Treatment of gastric outlet and duodenal obstructions with uncovered expandable metal stents

AIM:To investigate and evaluate the technical feasibility and clinical effectiveness of fluoroscopically guided peroral uncovered expandable metal stent placement to treat gastric outlet and duodenal obstructions. METHODS:Fifteen consecutive patients underwent peroral placement of Wallstent^(TM)Enteral Endoprosthesis to treat gastric outlet and duodenal obstructions(14 malignant,1 benign).All procedures were completed under fluoroscopic guidance without endoscopic assistance.Follow-up was completed until the patients died or were lost,and the clinical outcomes were analyzed. RESULTS:The technique success rate was 100%,and the oral intake was maintained in 12 of 14 patients varying from 7 d to 270 d.Two patients remained unable to resume oral intake,although their stents were proven to be patent with the barium study.One patient with acute necrotizing pancreatitis underwent enteral stenting to treat intestinal obstruction,and nausea and vomiting disappeared.Ten patients died during the follow- up period,and their mean oral intake time was 50 d. No procedure-related complications occurred.Stent migration to the gastric antrum occurred in one patient 1 year after the procedure,a tumor grew at the proximal end of the stent in another patient 38 d post-stent insertion. CONCLUSION:Fluoroscopically guided peroral metal stent implantation is a safe and effective method to treat malignant gastrointestinal obstructions,and complications can be ignored based on our short-term study.Indications for this procedure should be discreetly considered because a few patients may not benefit from gastrointestinal insertion,but some benign gastrointestinal obstructions can be treated using this procedure.

Treating bilio-duodenal obstruction: Combining new endoscopic technique with 6 Fr stent introducer

Periampullary cancer may cause not only biliary but also duodenal obstructions. In patients with concomitant duodenal obstructions, endoscopic biliary stenting remains technically difficult and may often require percutaneous transhepatic biliary drainage. We describe a method of metal stent placement via a thin forwardviewing endoscope in patients with simultaneous biliary and duodenal obstruction. In two consecutive patients with biliary and duodenal obstruction due to pancreatic cancer, a new biliary metal stent mounted in a slim delivery catheter was placed via a thin forward viewing endoscope after passage across the duodenal stenosis without balloon dilation. In both patients, with our new placement technique, metallic stents were successfully placed in a short time without adverse events. After biliary stenting, one patient received curative resection and the other received duodenal stenting for palliation. Metallic stent placement with a forward-viewing thin endoscope is a beneficial technique, which can avoid percutaneous drainage in patients with bilio-duodenal obstructions due to periampullary cancer.

Duodenal obstruction after successful embolization for duodenal diverticular hemorrhage: A case report

We present a 69-year-old woman with a duodenal obstruction after successful selective transcatheter arterial embolization (TAE) for a duodenal diverticular hemorrhage. Two weeks after TAE, the patient showed abrupt symptoms of duodenal obstruction. Resolving hematomas after successful selective transcatheter arterial embolization should be thoroughly observed because they might result in duodenal fibrotic encasement featuring inflammatory duodenal wall thickening, duodenal deformity, dysmotility, and fi nally obstruction.

Duodenal obstruction following acute pancreatitis caused by a large duodenal diverticular bezoar

Bezoars are concretions of indigestible materials in the gastrointestinal tract. It generally develops in patients with previous gastric surgery or patients with delayed gastric emptying. Cases of periampullary duodenal divericular bezoar are rare. Clinical manifestations by a bezoar vary from no symptom to acute abdominal syndrome depending on the location of the bezoar. Biliary obstruction or acute pancreatitis caused by a bezoar has been rarely reported. Small bowel obstruction by a bezoar is also rare, but it is a complication that requires surgery. This is a case of acute pancreatitis and subsequent duodenal obstruction caused by a large duodenal bezoar migrating from a periampullary diverticulum to the duodenal lumen, which mimicked pancreatic abscess or microperforation on abdominal computerized tomography. The patient underwent surgical removal of the bezoar and recovered completely.

Balloon dilation of congenital perforated duodenal web in newborns: Evaluation of short and long-term results

BACKGROUND Incomplete congenital duodenal obstruction(ICDO)is caused by a congenitally perforated duodenal web(CPDW).Currently,only six cases of balloon dilatation of the PDW in newborns have been described.AIM To present our experience of balloon dilatation of a perforated duodenal memb-rane in newborns with ICDO.METHODS Five newborns who underwent balloon dilatation of the CPDW along a prein-stalled guidewire between 2021 and 2023 were included.Nineteen newborns diagnosed with ICDO who underwent laparotomy were included in the control group.RESULTS In all cases,good anatomical and clinical results were obtained.In three cases,a follow-up study was conducted after 1 year.The average time to start enteral feeding per os was significantly earlier in the study group(4.4 d)than in the laparotomic group(21.2 days;P<0.0001).The time spent by patients in the intensive care unit and hospital after balloon dilatation was also significantly shorter.We determined the selection criteria for possible and effective CPDW balloon dilatation in newborns as follows:(1)Presence of dynamic radiographic signs of the passage of a radiopaque substance beyond the zone of narrowing or radiographic signs of pneumatisation of the duodenum and small bowel distal to the web;(2)presence of endoscopic signs of CPDW;(3)successful cannulation with a guidewire performed parallel to the endoscope,with holes in the congenital duodenal web;and(4)successful positioning of the balloon performed along a freestanding guidewire on the web.CONCLUSION Strictly following selection criteria for newborns with ICDO caused by CPDW ensures that endoscopic balloon dilatation using a pre-installed guidewire is safe and effective and shows good 1-year follow-up results.

Congenital duodenal obstruction in neonates:a decade's experience from one center

Background:Congenital duodenal obstruction(CDO)is one of the most common anomalies in newborns,and accounting for nearly half of all cases of neonatal intestinal obstruction.This study aimed to review our single-center experience in managing congenital duodenal obstruction while evaluate the outcomes.Methods:We conducted a retrospective analysis of the records of all neonates dianogsed with congenital duodenal obstruction admitted to our center between January 2003 and December 2012.We analyzed demographic criteria,clinical manifestations,associated anomalies,radiologic findings,surgical methods,postoperative complications,and fi nal outcomes.Results:The study comprised 287 newborns(193 boys and 94 girls).Birth weight ranged from 950 g to 4850 g.Fifty-three patients were born prematurely between 28 and 36 weeks'gestation.Malrotation was diagnosed in 174 patients,annular pancreas in 66,duodenal web in 55,duodenal atresia or stenosis in 9,preduodenal portal vein in 2,and congenital band compression in 1.Twenty patients had various combinations of these conditions.Presenting symptoms included bilious vomiting,dehydration,and weight loss.X-rays of the upper abdomen demonstrated the presence of a typical double-bubble sign or air-fluid levels in 68.64%of patients,and confi rmatory upper and/or lower gastrointestinal contrast studies were obtained in 64.11%.Multiple associated abnormalities were observed in 50.52%of the patients.Various surgical approaches were used,including Ladd's procedure,duodenoplasty,duodenoduodenostomy,duodenojejunostomy,or a combination of these.Seventeen patients died postoperatively and 14 required re-operation.Conclusions:Congenital duodenal obstruction is a complex entity with various etiologies and often includes multiple concomitant disorders.Timely diagnosis and aggressive surgery are key to improving prognosis.Care should be taken to address all of the causes of duodenal obstruction and/or associated alimentary tract anomalies during surgery.

Malrotation causing duodenal chronic obstruction in an adult

Congenital duodenal obstruction is rare in adulthood. An unusual presentation of this condition has led to difficult preoperative diagnosis.We present a case of proximal jejunal obstruction by a congenital band in an adult and review the literature.

Duodenojejunostomy treatment of groove pancreatitis-induced stenosis and obstruction of the horizontal duodenum:A case report

BACKGROUND Groove pancreatitis(GP)is a rare condition affecting the pancreatic groove region within the dorsal-cranial part of the pancreatic head,duodenum,and common bile duct.As a rare form of chronic pancreatitis,GP poses a diagnostic and therapeutic challenge for clinicians.GP is frequently misdiagnosed or not considered;thus,the diagnosis is often delayed by weeks or months.The treatment of GP is complicated and often requires surgical intervention,especially pancreatoduodenectomy.CASE SUMMARY A 66-year-old man with a history of long-term drinking was admitted to the gastroenterology department of our hospital,complaining of vomiting and acid reflux.Upper gastrointestinal endoscopy showed luminal stenosis in the descending part of the duodenum.Abdominal computed tomography showed slight exudation in the descending and horizontal parts of the duodenum with broadening of the groove region,indicating local pancreatitis.The symptoms of intestinal obstruction were not relieved with conservative therapy,and insertion of an enteral feeding tube was not successful.Exploratory laparoscopy was performed and revealed a hard mass with scarring in the horizontal part of the duodenum and stenosis.Intraoperative frozen section analysis showed no evidence of malignancy,and side-to-side duodenojejunostomy was performed.Routine pathologic examination showed massive proliferation of fibrous tissue,hyaline change,and the proliferation of spindle cells.Based on the radiologic and pathologic characteristics,a diagnosis of GP was made.The patient presented with anastomotic obstruction postoperatively and took a long time to recover,requiring supportive therapy.CONCLUSION GP often involves the descending and horizontal parts of the duodenum and causes duodenal stenosis,impaired duodenal motility,and gastric emptying due to fibrosis.

Spontaneous resolution of idiopathic intestinal obstruction after pneumonia: A case report

BACKGROUND Duodenal obstruction is a common clinical scenario that can either be mechanical or a pseudo-obstruction.Clinical management of intestinal obstruction starts from localization and proceeds to histological examination of the stenotic intestine.Systemic factors and dysfunction of distant organs might contribute to the development of intestinal obstruction.Here,we report a unique case of idiopathic mechanical duodenal obstruction,which resolved spontaneously after 3 mo of conservative treatment,but was followed by intestinal pseudo-obstruction.CASE SUMMARY An 84-year-old woman presented with worsened postprandial vomiting accompanied by prolonged pneumonia.Thorough noninvasive investigations revealed complete circumferential stenosis in the descending duodenum without known cause.Exploratory surgery was postponed due to septic shock and possible pulmonary fungal infection.Conservative treatment for 3 mo for ileus and control of pulmonary infection resolved the intestinal obstruction completely.Unfortunately,2 wk later,she had regurgitation and postprandial vomiting again,complicated by deteriorating wheezing and dyspnea.Computed tomography revealed a dilated stomach and proximal duodenum without new intestinal stricture or pulmonary infiltration.The patient fully recovered after combined treatment with antireflux agents,enema,prokinetics,and bronchodilators.CONCLUSION This complicated case highlights the inter-relationship of local and systemic contributions to ileus and gut dysfunction,which requires multidisciplinary treatment.

Uncommon presentation of a common disease-Bouveret's syndrome:A case report and systematic literature review

AIM To investigate and summarise the current evidence surrounding management of Bouveret's syndrome(BS).METHODS A MEDLINE search was performed for the BS. The search was conducted independently by two clinicians(Yahya ALHabbal and Matthew Ng) in April 2016. A case of BS is also described.RESULTS A total of 315 articles, published from 1967 to 2016, were found. For a clinically meaningful clinical review, articles published before 01/01/1990 and were excluded, leaving 235 unique articles to review. Twenty-seven articles were not available(neither by direct communication nor through inter-library transfer). These were also excluded. The final number of articles reviewed was 208. There were 161 case reports, 13 reviews, 23 images(radiological and clinical images), and 11 letters to editor. Female to male ratio was 1.82. Mean age was 74 years. Treatment modalities included laparotomy in the majority of cases, laparoscopic surgery, endoscopic surgery and shockwave lithotripsy.CONCLUSION There is limited evidence in the literature about the appropriate approach. We suggest an algorithm for management of BS.

Another new variant of Bouveret's syndrome

Although Bouveret's syndrome,i.e.gastric outlet obstruction by a large gallstone impacted in the proximal duodenum secondary to a cholecystoduodenal fistula,is rare,its pathogenesis and clinical features are well characterized.However,existence of variant forms of the syndrome are not well known,and as far as we know,only two cases of variant Bouveret's syndrome have been described in the English-language literature.We present a case of another new variant of Bouveret's syndrome in a 54-year-old Korean woman.

Clinical characteristics of adult-type annular pancreas:A case report

BACKGROUND Annular pancreas(AP)is a rare congenital abnormal rotation of the pancreas.AP rarely occurs in adults.Pancreatic tumors and ampullary tumors are related to AP,so the discovery and treatment of AP are essential.CASE SUMMARY This study investigated the clinical manifestations,imaging features,complications,and treatment of six patients diagnosed with AP at the Department of Hepatobiliary and Pancreatic Surgery,First Hospital of Jilin University from January 2010 to June 2020.There were four males and two females,with an average age of 56.00±9.86 years old.In this study,abdominal pain and jaundice were the main clinical manifestations.Imaging can show the“crocodile jaw sign”or“double bubble sign”.CONCLUSION For patients with duodenal or biliary obstruction,physicians should give priority to AP when imaging examinations suggest that the duodenum is wrapped with tissue similar to the density of the pancreas.Symptomatic patients should actively undergo surgical treatment.

Superior mesenteric artery syndrome in a patient with esophageal stenosis: A case report

BACKGROUND Superior mesenteric artery syndrome(SMAS)is a rare condition,characterized by duodenal obstruction caused by compression of its third part by the superior mesenteric artery(SMA).Most cases of SMAS are associated with weight loss,and the most frequent clinical manifestations are nausea,vomiting,postprandial fullness,and abdominal pain.Treatment of SMAS is usually conservative,consisting mainly of adequate nutritional support,but in refractory cases surgery may be necessary,with gastrojejunostomy and duodenojejunostomy being the most commonly performed procedures.CASE SUMMARY We describe the case of a man in his forties with a pre-existing diagnosis of esophageal stricture due to sodium hydroxide ingestion,who suffered significant weight loss after replacement of his jejunostomy tube.He was admitted to the hospital due to pain and abdominal distension.A computerized tomography scan showed significant distension of the stomach and duodenum with narrowing of the duodenum at the point at which it is crossed by the superior mesenteric artery,thus establishing the diagnosis of SMAS.Due to the presence of the esophageal stricture,the patient was incapable of emesis;however,passage of a nasogastric tube for decompression was not possible.Considering the risk of gastric perforation due to distention,we opted for surgical treatment in the form of a surgical gastrojejunostomy after which he showed complete resolution of all symptoms and was discharged from the hospital 5 d after the procedure.CONCLUSION Diagnosis of SMAS can be challenging in patients with esophageal stenosis,and risk of gastric perforation may preclude conservative treatment.

Post hoc validation of a tool that accurately predicts the outcome of endoscopic therapy in Bouveret syndrome

Background Bouveret syndrome is characterized by gallstone impaction in the upper gastrointestinal tract causing gastric outlet obstruction.In Bouveret syndrome,endoscopic gallstone removal can avert the need for surgery.However,in cases in which endoscopic therapy is unlikely to succeed,endoscopic attempts delay definitive treatment and compound patient risks.We previously developed a model that predicts endoscopic outcomes from data derived through a systematic review.This tool uses gallstone length,site of impaction,and the number of planned methods of lithotripsy to predict the likelihood of endoscopic success with an accuracy of 81.0%.This study aimed to evaluate our tool performance in an independent,non-training data set and assess endoscopic and surgical outcomes.Methods Systematic searches of the PubMed,Scopus,and Cochrane databases were performed for articles published between 16 April 2018 and 1 June 2021.The data reported after our previous study were harvested and inputted into the tool to evaluate their ability to accurately predict outcomes when compared with actual outcomes.Results Newly collated data in fields of interest showed no significant statistical differences compared with previous training data sets.Endoscopic therapy was successful in 41.9%of cases.Gallstones of ≤4 cm had a higher chance of successful endoscopic intervention(odds ratio 6.7,95%confidence interval 1.7–25.8,P<0.01).Complications of surgery were reported in 29.5%;there was one fatality reported.Post hoc evaluation of our predictive tool demonstrated an AUROC score of 0.80.Conclusions We have demonstrated in an independent data set that the tool can be used to accurately predict outcomes of endoscopic therapy.Patients in whom endoscopic therapy is most likely to fail should be offered an early surgical opinion.