been used successfully to treat stenosis of such areas as the blood vessels, bile duct, esophagus, and trachea. With the development of newer stents and delivery systems, metallic stents may have a role in the nonsurgical treatment of gastroduodenal obstruction. Stents may allow the physician to avoid complicated surgical procedures. Currently, only the Wallstent has FDA approval for palliation in malignant gastroduodenal obstruction. Significant complications include the following: malposition, misdeployment, tumor ingrowth or overgrowth, migration, bleeding, and perforation.21
A review of 19 studies published in 2004 quoted clinical success rates of 80-90%.22 Subsequent multicenter trials using the enteral Wallstent in 176 patients with malignant GOO resulted in 89% of patients tolerating oral intake for a median of 219 days postprocedure. Of the 84% in whom the stent was successful after the initial procedure, 22% required restenting to tolerate an oral diet. In addition, as other studies have demonstrated, chemotherapy was independently associated with an increased tolerance in oral intake.23
One proposed solution uses covered metallic stents that have a lower incidence of tumor ingrowth. A 60% rate of tumor ingrowth in uncovered stents versus a 10% rate of tumor ingrowth in covered stents has been reported. Furthermore, with the double stent technique, that is, simultaneous placement of both covered stents and uncovered stents, lower early restenosis rates have been achieved. A stent patency of 21.5 days for uncovered stents versus 150 days for double stents has been achieved.24
Several retrospective studies have been performed to compare the results of stenting versus surgical intervention. Survival rates are equivalent; however, costs, length of stay, and number of subsequent procedures are all decreased following stenting.25,26 In addition, a delay of gastric emptying and morbidity decrease with the use of metallic stents.27 These promising results suggest that stents may eventually replace surgery as palliative intervention for unresectable periampullary malignancies.
Preoperative Details
Perform standard preoperative evaluation in these patients. Correct fluid and electrolyte abnormalities prior to surgery.
Perform gastric decompression by NGT and suction and alert the anesthesiologist to the potential risk for aspiration upon induction.
Perform a preoperative nutritional evaluation and initiate appropriate nutritional therapy (ie, TPN or enteral feedings via a percutaneous jejunostomy placed distal to the obstruction) as soon as possible. Maximizing preoperative nutrition can greatly reduce or eliminate postoperative complications related to delayed healing.
Intraoperative Details
Intraoperative details depend upon the etiology of the underlying disease and the reason that the specific surgical procedure is undertaken.
Postoperative Details
Admit patients to a monitor unit after the procedure. Pay special attention to fluid and electrolyte status.
Most surgeons agree that perioperative antibiotics are advisable but may be limited to use during the immediate perioperative period in the absence of intervening infection.
If a gastric reconstruction is performed, an NGT is recommended. The length of time that the NGT should remain in place is controversial; however, it is important to remember that a previously dilated stomach, the performance of a vagotomy, and the presence of metastatic cancer may all contribute to decreased gastric motility. An anatomically patent gastrojejunostomy may fail to empty for days. This syndrome of delayed gastric emptying is a well-known entity and requires surgical patience. Again, preoperative planning for feeding access becomes important during this immediate postoperative period.
Aggressive pulmonary toilet, prophylaxis for gastritis and deep venous thrombosis (DVT), and early ambulation are advisable.
Follow-up
Closely monitor patients after surgery and upon discharge.28 After relief of gastric outlet obstruction, patients may continue to experience gastric dysmotility and may require medication to stimulate gastric emptying and motility.
In patients with malignancy, the potential for progressive and recurrent disease always remains. These patients should be monitored by a surgeon or an oncologist.
Closely monitor patients whose treatment consisted of balloon dilatation because most of these patients require subsequent dilatations to achieve satisfactory results.Complications
Although the risk is small, patients undergoing endoscopic treatment with either balloon dilatation or stenting are at risk for perforation. Several literature reports exist regarding migration of the stents and reocclusion requiring further intervention.
Operative complications in patients undergoing surgery for gastric outlet obstruction (GOO) often are related to the nutritional status of the patients. Commencing nutritional support upon recognition of the presence of GOO is important. If surgery is anticipated, delaying the surgery or any intervention until TPN has been instituted for at least 1 week is often prudent.
Acute intervention may be technically difficult because of significant gastric dilatation and gastric wall edema. This circumstance may increase the rate of anastomotic leak. On occasion, delaying surgical intervention for several days while the stomach is decompressed by nasogastric suction may be prudent.
Alert patients undergoing gastric resection for benign or malignant disease to the possibility of well-known postgastrectomy syndromes, such as dumping, alkaline gastritis, and afferent loop syndrome. Severe symptoms may be present in 1-2% of patients.
More on Gastric Outlet Obstruction |
| Overview: Gastric Outlet Obstruction |
| Workup: Gastric Outlet Obstruction |
 Treatment: Gastric Outlet Obstruction |
| Follow-up: Gastric Outlet Obstruction |
| Multimedia: Gastric Outlet Obstruction |
| References |
| Further Reading |
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References
Andersson A, Bergdahl L. Carcinoid tumors of the appendix in children. A report of 25 cases. Acta Chir Scand. 1977;143(3):173-5. [Medline].
Gibson JB, Behrman SW, Fabian TC, Britt LG. Gastric outlet obstruction resulting from peptic ulcer disease requiring surgical intervention is infrequently associated with Helicobacter pylori infection. J Am Coll Surg. Jul 2000;191(1):32-7. [Medline].
Lam YH, Lau JY, Fung TM, et al. Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection. Gastrointest Endosc. Aug 2004;60(2):229-33. [Medline].
Taskin V, Gurer I, Ozyilkan E, Sare M, Hilmioglu F. Effect of Helicobacter pylori eradication on peptic ulcer disease complicated with outlet obstruction. Helicobacter. Mar 2000;5(1):38-40. [Medline].
Gouma DJ, van Geenen R, van Gulik T, de Wit LT, Obertop H. Surgical palliative treatment in bilio-pancreatic malignancy. Ann Oncol. 1999;10 Suppl 4:269-72. [Medline].
Doberneck RC, Berndt GA. Delayed gastric emptying after palliative gastrojejunostomy for carcinoma of the pancreas. Arch Surg. Jul 1987;122(7):827-9. [Medline].
Abdel-Salam WN, Katri KM, Bessa SS, et al. Laparoscopic-assisted truncal vagotomy and gastro-jejunostomy: trial of simplification. J Laparoendosc Adv Surg Tech A. Apr 2009;19(2):125-7. [Medline].
Siu WT, Tang CN, Law BK, Chau CH, Yau KK, Yang GP, et al. Vagotomy and gastrojejunostomy for benign gastric outlet obstruction. J Laparoendosc Adv Surg Tech A. Oct 2004;14(5):266-9. [Medline].
Kim SM, Song J, Oh SJ, et al. Comparison of laparoscopic truncal vagotomy with gastrojejunostomy and open surgery in peptic pyloric stenosis. Surg Endosc. Jun 2009;23(6):1326-30. [Medline].
Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet. Jan 31 2009;373(9661):390-8. [Medline].
Jaffin BW, Kaye MD. The prognosis of gastric outlet obstruction. Ann Surg. Feb 1985;201(2):176-9. [Medline].
Khullar SK, DiSario JA. Gastric outlet obstruction. Gastrointest Endosc Clin N Am. Jul 1996;6(3):585-603. [Medline].
Kurtz RC, Sherlock P. Carcinoma of the stomach. In: Bockus Gastroenterology. 4th ed. Philadelphia, Pa: WB Saunders Co; 1985.
Lillemoe KD, Sauter PK, Pitt HA, Yeo CJ, Cameron JL. Current status of surgical palliation of periampullary carcinoma. Surg Gynecol Obstet. Jan 1993;176(1):1-10. [Medline].
Lillemoe KD, Cameron JL, Hardacre JM, Sohn TA, Sauter PK, Coleman J, et al. Is prophylactic gastrojejunostomy indicated for unresectable periampullary cancer? A prospective randomized trial. Ann Surg. Sep 1999;230(3):322-8; discussion 328-30. [Medline].
Arciero CA, Joseph N, Watson JC, Hoffman JP. Partial stomach-partitioning gastrojejunostomy for malignant duodenal obstruction. Am J Surg. Mar 2006;191(3):428-32. [Medline].
Bergamaschi R, Marvik R, Thoresen JE, Ystgaard B, Johnsen G, Myrvold HE. Open versus laparoscopic gastrojejunostomy for palliation in advanced pancreatic cancer. Surg Laparosc Endosc. Apr 1998;8(2):92-6. [Medline].
Alam TA, Baines M, Parker MC. The management of gastric outlet obstruction secondary to inoperable cancer. Surg Endosc. Feb 2003;17(2):320-3. [Medline].
Kantsevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc. Aug 2005;62(2):287-92. [Medline].
Chopita N, Vaillaverde A, Cope C, et al. Endoscopic gastroenteric anastomosis using magnets. Endoscopy. Apr 2005;37(4):313-7. [Medline].
Adler DG, Merwat SN. Endoscopic approaches for palliation of luminal gastrointestinal obstruction. Gastroenterol Clin North Am. Mar 2006;35(1):65-82, viii. [Medline].
Baron TH. Surgical versus endoscopic palliation of malignant gastric outlet obstruction: big incision, little incision, or no incision?. Gastroenterology. Oct 2004;127(4):1268-9. [Medline].
Telford JJ, Carr-Locke DL, Baron TH, Tringali A, Parsons WG, Gabbrielli A, et al. Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study. Gastrointest Endosc. Dec 2004;60(6):916-20. [Medline].
Song GA, Kang DH, Kim TO, Heo J, Kim GH, Cho M, et al. Endoscopic stenting in patients with recurrent malignant obstruction after gastric surgery: uncovered versus simultaneously deployed uncovered and covered (double) self-expandable metal stents. Gastrointest Endosc. May 2007;65(6):782-7. [Medline].
Yim HB, Jacobson BC, Saltzman JR, Johannes RS, Bounds BC, Lee JH, et al. Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc. Mar 2001;53(3):329-32. [Medline].
Del Piano M, Ballare M, Montino F, Todesco A, Orsello M, Magnani C, et al. Endoscopy or surgery for malignant GI outlet obstruction?. Gastrointest Endosc. Mar 2005;61(3):421-6. [Medline].
Wong YT, Brams DM, Munson L, Sanders L, Heiss F, Chase M, et al. Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation. Surg Endosc. Feb 2002;16(2):310-2. [Medline].
Huang YL, Lee HC, Yeung CY, et al. Sonogram before and after pyloromyotomy: the pyloric ratio in infantile hypertrophic pyloric stenosis. Pediatr Neonatol. Jun 2009;50(3):117-20. [Medline].
Quigley RL, Pruitt SK, Pappas TN, Akwari O. Primary hypertrophic pyloric stenosis in the adult. Arch Surg. Sep 1990;125(9):1219-21. [Medline].
Chopita N, Landoni N, Ross A, Villaverde A. Malignant gastroenteric obstruction: therapeutic options. Gastrointest Endosc Clin N Am. Jul 2007;17(3):533-44, vi-vii. [Medline].
Holt AP, Patel M, Ahmed MM. Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice?. Gastrointest Endosc. Dec 2004;60(6):1010-7. [Medline].
Lillemoe KD, Cameron JL, Yeo CJ, Sohn TA, Nakeeb A, Sauter PK, et al. Pancreaticoduodenectomy. Does it have a role in the palliation of pancreatic cancer?. Ann Surg. Jun 1996;223(6):718-25; discussion 725-8. [Medline].
Mauro MA, Koehler RE, Baron TH. Advances in gastrointestinal intervention: the treatment of gastroduodenal and colorectal obstructions with metallic stents. Radiology. Jun 2000;215(3):659-69. [Medline].
Schwarz A, Beger HG. Biliary and gastric bypass or stenting in nonresectable periampullary cancer: analysis on the basis of controlled trials. Int J Pancreatol. Feb 2000;27(1):51-8. [Medline].
Shyr YM, Su CH, Wu CW, Lui WY. Prospective study of gastric outlet obstruction in unresectable periampullary adenocarcinoma. World J Surg. Jan 2000;24(1):60-4; discussion 64-5. [Medline].
Wade TP, Neuberger TJ, Swope TJ, Virgo KS, Johnson FE. Pancreatic cancer palliation: using tumor stage to select appropriate operation. Am J Surg. Jan 1994;167(1):208-12; discussion 212-3. [Medline].
Further Reading
Clinical guidelines:
ACR Appropriateness Criteria® vomiting in infants up to 3 months of age. American College of Radiology - Medical Specialty Society. 1995 (revised 2008). 8 pages. NGC:007011
Evidence based clinical practice guideline hypertrophic pyloric stenosis. Cincinnati Children's Hospital Medical Center - Hospital/Medical Center. 2001 Aug 8 (revised 2007 Nov 4). 17 pages. NGC:006224
Surgical treatment of pancreatic cancer. Society for Surgery of the Alimentary Tract, Inc - Medical Specialty Society. 1996 (revised 2004 May 15). 3 pages. NGC:003753
Clinical trials:
Frequency of Formula Change Prior to the Accurate Diagnosis of Pyloric Stenosis
Magnetic Anastomosis Device Relief of Malignant Gastric Outlet Obstruction (MAD)
Open vs Laparoscopic Pyloromyotomy for Pyloric Stenosis
Keywords
gastric outlet obstruction, pancreatic cancer, peptic ulcer, pyloric stenosis, gastric cancer, peptic ulcer disease, vagotomy, gastrojejunostomy, gastric outlet, pyloroplasty, periampullary cancer, antrectomy, gastric obstruction
