Gastric Outlet Obstruction (GOO): Management

1. Initial Resuscitation (all patients)

• NG tube decompression to rest the stomach and reduce vomiting/aspiration risk
• IV fluid resuscitation - the classic finding is hypochloremic, hypokalemic metabolic alkalosis from repeated vomiting of HCl and K+. Correct with isotonic (0.9%) saline plus potassium chloride - this is essential before any surgery (Bailey and Love's Short Practice of Surgery, p. 1190).
• Nutritional support if obstruction prolonged (NG feeding or TPN)
• Correct anemia if present

2. Diagnostic Workup

• Upper endoscopy with biopsy is mandatory to exclude malignancy - with declining peptic ulcer incidence, GOO should be considered malignant until proven otherwise (Bailey and Love's, p. 1189-1190).
• CT abdomen to assess extent/resectability if malignant cause suspected.

3. Definitive Treatment - depends on cause

• Aggressive medical therapy first: high-dose PPI, H. pylori eradication - can resolve edema/inflammation-driven components and may delay/avoid surgery for 1-2 years in roughly half of patients (Current Surgical Therapy 14e, p. 132-133).
• Endoscopic balloon dilation of the stricture - effective for benign fibrotic stenosis, often repeated.
• If medical/endoscopic therapy fails or obstruction is fixed/fibrotic: surgery
  • Vagotomy and drainage - pyloroplasty or gastrojejunostomy (the traditional definitive approach)
  • Antrectomy with vagotomy (Billroth I/II) in select stable patients
  • Simple gastrojejunostomy bypass if dense scarring precludes safe pyloroplasty

• If resectable and patient fit -> surgical resection (gastrectomy) with curative intent.
• If unresectable/palliative, three options are compared in the literature:
  1. Endoscopic self-expanding metal stent (SEMS) placement - faster symptom relief, shorter hospital stay, lower morbidity, but higher rates of stent obstruction/re-intervention and shorter patency, especially with longer survival.
  2. Surgical gastrojejunostomy (open or laparoscopic) - better long-term patency and fewer re-interventions, but higher initial morbidity and slower return to oral intake; preferred in patients with better prognosis/longer expected survival.
  3. EUS-guided gastroenterostomy (EUS-GE) - a newer minimally invasive option combining strong patency (comparable to surgical GJ) with less invasiveness than open surgery, though technically demanding.

Summary

• Resuscitate first: NG decompression + isotonic saline/KCl for the alkalosis.
• Biopsy to rule out cancer - never assume benign.
• Benign: PPI/H. pylori therapy -> endoscopic dilation -> surgery (vagotomy + drainage or resection) if refractory.
• Malignant: resect if operable; if palliative, choose stent (short prognosis) vs. surgical or EUS-guided gastroenterostomy (longer prognosis, better durability).