Gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries and contributes significantly to high morbidity and mortality
[1–6]. This study was conducted in our environment to describe our own experiences in the management of this challenging disease; the problem not previously studied at our centre or any other hospital in the country. In this review, the highest age incidence of the patients at presentation was in the fourth decade of age and males were more affected. Most of the patients with benign gastric outlet obstruction in our study were in younger age group while malignant causes were in elder age group. The incidence of malignant gastric outlet obstruction in patients of older age group was also reported by others
[1, 7, 13]. Our demographic profile is in sharp contrast to what is reported in other studies
[6, 9] where the majority of the patients are in the fifth and sixth decade of life. This discrepancy in age incidence may be attributed to by the large number of children in the current study. We could not establish the reasons for the male predominance.
Gastric outlet obstruction has been reported to be more prevalent in people with low socio-economic status
. This is reflected in our study where most of patients had either primary or no formal education and more than seventy-five percent of them were unemployed. The majority of patients in the present study came from the rural areas located a considerable distance from the study area and more than eighty percent of them had no identifiable health insurance. Similar observation was reported by others
[6, 13]. This observation has an implication on accessibility to health care facilities and awareness of the disease.
The majority of patients in this study had malignant gastric outlet obstruction which is in agreement with other studies reported elsewhere
[1, 3–5], but at variant with Kolisso
 in Ethiopia who reported benign gastric outlet obstruction (peptic ulcer disease) as the most common cause of gastric outlet obstruction. In our study, gastric cancer was the commonest cause of malignant gastric outlet obstruction while peptic ulcer disease was the commonest benign cause. This is keeping with other studies which reported similar etiological pattern
[1, 13, 14]. The predominant causes of gastric outlet obstruction have changed substantively with the identification of Helicobacter pylori and the use of proton pump inhibitors. Until the late 1970s, benign disease was responsible for the majority of cases of gastric outlet obstruction in adults, while malignancy accounted for only 10 to 39 percent of cases
[2, 13]. By contrast, in recent decades, 50 to 80 percent cases have been attributable to malignancy
[2, 13, 15, 16].
The clinical presentation of gastric outlet obstruction in our patients is not different from those in other studies
[2–7], with non-bilious vomiting being common to all the patients. In keeping with other studies
[6, 16], the majority of our patients had symptoms of more than 6 months duration at the time of presentation. Late presentation in our study may be attributed to lack of accessibility to health care facilities and lack of awareness of the disease. It is worth noting that seventeen (18%) of our gastric outlet obstruction patients secondary to complicated peptic ulcer had no previous history of ulcer symptoms prior to the onset of illness. Patients with no previous diagnosis of peptic ulcer have a higher risk of developing complications such as gastric outlet obstruction than patients with a known history of ulcer disease. This may be because preventative measures are more likely to have been taken in patients with a known history of peptic ulcer disease. Furthermore, these patients are perhaps more likely to seek treatment earlier.
The presence of co-existing medical illness has been reported elsewhere to have an effect on the outcome of patients with gastric outlet obstruction
. This is reflected in our study where patients with co-existing medical illness had significantly high mortality rate.
The prevalence of HIV infection in the present study was 9.8%, a figure that is significantly higher than that in the general population in Tanzania (6.5%)
. This difference was statistically significant (P < 0.001). However, failure to detect HIV infection during window period and exclusion of some patients from the study may have underestimated the prevalence of HIV infection among these patients. We could not establish the reason for the high HIV seroprevalence in our study population and we could not find any literature regarding the effect of HIV infection on the etiology and outcome of patient with gastric outlet obstruction. This calls for a need to research on this observation. In this study, HIV infection was found to be associated with poor postoperative outcome. This observation calls for routine HIV screening in patients with gastric outlet obstruction.
In agreement with other studies
[1, 6], the diagnosis of gastric outlet obstruction in this study was based on clinical presentation, an upper gastrointestinal barium study, and/or an inability during upper endoscopy to intubate the second portion of the duodenum (upper gastrointestinal endoscopy) and confirmed by histology and intra-operative findings. Other diagnostic investigations included abdominal ultrasound and computerized tomography (CT) scan.
The treatment of gastric outlet obstruction depends on the cause, but is usually either surgical or medical. In most patients with peptic ulcer disease, the edema will usually settle with conservative management with nasogastric suction, replacement of fluids and electrolytes and proton pump inhibitors
. Surgery is indicated in cases of gastric outlet obstruction in which there is significant obstruction and in cases where medical therapy has failed
[8, 18]. In the current study, gastro-jejunostomy was the most frequent type of surgical procedure performed. This is in line with other studies done elsewhere
[19–21]. The high rate of gastro-jejunostomy in our study is attributed to the large number of patients with malignant gastric outlet obstruction. Traditionally, malignant gastric outlet obstruction has been treated surgically, usually by creating a gastro-jejunostomy. More recently, the use of endoscopically placed self-expandable metal stents (SEMS) has become a routine practice
[9, 10]. However, this procedure was not popular in our study due to lack of this facility in our centre.
The presence of complications has an impact on the final outcome of patients presenting with gastric outlet obstruction
. In our review, the postoperative complication rate was 32.1%, a figure which is higher than that reported by other authors
[22, 23]. In agreement with other studies
[6, 22, 23], surgical site infection was the most common postoperative complications in the present study. High rate of surgical site infection in this study may be attributed to HIV seropositivity and low CD 4 count.
The overall median duration of hospital stay in the present study was 14 days which is higher than that reported by Kolisso
 in Ethiopia. This can be explained by the presence of large number of patients with postoperative complications in our study. However, due to the poor socio-economic conditions in Tanzania, the duration of inpatient stay for our patients may be longer than expected. Prolonged duration of hospital stay has an impact on hospital resources as well as on increased cost of health care, loss of productivity and reduced quality of life.
The overall mortality rate in this study was 18.5% and it was significantly associated with the age > 60 years, co-existing medical illness, malignant cause, HIV positivity, low CD 4 count (<200 cells/μl), high ASA class and presence of surgical site infection. Addressing these factors responsible for high mortality in our patients is mandatory to be able to reduce mortality associated with this disease.
Self discharge by patient against medical advice is a recognized problem in our setting. Similarly, poor follow up visits after discharge from hospitals remain a cause for concern. These issues are often the results of poverty, long distance from the hospitals and ignorance and need to be addressed.
Delayed presentation and the large number of loss to follow up were the major limitations in this study. However, despite these limitations, the study has provided local data that can be utilized by health care providers to plan for preventive strategies as well as establishment of management guidelines for these patients. The challenges identified in the management of patients with gastric outlet obstruction in our environment need to be addressed, in order to deliver optimal care for these patients.