Malignant gastric outlet obstruction:Which is the best therapeutic option?

Malignant gastric outlet obstruction(MGOO)is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration,with consequent reduction or impossibility of an adequate oral intake.MGOO is mainly secondary to advanced pancreatic or gastric cancers,and significantly impacts on patients’survival and quality of life.Patients suffering from this condition often present with intractable vomiting and severe malnutrition,which further compromise therapeutic chances.Currently,palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents.Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions,at the cost of higher procedure-related risks and longer hospital stay.On the other hand,enteral stenting provides rapid clinical improvement,but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent reinterventions.Recently,a third way has come from interventional endoscopic ultrasound,through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent.This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy,and brought encouraging results so far,even if prospective comparative trial are still lacking.In this Review,we described technical aspects and clinical outcomes of the above-cited therapeutic approaches,and discussed the open questions about the current management of MGOO.

Lumen-apposing metal stents for malignant biliary obstruction: Is this the ultimate horizon of our experience?

In the last years, endoscopic ultrasonography (EUS) has evolved from a purely diagnostic technique to a more and more complex interventional procedure, with the possibility to perform several type of therapeutic interventions. Among these, EUS-guided biliary drainage (BD) is gaining popularity as a therapeutic approach after failed endoscopic retrograde cholangiopancreatography in distal malignant biliary obstruction (MBO), due to the avoidance of external drainage, a lower rate of adverse events and re-interventions, and lower costs compared to percutaneous trans-hepatic BD. Initially, devices created for luminal procedures (e.g., luminal biliary stents) have been adapted to the new trans-luminal EUSguided interventions, with predictable shortcomings in technical success, outcome and adverse events. More recently, new metal stents specifically designed for transluminal drainage, namely lumen-apposing metal stents (LAMS), have been made available for EUS-guided procedures. An electrocautery enhanced delivery system (EC-LAMS), which allows direct access of the delivery system to the target lumen, has subsequently simplified the classic multi-step procedure of EUS-guided drainages. EUS-BD using LAMS and ECLAMS has been demonstrated effective and safe, and currently seems one of the most performing techniques for EUS-BD. In this Review, we summarize the evolution of the EUS-BD in distal MBO, focusing on the novelty of LAMS and analyzing the unresolved questions about the possible role of EUS as the first therapeutic option to achieve BD in this setting of patients.

Percutaneous endoscopic gastrostomy and jejunostomy:Indications and techniques

Nutritional support is essential in patients who have a limited capability to maintain their body weight.Therefore,oral feeding is the main approach for such patients.When physiological nutrition is not possible,positioning of a nasogastric,nasojejunal tube,or other percutaneous devices may be feasible alternatives.Creating a percutaneous endoscopic gastrostomy(PEG)is a suitable option to be evaluated for patients that need nutritional support for more than 4 wk.Many diseases require nutritional support by PEG,with neurological,oncological,and catabolic diseases being the most common.PEG can be performed endoscopically by various techniques,radiologically or surgically,with different outcomes and related adverse events(AEs).Moreover,some patients that need a PEG placement are fragile and are unable to express their will or sign a written informed consent.These conditions highlight many ethical problems that become difficult to manage as treatment progresses.The aim of this manuscript is to review all current endoscopic techniques for percutaneous access,their indications,postprocedural follow-up,and AEs.