GOO management

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Gastric Outlet Obstruction (GOO) - Management

Definition and Causes

GOO is mechanical blockage at the pylorus or proximal duodenum preventing gastric emptying. In the modern era, malignancy should be considered until proven otherwise given the declining incidence of peptic ulcer disease (PUD).

Common causes:

Malignant: pancreatic cancer (51-73% in Western series), gastric cancer (main cause in Asian series), bile duct/duodenal/ampullary cancer, lymphoma
Benign: PUD scarring/edema (most common benign cause), Crohn's disease, pancreatic pseudocysts, bezoars, Bouveret's syndrome (gallstone), tuberculosis, caustic ingestion

Step 1: Initial Resuscitation

Metabolic correction (benign GOO key issue):

Vomiting of HCl causes hypochloraemic, hypokalaemic metabolic alkalosis
Correct with isotonic saline (0.9% NaCl) + potassium supplementation
Replacing NaCl and water allows the kidney to self-correct the acid-base disturbance
Alkalosis can lower ionised calcium - monitor for tetany
Note: malignant GOO causes less metabolic derangement due to relative hypochlorhydria

Gastric decompression:

Insert wide-bore nasogastric (NG) tube; a large-bore orogastric tube may be needed to lavage a heavily loaded stomach
Decompress fully before proceeding with investigation

Step 2: Investigation

Test	Purpose
Upper GI endoscopy (EGD) + biopsy	Mandatory - exclude malignancy, assess for PUD
CT scan (contrast-enhanced)	Assess tumor extent, resectability, biliary obstruction, rule out distal second obstruction
Barium upper GI series	Functional assessment, defines anatomy

Cytological or histological confirmation of malignancy is desirable before any definitive surgical or endoscopic intervention.

Step 3: Management by Etiology

A. Benign GOO (PUD-related)

Conservative management (try first):

PPI therapy + H. pylori eradication (confirm eradication with urea breath test or faecal antigen test)
Aggressive medical therapy leads to resolution in some patients as ulcer edema resolves
Endoscopic balloon dilation can delay surgery for 1-2 years in ~50% of patients but often requires repeat sessions

Surgical management (required for most patients needing hospitalisation or repeated dilation):

Procedure	Advantage	Disadvantage
Vagotomy + Antrectomy (V/A) - gold standard	Lower ulcer recurrence; pathological confirmation of benign cause	Higher operative mortality (~2%); technically demanding
Vagotomy + Gastrojejunostomy (V/GJ)	Lower operative mortality; laparoscopically feasible; reversible	Risk of missing malignancy; marginal ulcer risk

V/A preferred when the duodenum is manageable and cancer must be ruled out
V/GJ is a good alternative in higher-risk patients; patients should be followed closely for 2 years to ensure no missed malignancy
Historically, truncal vagotomy is the most common vagotomy type used; posterior truncal + anterior highly selective is also acceptable
Drainage procedure (gastroenterostomy) for benign disease; resection for malignancy

B. Malignant GOO (MGOO)

Most patients have advanced, unresectable disease with a mean survival of ~100 days (3.3 months). Treatment is therefore largely palliative.

Palliative options - SEMS vs. Surgical Gastrojejunostomy:

Feature	Duodenal SEMS	Surgical GJ
Recovery of oral intake	Faster	Slower
Hospital stay	Shorter	Longer
Cost	Lower	Higher
Long-term symptom relief	Inferior (stent re-obstruction)	Superior
Reintervention rate	Higher	Lower
Fitness requirement	Suitable for poor surgical candidates	Requires surgical fitness

Current guidance (from RCT data):

SEMS - preferred for patients in poor clinical condition, unfit for surgery, or with life expectancy < 2 months; offers faster short-term recovery
Surgical gastrojejunostomy - superior for long-term palliation in patients who can tolerate surgery and have longer expected survival

EUS-guided gastroenterostomy (EUS-GE): An emerging endoscopic technique now supported by recent systematic reviews (see below) as an alternative to both surgical GJ and SEMS, particularly showing durable results in benign GOO.

Resectable malignancy: Appropriate oncological resection (e.g., pancreaticoduodenectomy for periampullary or duodenal cancer; distal/total gastrectomy for gastric cancer) with curative intent.

Summary - Management Algorithm

GOO confirmed on CT + EGD with biopsy
         |
    ┌────┴────┐
 Benign       Malignant
    |              |
Resuscitate    Resectable?
IV saline         |        |
+K+             Yes       No (palliative)
NG tube          |              |
    |         Oncological    Fit for
Medical Rx    resection      surgery?
+Endoscopic                  |      |
 balloon dilation           Yes     No
    |                        |       |
 Failed/                Surgical  SEMS
 recurrent               GJ      placement
    |
Vagotomy + 
Antrectomy or
Gastrojejunostomy

Recent Evidence (2024-2026)

Three recent systematic reviews/meta-analyses update the evidence:

EUS-GE vs. duodenal stenting (PMID: 39465748) - EUS-guided gastroenterostomy shows favorable outcomes vs. SEMS, with lower reintervention rates.
EUS-GE for benign GOO (PMID: 39761155, J Clin Gastroenterol, 2026) - supports EUS-GE as an effective option for benign GOO with good technical success and low adverse event rates.
Palliative approaches for GOO in locally advanced pancreatic cancer (PMID: 41241872, J Surg Oncol, 2026) - comparing surgical bypass vs. endoscopic approaches specifically in pancreatic cancer patients.

Sources: Current Surgical Therapy 14e; Bailey & Love's Short Practice of Surgery 28e; Clinical Gastrointestinal Endoscopy 3e; Sleisenger & Fordtran's GI & Liver Disease.

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