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Management issue Gastric Outlet Obstruction

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Title: Management issue Gastric Outlet Obstruction


1
Management issueGastric Outlet Obstruction
2
Case
  • A 50yr. Female
  • Presented with c/o
  • Vomitings x 1 yr
  • non-bilious, projectile, 2-3 hrs after meals, no
    blood, no anorexia, no weight loss

3
Case
  • Examination succussion splash
  • Rest examination WNL
  • Clinical impression Gastric outlet obstruction

4
Case
  • Blood investigations WNL.
  • USG Abd thickening of the antro-pyloric region
    of the stomach.
  • CECT Abd thickening of the antro-pyloric region
    of the stomach.

5
Case
6
Case
7
Case
  • Clinical impression benign disease
  • UGIE

8
Case
  • Biopsy s/o Signet ring cell adenocarcinoma
  • Management ??

9
GOO definition
  • It is the clinical and pathophysiological
    consequence of any disease process that produces
    a mechanical impediment to gastric emptying.

10
Acute GOO
  • PUD in the acute setting due to edema and
    inflammation
  • Corrosive injury
  • Intragastric gallstone induced bezoar
  • Prostaglandin induced gastric foveolar
    hyperplasia
  • Gastric volvulus

11
Acute GOO corrosive injury
12
Acute GOO corrosive injurymanagement
  • Early recognition of complications like
    perforation
  • Maintenance of airways
  • Endoscopic assessment of the injury.

Grade 1 or 2a injury oral feeds
Grade 2b and 3a TPN, jejunostomy feeding,
nasoenteral feeds
Steroids, antibiotics not shown to prevent late
complications
Grade 3b injury observe for complications,
Surgery consult
R/o perforation
13
Chronic gastric outlet obstructionIntroduction
etiology
  • 2 well-defined groups of causesbenign and
    malignant.

14
  • Incidence of GOO
  • lt5 in patients with PUD
  • 15-20 in patients with peripancreatic
    malignancy
  • Indian data Ca GB causes GOO most frequently
    (data from SGPGI, Lucknow)

15
Demographic data from India
  • Kapoor VK et al 145 cases of malignant
    obstructive jaundice
  • Ca GB 74/145
  • Ca Panc 64/145
  • Misra SP et al 74 pts. With GOO
  • 56 (76) malignant
  • 18 (24) benign

16
Aetiology of Gastric OutletObstruction (n52)
ABDUL SAMAD,et al Pak J Surg. 2007
17
Role of CECT in differential diagnosis
Advanced gastric cancer focal wall thickening
in the antrum with marked enhancement of the
mucosal layer
18
Role of CECT in differential diagnosis
Advanced gastric cancer large, polypoid
carcinoma with gross infiltration of the
perigastric fatty tissue (arrows).
19
Role of CECT in differential diagnosis
Advanced gastric cancer circumferential
thickening of the gastric wall with loss of
gastric folds due to linitis plastica.
20
Role of CECT in differential diagnosis
Gastric lymphoma focal thickening of the antral
wall (arrows).
21
Role of CECT in differential diagnosis
Polypoid advanced gastric lymphoma segmental
thickening (arrowhead) and a large polypoid
filling defect arising from the posterior wall of
the stomach (arrow).
22
Role of CECT in differential diagnosis
Metastases to the stomach Coronal reformatted
image of the gastric antrum and body shows
rounded, calcified metastases from ovarian cancer
in the antrum.
23
Role of CECT in differential diagnosis
Direct invasion of the stomach direct invasion
of the stomach by an adenocarcinoma of the
pancreatic tail (arrow).
24
Role of CECT in differential diagnosis
Direct invasion of the stomach gastric outlet
obstruction due to infiltration by a
cholangiocarcinoma
25
Role of CECT in differential diagnosis
26
Role of CECT in differential diagnosis
Gastritis CT scan shows gastritis of the antrum
as focal thickening and enhancement of the wall
(arrows) with preserved mucosal lining.
27
Role of CECT in differential diagnosis
28
Etiology
  • Benign causes
  • PUD
  • Gastric polyps
  • Ingestion of caustics
  • Pyloric stenosis
  • Congenital duodenal webs
  • Gallstone obstruction (bouveret syndrome)
  • Pancreatic pseudocysts
  • Bezoars
  • Gastric TB
  • Gastric crohns
  • Malignant causes
  • Pancreatic cancer
  • Carcinoma gall bladder
  • Ampullary cancer
  • Duodenal cancer
  • Cholangiocarcinoma
  • Gastric cancer
  • Lymphoma
  • Metastases to the gastric outlet

29
Clinical presentation
  • Nausea and vomiting cardinal symptoms of GOO.
  • Vomiting nonbilious, characteristically contains
    undigested food particles. In the early stages
    may be intermittent and usually occurs within 1
    hour of a meal.

30
Clinical presentation
  • Early satiety and epigastric fullness.
  • Weight loss.
  • Abdominal pain.
  • Physical examination
  • Chronic dehydration and malnutrition.
  • Dilated stomach tympanitic mass, sucussion
    splash

31
Clinical presentation
  • Fluid and electrolyte abnormalities hypokalemic
    hypochloremic metabolic alkalosis, inc. BUN and
    Sr. Cr.

32
Work up
  • Laboratory Studies
  • CBC
  • Electrolytes
  • LFTs, PT
  • Imaging Studies
  • Plain abdominal radiographs
  • Contrast upper GI studies
  • CT scans with oral contrast

33
Work up
  • UGIE
  • Saline load test
  • Nuclear gastric emptying studies

34
Initial management
  • First and foremost is hydration and correction of
    electrolyte imbalances
  • Sodium chloride solution initial IV fluid of
    choice.
  • Potassium deficits must be corrected.
  • NG tube to decompress stomach.

35
Benign disease issues
  • Balloon dilatation
  • Surgery
  • H. Pylori whether to treat or not??
  • Any role of corticosteroids for corrosive gastric
    outlet obstruction??
  • ATT for remission of disease in cases of TB
  • PPIs as an adjuvant therapy for PUD

36
Balloon dilatation
  • Type of dilators Ideal TTS dilator
  • How much to dilate Ideal 15 mm
  • Available sizes 6-20 mm

37
Balloon dilatation
38
Balloon dilatation
RAKESH KOCHHAR et al. PGI, Chandigarh Journal of
Gastroenterology and Hepatology (2004) 19,
39
Surgery for benign GOO
  • Vagotomy and antrectomy
  • Vagotomy and pyloroplasty
  • Truncal vagotomy and gastrojejunostomy
  • Pyloroplasty
  • Laparoscopic variants
  • Vagotomy and antrectomy with Billroth II
    reconstruction (Gastro-jejunostomy) procedure of
    choice

40
Lap v/s open surgery
41
Balloon dilatation v/s surgery Benign GOO
  • No head to head comparative study
  • Balloon dilatation less morbidity, less
    expensive, good long term results

42
H Pylori and GOO
43
Stenting in benign GOO
  • Limited experience
  • A. J. dorman et al.(2001) 2 patients with
    benign GOO were stented
  • Needs further studies for definite role

44
Intralesional steroids for corrosive benign GOO
  • Kochhar et al. (PGIMER, Chandigarh)
  • 3 patients with intralesional steroid injections
    combined with TTS balloon dilation
  • All the 3 patients responded well and were
    asymptomatic till follow up

45
Benign GOO
  • Balloon dilatation may be the therapy of choice

46
Malignant GOO
  • Metallic stenting
  • Surgery
  • Feeding jejunostomy
  • Role of adjuvant therapy??

47
Stenting for malignant GOO
  • Gastric Outlet Obstruction Scoring System (GOOSS)

Used to assess baseline oral intake and is
particularly helpful when assessing response to
therapy by any modality (endoscopic, surgical, or
oncologic)
48
Commercially available enteral stents
49
Commercially available enteral stents
Covered stent
Uncovered stent
50
Commercially available enteral stents
Covered stent
Uncovered stent
51
Self-expanding Metal Stents for Gastroduodenal
Malignancies Systematic review of their clinical
effectiveness
Characteristics of the pooled patient population
52
Self-expanding Metal Stents for Gastroduodenal
Malignancies Systematic review of their clinical
effectiveness
Technical and clinical results
53
Self-expanding Metal Stents for Gastroduodenal
Malignancies Systematic review of their clinical
effectiveness
Oral intake status
54
Self-expanding Metal Stents for Gastroduodenal
Malignancies Systematic review of their clinical
effectiveness
Complications
55
Self-Expandable Metallic Stents (SEMS) for
Palliating Gastric Outlet Obstruction (GOO) in
Gallbladder Carcinoma (GBC) An Assessment of
Survival and Quality of Life
  • 150 patients with advanced GBC
  • 45/150 (30) patients had GOO
  • Twenty agreed for palliation of GOO
  • 80 showed symptom improvement within 48 hrs.
  • Overall survival in enteral SEMS group 120 days
    (23-289) was longer than that in the 25 patients
    who did not opt for palliation of GOO 30 days
    (8-113)

VA Saraswat et al. SGPGI, Lucknow (unpublished
data)
56
Surgery for malignant GOO
  • Gastrojejunostomy surgical treatment of choice
    for GOO secondary to malignancy.

57
Laparoscopic v/s Open surgery
58
Stent v/s Gastrojejunostomy for palliation of
malignant GOO
59
Stent v/s Gastrojejunostomy for palliation of
malignant GOO
Stent placement favorable short-term results GJJ
may be a better treatment option in patients with
a more prolonged survival.
60
What if the patient has biliary and gastric
outlet obstruction??
  • Biliary obstruction should be relieved first
    followed by gastric outlet obstruction
  • Surgical approach Double bypass (laparoscopic
    gastric and biliary bypass)

61
Role of adjuvant therapy
  • Combined Arterial Infusion and Stent
    Implantation Compared with Metal Stent Alone in
    Treatment of Malignant Gastroduodenal Obstruction
  • Cardiovasc Intervent Radiol, Aug, 2009
  • Retrospective analysis
  • Dual interventional therapy (DIT) prosthesis
    insertion is followed by intra-arterial
    chemotherapy via the tumor-feeding arteries.
  • Both MSI and DIT offer effective palliation for
    malignant gastroduodenal obstruction
  • DIT appears to offer superior survival over MSI
    alone.

62
What is new in metal stents
  • Gastroduodenal ComVi stents Biocompatible PTFE
    membrane tube is hold between inside and outside
    D type stent bodies
  • Designed to have advantages of uncovered (low
    migration rate) and covered (low ingrowth rate)
    stents.

63
What is new in metal stents
Com vi stent
Conventional D-type stent
64
Management algorithm
Patient with s/s of GOO
R/o Gastroparesis
Fluid and electrolyte management NS fluid of
choice
Benign disease
Malignant disease
Eradicate H. Pylori if positive
Yes
Resectable lesion
Balloon dilatation
No
Definite surgery
Successful
Can the lesion be stented
Yes
No
Follow up
Lap GJJ
No
Yes
GJJ Feeding jejunostomy
Metal stenting
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