Duodenal stenting and gastrojejunostomy for malignant gastric outlet obstruction

Gallbladder cancer invades the duodenum by direct extension or hilar nodes. The Dutch SUSTENT randomised trial (39 patients) found that food intake improved faster after stent placement than after gastrojejunostomy (median 5 versus 8 days) but that long-term relief was better after surgery (72 versus 50 days with adequate intake), with more major complications, recurrent obstruction and reinterventions after stenting and no difference in survival (56 versus 78 days) or quality of life; the authors proposed stents for those expected to live under two months and bypass for the rest. Endoscopic ultrasound-guided gastroenterostomy with a lumen-apposing metal stent is the newer middle path: in a 93-patient international comparison it matched surgical bypass for clinical success (87 versus 90 percent) with a trend to fewer adverse events (16 versus 25 percent) and recurrences (3 versus 14 percent). Duodenal obstruction often coexists with biliary obstruction, and the biliary stent should be placed first or through the enteral stent.