Opinion Review
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 28, 2020; 26(16): 1847-1860
Published online Apr 28, 2020. doi: 10.3748/wjg.v26.i16.1847
Malignant gastric outlet obstruction: Which is the best therapeutic option?
Edoardo Troncone, Alessandro Fugazza, Annalisa Cappello, Giovanna Del Vecchio Blanco, Giovanni Monteleone, Alessandro Repici, Anthony Yuen Bun Teoh, Andrea Anderloni
Edoardo Troncone, Giovanna Del Vecchio Blanco, Giovanni Monteleone, Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
Alessandro Fugazza, Annalisa Cappello, Alessandro Repici, Andrea Anderloni, Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
Alessandro Repici, Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
Anthony Yuen Bun Teoh, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
Author contributions: All authors have approved the final draft submitted.
Conflict-of-interest statement: Dr. Anderloni reports personal fees from Boston Scientific, during the conduct of the study; personal fees from Boston Scientific, outside the submitted work; Dr. Repici reports personal fees from Boston Scientific, personal fees from Fujifilm, during the conduct of the study; personal fees from Boston Scientific, personal fees from Fujifilm, outside the submitted work; Dr. Teoh reports personal fees from Microtech Medical Corporations, personal fees from Boston Scientific, personal fees from Cook, personal fees from Taewoong, during the conduct of the study; personal fees from Microtech Medical Corporations, personal fees from Boston Scientific, personal fees from Cook, personal fees from Taewoong, outside the submitted work; The other Authors declare no conflict of interests.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Andrea Anderloni, MD, PhD, Chief Doctor, Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Via Manzoni 56, Milan 20089, Italy. andrea.anderloni@humanitas.it
Received: February 2, 2020
Peer-review started: February 2, 2020
First decision: February 29, 2020
Revised: March 6, 2020
Accepted: April 17, 2020
Article in press: April 17, 2020
Published online: April 28, 2020
Processing time: 85 Days and 22 Hours
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.