Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction:A case report and review of literature

BACKGROUND Mycobacterium tuberculosis(TB)is the causative agent of TB,a chronic granulo-matous illness.This disease is prevalent in low-income countries,posing a significant global health challenge.Gastrointestinal TB is one of the three forms.The disease can mimic other intra-abdominal conditions,leading to delayed diagnosis owing to the absence of specific symptoms.While gastric outlet obs-truction(GOO)remains a frequent complication,its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy.Gastroduodenal TB can cause upper gastrointestinal hemorrhage,obstruction,and malignancy-like tumors.CASE SUMMARY A 23-year-old male presented with recurrent epigastric pain,distension,nausea,vomiting,and weight loss,prompting a referral to a gastroenterologist clinic.Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation.However,treatment was interrupted,possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes.Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall.Resection revealed gastric wall effacement with TB.CONCLUSION Primary gastric TB is rare,frequently leading to GOO.Given its rarity,suspicions should be promptly raised when encountering relevant symptoms,often requiring surgical intervention for diagnosis and treatment.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.

Transoral outlet reduction:Outcomes of endoscopic Roux-en-Y gastric bypass revision in 284 patients at a community practice

BACKGROUND Transoral outlet reduction(TORe)is a minimally invasive endoscopic revision of Roux-en-Y gastric bypass(RYGB)for weight recurrence;however,little has been published on its clinical implementation in the community setting.AIM To characterize the safety and efficacy of TORe in the community setting for adults with weight recurrence after RYGB.METHODS This is a retrospective cohort study of argon plasma coagulation and purse-string suturing for gastric outlet reduction in consecutive adults with weight recurrence after RYGB at a single community center from September 2020 to September 2022.Patients were provided longitudinal nutritional support via virtual visits.The primary outcome was total body weight loss(TBWL)at twelve months from TORe.Secondary outcomes included TBWL at three months and six months;excess weight loss(EWL)at three,six,and twelve months;twelve-month TBWL by obesity class;predictors of twelve-month TBWL;rates of post-TORe stenosis;and serious adverse events(SAE).Outcomes were reported with descriptive statistics.RESULTS Two hundred eighty-four adults(91.9%female,age 51.3 years,body mass index 39.3 kg/m^(2))underwent TORe an average of 13.3 years after RYGB.Median pre-and post-TORe outlet diameter was 35 mm and 8 mm,respectively.TBWL was 11.7%±4.6%at three months,14.3%±6.3%at six months,and 17.3%±7.9%at twelve months.EWL was 38.4%±28.2%at three months,46.5%±35.4%at six months,and 53.5%±39.2%at twelve months.The number of follow-up visits attended was the strongest predictor of TBWL at twelve months(R^(2)=0.0139,P=0.0005).Outlet stenosis occurred in 11 patients(3.9%)and was successfully managed with endoscopic dilation.There was one instance of post-procedural nausea requiring overnight observation(SAE rate 0.4%).CONCLUSION When performed by an experienced endoscopist and combined with longitudinal nutritional support,purse-string TORe is safe and effective in the community setting for adults with weight recurrence after RYGB.

Outcomes of Transcatheter Closure in Outlet-Type Ventricular Septal Defect after 1 Year

Background:Ventricular septal defect(VSD)is the most common congenital heart disease.Transcatheter VSD closure is an effective treatment for patients with muscular and perimembranous VSD.However,there is a limit data for outlet VSD,especially impact to the aortic valve leaflet after transcatheter closure.This study aims to assess the outcomes of transcatheter closure of the outlet-type ventricular septal defect(OVSD)after 1 postoperative year.Methods:A retrospective study was performed including 50 patients who underwent transcatheter(n=25)and surgical(n=25)OVSD closure during the exact time frame at two medical centres.Results:The median age and body weight of patients in the transcatheter group were significantly higher than those of patients in the surgical group(7.0 vs.2.8 years;27.0 vs.11.4 kg;p<0.01).The defect size in the surgical group was significantly larger than that in the transcatheter group(5.0 vs.3.0 mm;p<0.01).All OVSD patients have successful transcatheter closure(100%)as effective as surgical closure.Less than small residual shunt was present 20%and 8%immediately after the procedure in the transcatheter and surgical groups(p=0.50),which decreased to 12%and 4%at the 1-year follow-up(p=0.61),respectively.No incidence of complete atrioventricular block and other complications was observed in both groups,and no significant differences were noted in the new onset or worsening of the aortic regurgitation in both groups(p=1.0).Conclusions:Transcatheter treatment could be effectively and safely achieved for OVSD closure at 1-year follow-up.

Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report

BACKGROUND Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer(GC)in the middle-or lower-third regions with gastric outlet obstruction(GOO).Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy.This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy(SPGJ)for obstruction relief,in a patient with GOO.CASE SUMMARY During the initial esophagogastroduodenoscopy,an advanced growth was detected in the lower part of the stomach,which caused an obstruction in the pyloric ring.Following this,a computed tomography(CT)scan revealed the presence of lymph node metastases and tumor invasion in the duodenum,but no evidence of distant metastasis was found.Consequently,we performed a modified SPGJ,a complete laparoscopic SPGJ combined with No.4sb lymph node dissection,for obstruction relief.Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab(programmed death ligand-1 inhibitor)were administered thereafter.A preoperative CT showed partial response;therefore,completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy,and pathological complete remission was achieved.CONCLUSION Laparoscopic SPGJ combined with No.4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Is there a correlation between the outcome of transurethral resection of prostate and preoperative degree of bladder outlet obstruction？

To compare the impact of transurethral resection of prostate （TURP） on symptom scores and maximal flow rates （Qmax） in patients with equivocal bladder outlet obstruction （BOO） and definite BOO and to assess the relationship between the surgical outcomes and degree of preoperative BOO, we prospectively evaluated men with lower urinary tract symptoms and bladder outlet obstruction index （BOO1） greater than 20, who were refractory to conventional medical treatment and underwent TURP. Urodynamic evaluation, International Prostate Symptom Score （IPSS）, uroflowmetry, post-void residual volume （PVR） check and transrectal ultrasound were performed. 20〈B001〈40 was defined as equivocal BOO and BOO1 〉~40 as definite BOO. Changes of IPSS, Qmax, PVR and correlation analysis was performed between the degree of improvement of Qmax, subdomains of I PSS and BOO1. Fifty-four patients showed equivocal BOO and 80 patients showed definite BOO. Preoperatively equivocal BOO group and definite BOO group showed significant differences in maximal bladder capacity and prevalence of detrusor overactivity, whereas no difference was noted in prostate volume. Postoperatively both groups showed improvements in Qmax, obstructive （IPSSO） and irritative （IPSSI） subdomain of IPSS, but the degree of improvement in Qmax and IPSSI subdomain was statistically significantly greater in definite BOO group. The degree of improvement of Qmax and IPSSI showed weak correlation with preoperative BOO1. As a weak correlation was identified between preoperative degree of BOO and outcome of TURP, other factors other than BOO1 such as severity of patients＇ symptoms should be considered in deciding treatment modality.

中国OUTLETS零售业态经营模式探析

OUTLETS是当代较为流行的零售业态之一,在中国有很大的市场容量,但同时也对目前的零售业格局形成一定影响。本文首先介绍了OUTLETS的形成和经营特点;其次论述了OUTLETS在中国产生的背景,分析了目前中国OUTLETS的经营现状及存在问题;最后,在分析当前中国零售业经营环境的基础上,从宏观和微观两个层面探讨了OUTLETS的经营战略和策略。

美国纯数字新闻业的崛起——从News Organization到News Outlet

美国纯数字新闻业从2005年起迅速崛起,该行业在新闻理念、采编技术、受众行为、职业技能等方面都在影响和改变着美国的新闻业态。皮尤研究中心从2014年起在新闻业年度报告中对该行业进行单独分析,甚至对"新闻机构"的称谓也引入了"News Outlet"这个新词。鉴于美国纯数字新闻业巨大的商业潜力,一些商业巨头和传统媒体集团不断注入新的投资,但该行业目前两极分化严重,多数是投资大于回报,该行业模式是否会成为新闻业的一个新商业模式尚无定论。

Safe Power Outlet

The main goal of the safe power outlet project is to make power outlets smart and integrate it to all old and new electrical wiring of homes and offices to eliminate the costs.Using the designed socket,home and office electrical appliances can be smarten and controlled remotely through wireless technology.The device designed in this project,is a smart power outlet that supports Wi-Fi connection and the user can connect directly to it and control it by the specific mobile application.There is no need for any other interfaces such as a modem or router,and the user can connect directly to the device.This is the innovative part of the project making it different from the conventional power outlets on the market.All home and office appliances running on AC power can be connected to a safe outlet directly and without an interface;they can be controlled via wireless network by mobiles.This device smartens all old and conventional outlets without making any changes in wiring.It also enables the control via Wi-Fi on the outlets.

Procedure for prolapse and hemorrhoids vs traditional surgery for outlet obstructive constipation

AIM: To compare the clinical efficacies of two surgical procedures for hemorrhoid rectal prolapse with outlet obstruction-induced constipation.METHODS: One hundred eight inpatients who underwent surgery for outlet obstructive constipation caused by internal rectal prolapse and circumferential hemorrhoids at the First Affiliated Hospital of Xinjiang Medical University from June 2012 to June 2013 were prospectively included in the study.The patients with rectal prolapse hemorrhoids with outlet obstructioninduced constipation were randomly divided into two groups to undergo either a procedure for prolapse and hemorrhoids(PPH)(n = 54) or conventional surgery(n = 54; control group).Short-term(operative time,postoperative hospital stay,postoperative urinary retention,postoperative perianal edema,and postoperative pain) and long-term(postoperative anal stenosis,postoperative sensory anal incontinence,postoperative recurrence,and postoperative difficulty in defecation) clinical effects were compared between the two groups.The short- and long-term efficacies of the two procedures were determined.RESULTS: In terms of short-term clinical effects,operative time and postoperative hospital stay were significantly shorter in the PPH group than in the control group(24.36 ± 5.16 min vs 44.27 ± 6.57 min,2.1 ± 1.4 d vs 3.6 ± 2.3 d,both P < 0.01).The incidence of postoperative urinary retention was higher in the PPH group than in the control group,but the difference was not statistically significant(48.15% vs 37.04%).Theincidence of perianal edema was significantly lower in the PPH group(11.11% vs 42.60%,P < 0.05).The visual analogue scale scores at 24 h after surgery,first defecation,and one week after surgery were significantly lower in the PPH group(2.9 ± 0.9 vs 8.3 ± 1.1,2.0 ± 0.5 vs 6.5 ± 0.8,and 1.7 ± 0.5 vs 5.0 ± 0.7,respectively,all P < 0.01).With regard to long-term clinical effects,the incidence of anal stenosis was lower in the PPH group than in the control group,but the difference was not significant(1.85% vs 5.56%).The incidence of sensory anal incontinence was significantly lower in the PPH group(3.70% vs 12.96%,P < 0.05).The incidences of recurrent internal rectal prolapse and difficulty in defecation were lower in the PPH group than in the control group,but the differences were not significant(11.11% vs 16.67% and 12.96% vs 24.07%,respectively).CONCLUSION: PPH is superior to the traditional surgery in the management of outlet obstructive constipation caused by internal rectal prolapse with circumferential hemorrhoids.

Numerical Prediction and Performance Experiment in a Deep-well Centrifugal Pump with Different Impeller Outlet Width

The existing research of the deep-well centrifugal pump mainly focuses on reduce the manufacturing cost and improve the pump performance, and how to combine above two aspects together is the most difficult and important topic. In this study, the performances of the deep-well centrifugal pump with four different impeller outlet widths are studied by the numerical, theoretical and experimental methods in this paper. Two stages deep-well centrifugal pump equipped with different impellers are simulated employing the commercial CFD software to solve the Navier-Stokes equations for three-dimensional incompressible steady flow. The sensitivity analyses of the grid size and turbulence model have been performed to improve numerical accuracy. The flow field distributions are acquired and compared under the design operating conditions, including the static pressure, turbulence kinetic energy and velocity. The prototype is manufactured and tested to certify the numerical predicted performance. The numerical results of pump performance are higher than the test results, but their change trends have an acceptable agreement with each other. The performance results indicted that the oversize impeller outlet width leads to poor pump performances and increasing shaft power. Changing the performance of deep-well centrifugal pump by alter impeller outlet width is practicable and convenient, which is worth popularizing in the engineering application. The proposed research enhances the theoretical basis of pump design to improve the performance and reduce the manufacturing cost of deep-well centrifugal pump.

Self-expandable metal stents for malignant gastric outlet obstruction: A pooled analysis of prospective literature

AIM: To provide an overview of the clinical outcomes of self-expandable metal stent(SEMS) placement for malignant gastric outlet obstruction(MGOO).METHODS: A systematic literature search was performed in Pub Med of the literature published between January 2009 and March 2015. Only prospective studies that reported on the clinical success of stent placement for MGOO were included. The primary endpoint was clinical success,defined according to the definition used in the original article. Data were pooled and analyzed using descriptive statistics. Subgroup analyses were performed for partially covered SEMSs(PCSEMSs) and uncovered SEMSs(UCSEMSs) using Fisher's exact test.RESULTS: A total of 19 studies,including 1281 patients,were included in the final analysis. Gastric(42%) and pancreatic(37%) cancer were the main causes of MGOO. UCSEMSs were used in 76% of patients and PCSEMSs in 24%. The overall pooled technical success rate was 97.3% and the clinical success rate was 85.7%. Stent dysfunction occurred in 19.6% of patients,mainly caused by re-obstruction(12.6%) and stent migration(4.3%),and was comparable between PCSEMSs and UCSEMSs(21.2% vs 19.1%,respectively,P = 0.412). Re-obstruction was more common with UCSEMSs(14.9% vs 5.1%,P < 0.001) and stent migration was more frequent after PCSEMS placement(10.9% vs 2.2%,P < 0.001). The overall perforation rate was 1.2%. Bleeding was reported in 4.1% of patients,including major bleeding in 0.8%. The median stent patency ranged from 68 to 307 d in five studies. The median overall survival ranged from 49 to 183 d in 13 studies.CONCLUSION: The clinical outcomes in this large population showed that enteral stent placement was feasible,effective and safe. Therefore,stent placement is a valid treatment option for the palliation of MGOO.

Endoscopic balloon dilation for benign gastric outlet obstruction in adults

Gastric outlet obstruction(GOO) includes obstruction in the antropyloric area or in the bulbar or post bulbar duodenal segments.Though malignancy remains the most common cause of GOO in adults,a significant number of patients have benign disease.The latter include peptic ulcer disease,caustic ingestion,post-operative anastomotic state and inflammatory causes like Crohn's disease and tuberculosis.Peptic ulcer remains the most common benign cause of GOO.Management of benign GOO revolves around confirmation of the etiology,removing the offending agent Helicobacter pylori(H.pylori),non-steroidal anti-inflammatory drugs,etc.and definitive therapy.Traditionally,surgery has been the standard mode of treatment for benign GOO.However,after the advent of through-the-scope balloon dilators,endoscopic balloon dilation(EBD) has emerged as an effective alternative to surgery in selected groups of patients.So far,this form of therapy has been shown to be effective in causticinduced GOO with short segment cicatrization and ulcer related GOO.In the latter,EBD must be combined with eradication of H.pylori.Dilation is preferably done with wire-guided balloon catheters of incremental diameter with the aim to reach the end-point of 15 mm.While it is recommended that fluoroscopic control be used for EBD,this is not used by most endoscopists.Frequency of dilation has varied from once a week to once in three weeks.Complications are uncommon with perforation occurring more often with balloons larger than 15 mm.Attempts to augment efficacy of EBD include intralesional steroids and endoscopic incision.

Influence of Blade Outlet Angle on Inner Flow Field of Centrifugal Pump Transporting Salt Aqueous Solution

During transportation of salt aqueous solutions with centrifugal pump, crystallization phenomenon is frequently encountered. For this kind of two-phase flow, it is difficult to be accurately modeled since there are various medium properties and phase change characteristics. In view of experiment, several problems are hampering the implementation of precise measurement. Influences of blade outlet angle and medium temperature on crystallization rate were studied. Sodium sulfate solution was applied to simulate practical fluid in chemical industry. Particle image velocimetry（PIV） was employed to measure velocity distributions in rotating impeller. Crystallization processes in three impellers with different blade outlet angles were investigated. Relations among crystallization and flow parameters such as temperature and velocity were obtained. With the same blade wrap angle, when blade outlet angle is larger, diffusion of single flow passage gets stronger, relative velocity at blade outlet decreases and large scale vortex tends to appear near the blade working surface. For the impact of volume effect of particle phase on fluid viscosity, both liquid and solid phase velocities decrease with continual forming and growing of crystal particles. Velocity of solid phase is greater than that of liquid phase and its direction leans more closely to blade working surface. Solid particles tend to move towards blade working surface, as is more obvious in the impeller with large blade outlet angle. Therefore, collision between solid particles with stem part of blade working surface is more intensive in impeller with large blade outlet angle. Concerning transportation of salt aqueous solution, accurate PIV measurement is conducted in centrifugal impellers with different blade outlet angles. The results are useful and instructive in relevant engineering design and operation.

Numerical Investigation of the Aerodynamic Performance Affected by Spiral Inlet and Outlet in a Positive Displacement Blower

The flow in the positive displacement blower is very complex.The existing two-dimensional numerical simulation cannot provide the detailed flow information,especially flow characteristics along the axial direction,which is unfavorable to improve the performance of positive displacement blower.To investigate the effects of spiral inlet and outlet on the aerodynamic performance of positive displacement blower,three-dimensional unsteady flow characteristics in a three-lobe positive displacement blower with and without the spiral inlet and outlet are simulated by solving Navier-Stokes equations coupled with RNG k-ε turbulent model.In the numerical simulation,the dynamic mesh technique and overset mesh updating method are used.The computational results are compared with the experimental measurements on the variation of flow rate with the outlet pressure to verify the validity of the numerical method presented.The results show that the mass flow rate with the change of pressure is slightly affected by the application of spiral inlet and outlet,but the internal flow state is largely affected.In the exhaust region,the fluctuations of pressure,velocity and temperature as well as the average values of velocity are significantly reduced.This illustrates that the spiral outlet can effectively suppress the fluctuations of pressure,thus reducing reflux shock and energy dissipation.In the intake area,the average value of pressure,velocity and temperature are slightly declined,but the fluctuations of them are significantly reduced,indicating that the spiral inlet plays the role in making the flow more stable.The numerical results obtained reveal the three-dimensional flow characteristics of the positive displacement blower with spiral inlet and outlet,and provide useful reference to improve performance and empirical correction in the noise-reduction design of the positive displacement blowers.

A newly designed big cup nitinol stent for gastric outlet obstruction

AIM:To find out whether a newly designed big cup nitinol stent is suitable for treatment of patients with gastric outlet obstruction resulting from gastric cancer.METHODS:The new stent is composed of a proximal big cup segment(20 mm in length and 48-55 mm in diameter),a middle part(60 mm in length and 20 mm in diameter)covered by a polyethylene membrane and a distal sphericity(20 mm in length and 28 mm in diameter).Half of the proximal big cup segment is also covered by a polyethlene membrane,which is adjacent to the middle part of the stent.The stent is preloaded in a 6.0-mm-diameter introducer system.Thirteen patients with gastric outlet obstruction resulting from gastric cancer received the new stents under endoscopic and fluoroscopic guidance.RESULTS:Technical success was achieved in 12 of 13(92.3%)patients.Among the 12 patients in whom endoscopic stent was placed successfully,the clinical success rate was 91.7%during a follow-up of average 6.5 mo.During the first month follow-up,the migration rate was 0%,recurrent obstruction 0%and gastric bleeding 8.3%.During the follow-up between 2-12 mo,no migration,recurrent obstruction and gastric bleeding occurred.CONCLUSION:The proximal big cup segment seems to be effective and promising for technical efficacy,clinical outcome,and preventing migration and tumor ingrowth and increasing the emptying rate of sinus ventriculi.

Flow patterns and boundary conditions for inlet and outlet conduits of large pump system with low head

The flow patterns in the inlet and outlet conduits have a decisive effect on the safe, stable, and highly efficient operation of the pump in a large pumping station with low head. The numerical simulation of three-dimensional （3D） turbulence flow in conduits is an important method to study the hydraulic performance and conduct an optimum hydraulic design for the conduits. With the analyses of the flow patterns in the inlet and outlet conduits, the boundary conditions of the numerical simulation for them can be determined. The main obtained conclusions are as follows： （i） Under normal operation conditions, there is essentially no pre-swirl flow at the impeller chamber inlet of an axial-flow pump system, based on which the boundary condition at the inlet conduit may be defined. （ii） The circulation at the guide vane outlet of an axial-flow pump system has a great effect on the hydraulic performance of the outlet conduit, and there is optimum circulation for the performance. Therefore, it is strongly suggested to design the guide vane according to the optimum circulation. （iii） The residual circulation at the guide vane outlet needs to be considered for the inlet boundary condition of the outlet conduit, and the value of the circulation may be measured in a specially designed test model.

Effect of preoperative nutrition therapy type and duration on short-time outcomes in gastric cancer patient with gastric outlet obstruction

Objective:To avoid perioperative complications caused malnutrition,nutrition therapy is necessary in gastric outlet obstruction(GOO)patients.Compared to parenteral nutrition(PN),enteral nutrition(EN)is associated with many advantages.This study aimed to investigate whether preoperative EN has beneficial clinical effects compared to preoperative PN in gastric cancer patients with GOO undergoing surgery.Methods:According to the methods of preoperative nutrition therapy,143 patients were divided into EN group(n=42)and PN group(n=101)between January 2013 and December 2017 at the Chinese People’s Liberation Army General Hospital.Multiple logistic regression models were used to assess the association between the methods of preoperative nutrition therapy and postoperative day of flatus passage.The generalized additive model and twopiecewise linear regression model were used to calculate the inflection point of the preoperative nutritional therapy time on the postoperative day of flatus passage in the PN group.Results:EN shortened the postoperative day of flatus passage in gastric cancer patients with GOO,which is a protective factor,especially in patients who underwent non-radical operations and the postoperative day of flatus passage reduced when the preoperative PN therapy was up to 3 d and a longer PN therapy(>3 d)did not accelerate the postoperative recovery of gastrointestinal functions.Conclusions:Preoperative EN therapy would benefit gastric cancer patients with GOO by accelerating postoperative recovery.For patients with absolute obstruction,no more than 3-day PN therapy is recommended if patients can tolerate general anesthesia and surgery.

Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: A personal series and systematic review of the literature

The major symptoms of advanced hepatopancreaticbiliary cancer are biliary obstruction, pain and gastric outlet obstruction(GOO). For obstructive jaundice, surgical treatment should de consider in recurrent stent complications. The role of surgery for pain relief is marginal nowadays. On the last, there is no consensus for treatment of malignant GOO. Endoscopic duodenal stents are associated with shorter length of stay and faster relief to oral intake with more recurrent symptoms. Surgical gastrojejunostomy shows better long-term results and lower re-intervention rates, but there are limited data about laparoscopic approach. We performed a systematic review of the literature, according PRISMA guidelines, to search for articles on laparoscopic gastrojejunostomy for malignant GOO treatment. We also report our personal series, from 2009 to 2017. A review of the literature suggests that there is no standardized surgical technique either standardized outcomes to report. Most of the studies are case series, so level of evidence is low. Decisionmaking must consider medical condition, nutritional status, quality of life and life expectancy. Evaluation ofthe patient and multidisciplinary expertise are required to select appropriate approach. Given the limited studies and the difficulty to perform prospective controlled trials, no study can answer all the complexities of malignant GOO and more outcome data is needed.

Update on endoscopic management of gastric outlet obstruction in children

Endoscopic balloon dilatation(EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.