Self-expandable metal stents associated with higher cost and more complications vs balloon dilation for benign gastric outlet obstruction

Balloon dilation and self-expandable metal stents (SEMS) appear safe and effective in the management of benign gastric outlet obstruction (GOO), according to researchers from China. However, SEMS were associated with higher cost and more complications, are not recommended as first choice for the management of benign GOO compared to balloon dilation.

A middle-aged man was treated with balloon dilation for benign GOO due to peptic ulcer disease. (a) A pre-procedure CT showed a severe stricture and gastric retention. (b) Endoscopic view of the stricture, and the endoscope could not be passed. (c) The pathology of the biopsy tissue confirmed that it was a benign stenosis caused by inflammation, not a malignant stenosis. (d) Upper gastrointestinal radiography showed that the stenosis was located at the junction of the duodenal bulb and descending part, with a diameter of 2.8 mm and a length of 11.8 mm. (e) Balloon dilation (16 mm in diameter and 40 mm in length) was done by positioning the balloon within the stricture and inflating to its recommended diameter as long as the waist disappears. (f) Post-procedure gastrointestinal series visualized a relief of stricture. The patient had no recurrence or symptom after a follow-up of 5.6 months

The researchers stated that there are relatively few studies focusing specifically on benign GOO treatment outcomes comparing dilation and stenting. Therefore, they designed a study to evaluate the safety and efficacy of these two methods for benign GOO.

Patients with benign GOO who underwent either balloon dilation or stent placement were included in this study. GOO was confirmed via computerised tomography (CT), esophagogastroscopy and/or gastrointestinal series, with further biopsy to exclude malignant stricture if necessary.

A total of 70 patients with benign GOO were enrolled into the study between September 2019 and March 2025. Patients were divided into three groups according to the aetiology of stenosis and different treatments: Group A, only balloon dilation was used (n = 22); Group B, patients with postoperative stenosis and were treated with stenting (n = 26); Group C, patients with benign GOO except for postoperative stenosis and were treated with stenting (n = 22).

The stenting procedures were conducted under fluoroscopic and/or endoscopic guidance. The SEMS were delivered along a guidewire under fluoroscopic guidance or introduced through the therapeutic channel under the endoscopic view, and were inserted across the site of obstruction. The diameter of the SEMS was 18–22mm and the length was 60–120mm.

The four-point GOO scoring system (GOOSS) was used to score the pre-procedure and post-procedure symptoms. The stricture rate was calculated using the formula similar to previous reports [8, 9]: 100%-stricture diameter/normal diameter × 100%. Stricture is classified as mild (stricture rate 70–80%), moderate (stricture rate 80–90%) or severe stricture (stricture rate > 90%) according to the stricture rate.

Outcomes

A total of 70 patients with benign GOO were involved in this study. Except for four patients who had no significant obstruction symptoms, the remaining 66 patients had at least one significant symptoms of obstructions, including abdominal pain and/or bloating (n = 44), nausea or vomiting (n = 49), and others discomfort (n = 8). In total, 33 patients had duodenal strictures, 23 had pyloric stricture, ten had gastrojejunal anastomosis and four had efferent limb obstruction. There was no significant difference in the location of stricture between the balloon group (group A) and the stent groups (groups B and C, p=0.5644), and there was no significant difference in the cause of stricture (p=0.3427).

The technical success rates were 76.5% in group A, 87.1% in group B, and 86.7% in group C, respectively. Recurrences of stricture and stent restenosis were the main reasons for technical failures. In group A, 34 dilation procedures were performed, with a median of 1.0 dilation per patient. In group B, 31 stent procedures were performed, with a median of 1.5 stenting per patient.

GOOSS scores were compared between pre-procedure and post-procedure. No significant difference was found in GOOSS among the three groups pre-procedure (p=0.7807) and post-procedure follow-up (p=0.1201). Chi-square analyses revealed significant increase in GOOSS after procedure in all three groups, from GOOSS 1 to GOOSS 3 (p<0.05). A total of 32 patients (48.5%) were clinically cured, with the highest clinical cure rate of 68.2% in the group A (p=0.0389).

Complications were seen in 3, 12 and 6 patients in groups A, B and C respectively, with a significantly higher incidence in group B than in group A (p=0.0141).

“SEMS placement may not be a good option for benign GOO as there are no suitable stents. Uncovered stents may become difficult to be removed after long-term insertion, leading to restenosis of stent and reduced patency rate...” the authors reported. “Thus, the long-term efficacy and safety of SEMS is uncertain, with high rates of reintervention, hospital stay and healthcare costs.”

The findings were reported in the paper, ‘A real-world study of balloon dilation vs. self-expandable metal stents for benign gastric outlet obstruction’, published in BMC Gastroenterology. To access this paper, please click here