Practical guide to duodenal stenting for gastric outlet obstruction: Clinical outcomes, selection criteria, placement techniques, and management strategies

Abstract

Duodenal stenting is a widely used palliative treatment for gastric outlet obstruction (GOO) caused by unresectable malignancies. Compared to surgical gastrojejunostomy, duodenal stenting allows for earlier oral intake, shorter hospitalization, and earlier chemotherapy initiation. However, its long-term efficacy is limited by stent occlusion, which typically occurs 2-4 months post-procedure, due to tumor ingrowth, overgrowth, or food impaction. Covered stents can reduce tumor ingrowth but increase the migration risk, particularly in patients receiving chemotherapy. This review provides a comprehensive comparison of duodenal stenting, surgical gastrojejunostomy, and endoscopic ultrasound-guided gastroenterostomy, by discussing their clinical outcomes, advantages, and limitations. We further explore stent selection based on stricture characteristics, optimal placement techniques, post-procedural management, and for handling complications including occlusion, migration, bleeding, and perforation. Additionally, we address technical challenges and troubleshooting strategies, including management of guidewire-induced perforation, incomplete stent expansion, and bile duct obstruction for overlapping biliary and duodenal stricture cases. Despite its widespread clinical use, no prior review has comprehensively covered both the technical and clinical aspects of duodenal stenting so extensively. By providing a clinically oriented, practical guide, this review serves as a valuable resource for endoscopists and gastroenterologists, facilitating optimized decision-making and improved outcomes for patients with GOO in real-world practice.

Key Words: Duodenal stenting; Gastric outlet obstruction; Endoscopic management; Stent-related complications; Palliative care; Trouble-shooting

Core Tip: Duodenal stenting is a widely used palliative treatment for gastric outlet obstruction (GOO), offering early oral intake and shorter hospitalization compared to surgical bypass. However, long-term outcomes are impacted by stent occlusion, migration, and other complications. This review comprehensively compares duodenal stenting with surgical gastrojejunostomy and endoscopic ultrasound-guided gastroenterostomy, providing insights into optimal stent selection, placement techniques, post-procedural management, and troubleshooting strategies. By addressing key clinical challenges and areas requiring further research, this review serves as a practical guide to optimizing duodenal stenting for GOO in real-world practice.

INTRODUCTION

Gastric and duodenal stents are indicated for gastric outlet obstruction (GOO) caused by unresectable malignant tumors. The first report on endoscopic placement of self-expandable metal stents (SEMS) for malignant GOO was published in 1992[1]. Patients with GOO often experience persistent discomfort due to nausea, vomiting, abdominal pain, deterioration of the nutritional status leading to decreased activities of daily living, and a significant decline in quality of life due to the inability to enjoy meals[2].

The indication for duodenal stenting should be determined based on the severity of GOO symptoms rather than the degree of luminal stricture. When symptoms are present and an endoscope can still pass through the stenosis, stent placement is sometimes deferred due to concerns about migration. However, no studies have explicitly contraindicated duodenal stenting solely on the basis of endoscopic pass-ability[3,4]. A recent randomized controlled trial (RCT) targeted patients with severe GOO, defined as the inability to tolerate even liquids (GOO score = 0), but did not include the degree of stenosis as an inclusion criterion[4]. Furthermore, in cases of peritoneal carcinomatosis, impaired gastrointestinal motility and multiple bowel obstructions are likely to occur, making duodenal stenting a relative contraindication in European guidelines[5]. However, when peritoneal carcinomatosis is not the direct cause of GOO, its association with clinical failure of gastroduodenal stenting has been reported to be relatively weak[6]. As diagnosing peritoneal carcinomatosis can be challenging[7], careful assessment is required. If peritoneal dissemination is confirmed as the direct cause of GOO, stent placement should be avoided; otherwise, its indication should be cautiously considered on a case-by-case basis.

This review focused on practical clinical strategies for managing GOO, including clinical outcomes, treatment strategy, techniques for stent placement, and post-procedural management.

CLINICAL OUTCOMES

Comparison with surgical gastrojejunostomy[8]

First, we introduce the SUSTENT study[9], an RCT published in 2010. This study compared duodenal stenting and surgical gastrojejunostomy in terms of the duration of survival with a GOO scoring system (GOOSS) ≥ 2 (Table 1). The results showed that patients in the gastrojejunostomy group lived longer with GOOSS score ≥ 2 compared to the duodenal stenting group (72 days vs 50 days, P = 0.05). Additionally, the need for reintervention was higher in the duodenal stenting group. However, no significant difference was observed in overall survival between the two groups (78 days vs 56 days). Based on these findings, the study concluded that surgical gastrojejunostomy is preferable for patients with an expected survival of > 2 months[9].

Table 1 Gastric outlet obstruction scoring system.

Score	Oral intake status
0	Unable to consume orally (completely unable to eat)
1	Able to consume only liquids (only fluid diet)
2	Able to consume semi-solid foods (e.g., soup, yogurt)
3	Able to consume normal diet (no dietary restrictions)

An observational study[10] reported no significant differences between SEMS placement and surgical gastrojejunostomy in terms of the technical and clinical success rates or the incidence of early adverse events. However, the median duodenum patency duration was significantly shorter in the SEMS group than in the surgical gastrojejunostomy group (125 days vs 282 days, P = 0.001). Even when additional stenting was performed, the patency duration remained inferior to that of surgical bypass (210 days vs 282 days, P = 0.044). The median overall survival was also significantly shorter in the SEMS group than in the surgical bypass group (189 days vs 293 days, P = 0.003). Given the nature of observational study designs, patients with better performance status (PS) were more likely to undergo surgical gastrojejunostomy, which may have led to favorable outcomes in the surgery group. However, when survival was analyzed according to PS in the same study[10], a significant difference was observed among patients with PS 0-1 (P = 0.006), whereas no significant difference was found in patients with PS 2 (P = 0.208). Based on these findings, it was concluded that for patients with good PS (Eastern Cooperative Oncology Group 0-1), surgical bypass is preferable to SEMS placement for palliative treatment of GOO.

These two previous studies suggest that for patients with a PS of ≥ 2 or with an expected survival of < 2 months, surgical bypass does not demonstrate a clear advantage over duodenal stenting. Therefore, duodenal stenting is an appropriate treatment option for these patients.

A meta-analysis[11] reported that while postoperative mortality and major complication rates were comparable between the two groups, patients who underwent duodenal stenting were able to resume oral intake approximately 5 days earlier, and their hospital stay was approximately 10 days shorter compared to those of patients who underwent surgical gastrojejunostomy. Based on these findings, duodenal stenting is often preferred for patients with poor general condition in Japan.

Additionally, we introduce a statement by the American Society of Gastrointestinal Endoscopy (ASGE) regarding the choice between duodenal stenting and surgical bypass. ASGE acknowledges that providing definitive evidence favoring one approach over the other is difficult; however, they suggest using a 6-month survival threshold as a guideline. This recommendation considers both short-term benefits-such as shorter hospitalization, earlier oral intake, and faster initiation of chemotherapy-and long-term considerations, such as the need for reintervention[12]. For patients with an expected survival of 2-3 months, surgical bypass may increase the total time spent in the hospital, including follow-up visits, potentially reducing the time patients can spend enjoying their remaining life. Therefore, while treatment decisions should be tailored to individual cases, we generally follow a similar approach to ASGE and consider surgical gastrojejunostomy for patients with an expected survival of approximately 6 months or longer.

Comparison with endoscopic ultrasound-guided gastroenterostomy

Observational studies have reported that endoscopic ultrasound-guided gastroenterostomy (EUS-GE)[8] is associated with a lower rate of stent dysfunction requiring reintervention, compared to duodenal stenting (8.3% vs 32.0%, P = 0.021[13]; 4% vs 27%, P = 0.015[14]). Additionally, EUS-GE has been shown to have a higher initial clinical success rate (96% vs 76%). Other advantages of EUS-GE include a lower incidence of stent occlusion and fewer adverse events. However, hospitalization duration and technical success rates were comparable between the two methods[14]. A meta-analysis published in 2024 reported that EUS-GE had a higher clinical success rate, a longer total procedure time, a lower reintervention rate, and a lower risk of adverse events than those with duodenal stenting[15]. However, technical success rates and hospitalization duration were similar between the two groups.

The lower reintervention rate observed with EUS-GE may be attributed to the use of shorter lumen-apposing metal stents (LAMS), which allow for easier passage of food compared to duodenal stents[16]. Moreover, LAMS are placed in healthy tissue away from the tumor and can fully expand to their maximum diameter, whereas duodenal stents are more likely to be compressed by the tumor, limiting their expansion, and are also prone to ingrowth and overgrowth[17].

Based on these findings, EUS-GE appears to have superiority over duodenal stenting. Globally, EUS-GE is increasingly being recognized as a treatment option for malignant GOO. For example, the European Society of Gastrointestinal Endoscopy recommends the use of electrocautery-enhanced LAMS for EUS-GE and acknowledges the procedure as a viable therapeutic option[18]. However, in Japan, EUS-GE is not covered by the national health insurance and is currently performed only in select institutions with the approval of an ethics committee.

CLINICAL FEATURES OF DUODENAL STENT AND STRATEGY FOR PLACEMENT

The general outcomes of duodenal stenting have been reported in several studies, some of which overlap with the previously mentioned comparisons between surgical bypass and EUS-GE. The reported rates include a technical success rate of 96%, a clinical success rate of 89%, and a solid food intake rate ranging from 77% to 86%[19-21]. There are two main types of duodenal stents: Uncovered and covered stents.

Uncovered stents

Uncovered stents provide better tissue fixation, reducing the risk of migration. They are also more flexible, allowing for better adaptability to the natural curvature of the duodenum[22]. Additionally, uncovered stents permit bile flow through the stent interstices, minimizing the risk of bile duct obstruction[22].

Covered stents

The primary advantage of covered stents is the prevention of tumor ingrowth. However, they have a higher risk of migration, which can lead to intestinal obstruction requiring surgical intervention[23]. Covered stents are also relatively rigid and more expensive compared to uncovered stents[23].

Two RCTs comparing covered and uncovered stents reported no significant difference in duodenal patency after stent placement[24,25]. The studies indicated the following differences in the re-occlusion mechanisms between the two types: Covered stents had a higher incidence of migration, whereas uncovered stents had a higher incidence of tumor ingrowth. Additionally, covered stents were associated with a higher risk of biliary obstruction. Consequently, the reintervention rate was similar between the two groups[26].

Therefore, when choosing between covered and uncovered stents, the standard approach is to use uncovered stents to prevent migration. For patients scheduled to receive chemotherapy, uncovered stents are preferred, as chemotherapy may increase the risk of stent migration[27]. For patients with tumor bleeding or those requiring additional stenting due to ingrowth-related occlusion, covered stents should be considered[28]. Several case reports have demonstrated the hemostatic efficacy of covered stents[29]. In patients with malignant duodenal obstruction complicated by tumor bleeding, where interventional radiology or surgical intervention is not feasible, covered stents may be a reasonable option. To prevent covered stent migration, the OTSC^® STENTFIX (Ovesco Endoscopy AG, Tübingen, Germany) has been reported to be effective[30,31].

Two important mechanical properties of stents are radial force (RF) and axial force (AF). RF enables expansion and maintenance of stent patency, preventing the recurrence of GOO[8]. AF on the other hand, is the longitudinal force that attempts to straighten the stent after deployment. While high RF is essential for effective decompression, excessive AF, especially in angulated segments, can contribute to adverse events such as kinking or even perforation[32].

These properties are determined by the structural design of the stent wires. Stents can be broadly classified into: (1) Braided stents, in which wires are woven together; and (2) Laser-cut stents, in which a cylindrical metal tube is perforated with a laser to create the stent structure.

Currently, only the braided type is available for duodenal stents. Braided stents can be further categorized based on their weaving pattern into cross type, cross and hook type, and hook type. An increase in the proportion of cross wires results in a higher AF, while RF remains largely unaffected[33,34].

In biliary stents, a high AF has been associated with an increased incidence of kinking, and in coronary stents, a high AF has been reported as a significant predictor of major adverse events[34,35]. For duodenal stents, particularly when placed in highly angulated regions, selecting a stent with a low AF is considered important to prevent perforation and kinking[32,36,37]. These findings suggest that clinically, stents with a lower AF are preferable. A summary of the characteristics of various non-covered duodenal stents is presented in Table 2.

Table 2 Summary of the characteristics of various non-covered duodenal stents.

Product name	Manufacturer	Structure	Shape	Stent outer diameter	Re-sheath-ability1
Niti-S pyloric & duodenal stent	Century Medical	Hook	Straight	22 mm	No
JENTLLY NEO duodenal stent	Japan Lifeline	Cross and hook	Straight	22 mm	No
HANAROSTENT Naturfit duo	Boston Scientific	Cross and hook	Straight	22 mm	Yes
WallFlex duodenal soft	Boston Scientific	Cross	Partial flare	Body: 22 mm, Flare: 27 mm	Yes
Evolution duodenal stent	Cook Medical	Cross	Double flare	Body: 22 mm, Flare: 27 mm	Yes

¹Re-sheathability refers to the capability of stent withdrawal into the delivery system after partial deployment, allowing repositioning if necessary.

BASIC TECHNIQUES AND CONSIDERATIONS FOR GASTRIC AND DUODENAL STENT PLACEMENT

The first step in the procedure is the evaluation of the gastric and duodenal strictures. This assessment is performed using endoscopic examination with water-soluble contrast agents, which allows for the evaluation of the degree of obstruction, stricture length, and angulation[8].

In the past, multiple duodenal strictures were considered a contraindication for stenting; however, recent advancements have enabled the placement of duodenal stents in such cases[38,39]. Additionally, if the occlusion is within the reach of a small bowel endoscope, technical feasibility for stent placement is possible[40].

Determining the optimal stent length relative to the stricture is challenging, as it is influenced by stent shortening rate and AF, which affect flexibility and adaptability to angulation. Therefore, establishing a standardized guideline is difficult. However, according to previous reports and the Mini-Guidelines published by the Colorectal Stent Safety Technical Study Group, it is generally recommended, to ensure that at least 2-3 cm of stent extends beyond the obstructed segment[41,42]. For high AF stents (cross type), a longer stent length results in greater straightening of angulated segments over an extended distance. As perforation at the stent end is a concern, shorter stents are preferred for the cross type designs. For low AF stents (hook and cross type), at least 2 cm of stent should extend beyond both proximal and distal ends of the stricture. Considering potential positional shifts during placement, longer stents are generally recommended for these designs[41,42]. For low AF stents, a slightly longer stent does not significantly increase the risk of perforation, based on clinical experience. If the stent has the same weaving pattern, AF decreases as the stent length increases[34,43]. Referring to these previous reports, we opt for stents with a weaving pattern that does not exert excessive AF and choose the stent length based on the "at least 2 cm extension on both sides of the stricture" guideline to prevent excessive stress on the angulated stricture or stent edges.

One important consideration is the placement of the proximal stent end in the duodenal bulb. This positioning is associated with an increased risk of obstruction due to food impaction and a higher likelihood of perforation due to the stent edge[32,42,44]. Although no cases of perforation have been observed at our institution in patients with proximal stent placement in the duodenal bulb, avoiding this placement whenever possible is advisable. Stent shortening must also be considered when determining the placement position. The shortening rate of duodenal stents varies by manufacturer; however, in Japan, it is generally considered to be around 25%-50%. This evidence should be carefully taken into account when planning stent placement.

Very few reports detail the actual technique for duodenal stent placement. At our institution, we use the half-and-half technique, which we published in Digestive Endoscopy in 2024[40]. The procedure begins by advancing the endoscope towards the stricture site, injecting contrast medium through a catheter, and confirming the extent of the stricture. At this stage, a 1-2 cm gap between the proximal side of the stricture and the endoscope can facilitate a measurement (Figure 1A). Next, the endoscope is advanced closer to the stricture to enhance scope stability (Figure 1B). As the endoscope tip is positioned at the proximal side of the stricture, marking clips are unnecessary. The stent delivery system is then advanced, and the central marker is aligned with the stricture. The stent placement is initiated with approximately half of the stent remaining inside the endoscope channel; this is the half-and-half technique. The stent is partially deployed within the endoscope but not fully expanded at this stage. The stent is then fully released by simultaneously pushing out the delivery system while withdrawing the endoscope, ensuring that the stent remains in its intended position (Figure 1C). The half-and-half technique is further explained through video demonstrations in a previously published article[40].

Figure 1 Half-and-half technique. A: The technique begins by advancing the endoscope towards the stricture site, injecting contrast medium through a catheter, to confirm the extent of the stricture. At this stage, a 1-2 cm gap between the proximal side of the stricture and the endoscope can facilitate a measurement; B: The endoscope is advanced closer to the stricture to enhance scope stability. Since the endoscope tip is positioned at the proximal side of the stricture, marking clips are unnecessary; C: The stent delivery system is then advanced, and the central marker is aligned with the stricture. The stent placement is initiated with approximately half of the stent remaining inside the endoscope channel. The stent is partially deployed within the endoscope but is not fully expanded at this stage. The stent is then fully released by simultaneously pushing out the delivery system while withdrawing the endoscope, ensuring that the stent remains in its intended position.

This half-and-half technique allows for stable endoscope positioning while utilizing the working channel to deploy the stent, effectively preventing stent jumping. The technique also facilitates accurate stent placement even in challenging situations, such as during stent deployment using a balloon-assisted enteroscope.

POSTOPERATIVE MANAGEMENT AND COMPLICATION RESPONSE

Postoperative management

As full stent expansion takes approximately 24-48 hours, performing an abdominal plain X-ray during this period to assess expansion and potential stent migration can provide reassurance[8].

As discussed in the section on surgical bypass, duodenal stenting allows for an earlier resumption of oral intake, typically 5 d earlier than that in surgical bypass cases[11]. In one study, the median time to liquid intake was less than 1 day (0-3 days) in the duodenal stenting group compared to 2 days (1-24 days) in the surgical bypass group. The time to tolerating a regular diet was 2 days (0-5 days) in the duodenal stenting group vs 6.5 days (1-10 days) in the surgical bypass group[45]. This suggests that patients undergoing duodenal stenting can begin liquid intake the day after the procedure and consider progression to a regular diet within approximately 2 days. Given that duodenal stents fully expand within 24-48 hours[8], theoretically, advancing to a regular diet beyond day 2 is feasible. However, as previously mentioned, the solid food intake rate is approximately 80%, meaning that not all patients will tolerate a regular diet. Therefore, dietary guidance and goal setting should be individualized. Particularly, in cases with peritoneal dissemination, ascites, or poor PS, intestinal motility is often reduced, making clinical success less likely[7]. Therefore, before discharge, patients should transition from liquids to solids within their tolerated limits, and they should be advised to avoid leafy vegetables, which may increase the risk of stent occlusion[46].

Management of complications

The major complications associated with duodenal stenting include perforation, bleeding, stent migration, and stent occlusion[19]. We present the general outcomes of gastroduodenal stenting, with a particular focus on complications[19] (Table 3).

Table 3 Clinical outcomes of gastroduodenal stenting.

Technical success	Clinical success	Bleeding	Perforation	Obstruction	Migration	Median stent patency duration
97.3%	85.7%	4.1% (severe 0.8%)	1.2%	12.6%	4.3%	68-307 days

Stent occlusion occurs in approximately 15% of cases and is primarily caused by tumor ingrowth, overgrowth, or food impaction[19]. As mentioned in the comparison with surgical bypass, occlusion-related symptoms often appear after 2-4 months, necessitating careful follow-up for stent occlusion[9,10]. In general, placement of an additional stent is the standard management approach, with clinical outcomes comparable to the initial stent placement, making it a reasonable salvage option[47,48].

Incomplete stent expansion may lead to food impaction. In such cases, balloon dilation may be required[49]. When food impaction occurs due to incomplete stent expansion, endoscopic removal of the impacted food should be performed first. Subsequently, balloon dilation can be carefully attempted, with close attention to the risks of perforation, bleeding, and migration. In such cases, deferring additional stent placement may also be considered.

In cases of tumor ingrowth, a covered stent is often placed as an additional stent. However, this increases the risk of stent migration, which may lead to early re-occlusion of the duodenum. Therefore, the superiority of covered vs uncovered stents has not been conclusively demonstrated[50].

Chemotherapy has been reported to reduce the risk of stent occlusion but may also increase the risk of migration, particularly with covered stents, potentially leading to a shorter stent patency duration[21,27,51]. While chemotherapy reduces the risk of tumor ingrowth, it also lowers the tension exerted on the stent, making migration more likely. If a stent migrates, endoscopic retrieval should be attempted, whenever possible, to prevent intestinal obstruction or perforation caused by the dislodged stent[52].

Incidentally, the effectiveness of argon plasma coagulation (APC) in ablating ingrowth-related dysfunction of duodenal stents has been reported[53]. The evidence is currently limited to case reports, further research and accumulation of clinical data are warranted.

Perforation and major bleeding occur in approximately 1% of cases[20,54].

Post-stent perforation is believed to result from mechanical irritation at the stent edges[32]. Therefore, when placing a stent in an angulated region, selecting a stent with a lower AF and greater flexibility is recommended to enhance adaptability and reduce the risk of perforation[32]. In cases of minor perforation, conservative management is feasible if a follow-up computed tomography (CT) shows no fluid collection or contrast leakage. However, if there is a major perforation caused by the endoscopic instrumentation, or if fluid collection is identified in the retroperitoneal space on CT, surgical intervention should be considered[55,56].

As reported, bleeding occurs more frequently with uncovered stents compared to covered stents although bleeding after duodenal stent placement is rare[19]. While covered stents have shown hemostatic efficacy in several cases of tumor-related duodenal bleeding[29,57-59], this effect may be limited in cases of massive arterial bleeding, particularly when an uncovered stent has already been deployed. In such situations, the added covered stent may fail to sufficiently compress the bleeding site[60]. Moreover, conventional endoscopic hemostasis techniques such as clipping are often impractical through an indwelling stent. Although the evidence is limited, it is generally considered that minor bleeding may be controlled with the placement of a covered stent or transcatheter arterial embolization (TAE), while TAE is preferred in cases of major bleeding[60].

TROUBLESHOOTING (MANAGING DIFFICULT SITUATIONS DURING THE PROCEDURE)

No specific studies focus on the management of guidewire-induced perforation during duodenal stent placement. However, reports indicate that minor duodenal perforations occurring during endoscopic retrograde cholangiopancreatography can be managed conservatively[61,62]. Additionally, studies suggest that if follow-up CT after perforation shows no fluid collection or contrast leakage, conservative treatment is feasible[55,56]. Based on these findings, if a pinpoint perforation occurs due to a guidewire, proceeding with duodenal stent placement and closely monitoring the patient with follow-up CT may be a viable approach. If fluid collection in the retroperitoneal space is detected, surgical intervention should be considered[55,56]. There is a lack of research regarding nasogastric tube (NGT) placement and the timing of oral intake in cases where emergency surgery is not indicated, making it difficult to establish a standardized approach. From a limited number of existing reports, if contrast leakage is evident during the procedure, or if the patient develops abdominal pain, or CT reveals fluid collection after the procedure, NGT placement and a prolonged fasting period should be considered. However, in asymptomatic patients without fluid collection, omitting NGT placement and initiating oral intake the day after the procedure may be reasonable[55,56].

Most cases are performed using a therapeutic gastroscope for stent placement; however, in situations involving gastric dilation or distal duodenal strictures, the use of a colonoscope or a side-viewing duodenoscope may facilitate the procedure[63,64]. Furthermore, with a duodenoscope, the use of grasping forceps can also ease the stent placement process.

Stent placement is technically feasible even in cases of multiple duodenal strictures. However, with three or more strictures, the likelihood of clinical failure increases, and placing two stents during the same session further elevates the risk of perforation[38]. Therefore, in such cases, the indication for duodenal stenting should be determined with caution.

Although balloon dilation for incomplete stent expansion is rarely performed in malignant gastrointestinal strictures in recent years, balloon dilation is still required in some cases, as noted in the complications section[49]. Reports published before 2000 indicated that balloon dilation was considered safe for malignant esophageal strictures[65,66].

In cases where biliary obstruction coexists with duodenal stenosis, and the ampulla is near the duodenal stricture, the duodenal stent may cover the ampulla. In such patients, the biliary stent should be placed first, extending approximately 7-8 mm beyond the ampulla. The duodenal stent is then deployed with the biliary stent positioned in a side-to-end alignment. This strategy is designed to facilitate transpapillary re-intervention for biliary drainage[67]. However, if the distal end of the biliary stent is positioned above the duodenal stent or does not extend beyond the distal end of the duodenal stent, the risk of early biliary stent occlusion increases[68,69]. Therefore, in patients with close proximity between the ampulla and the duodenal stricture, an alternative strategy to prolong biliary stent patency without considering transpapillary re-intervention can be adopted. Specifically, in the initial session, the distal end of the transpapillary biliary stent should extend beyond the distal end of the duodenal stent, with EUS-guided drainage considered a viable strategy in cases of biliary stent occlusion[68].

CONCLUSION

Throughout this review, we have compared the outcomes of duodenal stenting for GOO with surgical bypass and EUS-GE, providing a comprehensive framework for optimizing treatment strategies. Furthermore, for cases in which duodenal stenting is selected, we have discussed stent selection based on stricture characteristics, placement techniques, post-procedural management, complication handling, and troubleshooting strategies for technical challenges during the procedure.

To the best of our knowledge, no previous review has compiled these aspects with this level of detail in a single paper. Recognizing this gap, we aimed to provide a practical, clinically oriented review to guide decision-making in real-world practice. Additionally, we identified several areas requiring further research, including the appropriateness of stent placement considering both GOO symptoms and the degree of luminal stenosis, strategies for managing guidewire-induced perforations, the safety of balloon dilation as an adjunct for incomplete stent expansion, and rescue treatment of duodenal stent occlusion due to tumor ingrowth using APC. We hope this review will be a valuable resource for endoscopists and clinicians, fostering advancements in GOO management and guiding future clinical research.