Elsevier

Gastrointestinal Endoscopy

Volume 93, Issue 2, February 2021, Pages 309-322.e4
Gastrointestinal Endoscopy

Guideline
ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

https://doi.org/10.1016/j.gie.2020.07.063Get rights and content

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Section snippets

Aims and scope

The aim of this document is to provide evidence-based recommendations for the endoscopic management of GOO. The committee formulated clinical questions central to the endoscopic management of GOO, comparing clinical outcomes and adverse events with different treatment options. This document addresses the following clinical questions:

  • 1.

    In patients with incurable malignant GOO undergoing a palliative intervention, what is the role of gastric and/or duodenal self-expandable metal stent (SEMS)

Overview

This guideline was conceptualized and created using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework,11,12 beginning with formulation of clinical questions in the Population, Intervention, Comparison, and Outcome (PICO) format. For each PICO question, several outcomes were included and ranked according to their importance. Systematic reviews (SRs) of the available literature were performed for each clinical question. The quality or certainty in the

Results

Question 1: In patients with incurable malignant GOO undergoing a palliative intervention, what is the role of gastric and/or duodenal SEMS placement compared with surgical GJ?

Recommendation: In patients with incurable malignant GOO undergoing palliative intervention, we suggest either SEMS placement or surgical GJ. The selected approach should be based on patient characteristics, preferences, multidisciplinary input, and local expertise. (Conditional recommendation, low quality of evidence)

Considerations for the pediatric population

GOO in pediatric patients is usually from benign etiologies. The most common cause is infantile hypertrophic pyloric stenosis, typically presenting with nonbilious emesis. Standard endoscopy is only used to exclude other diagnoses outside of infancy, and EUS has been used in some cases.99 Surgery is considered to be the standard management for infantile hypertrophic pyloric stenosis. Beyond infancy, peptic and caustic ulceration are the most common causes of GOO. Anatomic malformations

Summary and conclusions

Mechanical GOO occurs frequently with advanced malignancies and commonly affects those with progressive pancreatic and gastric cancer. SEMS placement and surgical GJ are acceptable treatment options, and multidisciplinary care, patient characteristics and preferences, and available local expertise should guide current treatment. Further investigation of outcomes from covered SEMS and EUS-GE would likely guide future management of malignant GOO. Ideal management of benign GOO remains uncertain,

Recommendations

  • 1.

    In patients with incurable malignant GOO undergoing palliative intervention, we suggest either SEMS placement or surgical GJ. The selected approach should be based on patient characteristics and preferences, multidisciplinary input, and local expertise. (Conditional recommendation, low quality of evidence)

Comment: Based on shared decision-making, in patients who are poor surgical candidates with short life expectancy (<6 months) and those who place a high value on resumption of oral diet and

Disclosure

The following authors disclosed financial relationships: A. C. Storm: Consultant for Apollo Endosurgery US Inc, Endo-TAGSS, and Enterasense; data and safety monitoring support from Erbe USA Inc. and GI Dynamics. D. S. Fishman: Contributor payment support for intellectual property from UpToDate. M. A. Khashab: Consultant for BSCI, Olympus, and Medtronic. M. Al-Haddad: Research and teaching support from Boston Scientific. S. K. Amateau: Consultant for Boston Scientific Corporation, Cook Medical

Acknowledgment

We thank Deborah Bowman (patient advocate) and Kellee Kaulback (librarian) for their contributions to this guideline.

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    This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

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