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.

Application value of enhanced recovery after surgery for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy

AIM To evaluate the safety and feasibility of enhanced recovery after surgery(ERAS) for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy.METHODS The clinical data of 42 patients who were divided into an ERAS group(n = 20) and a control group(n = 22) were collected. The observed indicators included operation conditions, postoperative clinical indexes, and postoperative serum stress indexes. Measurement data following a normal distribution are presented as mean ± SD and were analyzed by t-test. Count data were analyzed by χ~2 test.RESULTS The operative time, volume of intraoperative blood loss, and number of patients with conversion to opensurgery were not significantly different between the two groups. Postoperative clinical indexes, including the time to initial anal exhaust, time to initial liquid diet intake, time to out-of-bed activity, and duration of hospital stay of patients without complications, were significantly different between the two groups(t = 2.045, 8.685, 2.580, and 4.650, respectively, P < 0.05 for all). However, the time to initial defecation, time to abdominal drainage-tube removal, and the early postoperative complications were not significantly different between the two groups. Regarding postoperative complications, on the first and third days after the operation, the white blood cell count(WBC) and C reactive protein(CRP) and interleukin-6(IL-6) levels in the ERAS group were significantly lower than those in the control group.CONCLUSION The perioperative ERAS program for total laparoscopic uncut Roux-en-Y gastrojejunostomy after distal gastrectomy is safe and effective and should be popularized. Additionally, this program can also reduce the duration of hospital stay and improve the degree of comfort and satisfaction of patients.

Transgastric endoscopic gastrojejunostomy using holing followed by interrupted suture technique in a porcine model

AIM: To demonstrate the feasibility and reproducibility of a pure natural orifice transluminal endoscopic surgery(NOTES) gastrojejunostomy using holing followed by interrupted suture technique using a single endoloop matched with a pair of clips in a non-survival porcine model.METHODS: NOTES gastrojejunostomy was performed on three female domestic pigs as follows: Gastrostomy, selection and retrieval of a free-floating loop of the small bowel into the stomach pouch, hold and exposure of the loop in the gastric cavity using a submucosal inflation technique, execution of a gastro-jejunal mucosal-seromuscular layer approximation using holing followed by interrupted suture technique with endoloop/clips, and full-thickness incision of the loop with a Dual knife.RESULTS: Pure NOTES side-to-side gastrojejunostomy was successfully performed in all three animals. No leakage was identified via methylene blue evaluation following surgery.CONCLUSION: This novel technique for preforming a gastrointestinal anastomosis exclusively by NOTES is technically feasible and reproducible in an animal model but warrants further improvement.

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.

Management of afferent loop obstruction from recurrent metastatic pancreatic cancer using a venting gastrojejunostomy

Pancreatic cancer is an aggressive malignancy poten-tially curable with surgical intervention. Following pan-creaticoduodenectomy for suspected pancreatic head malignancy, patients have a high risk for both immedi-ate and delayed problems due to surgical complica-tions and recurrent disease. We report here a patient with pancreatic cancer treated with pancreaticoduode-nectomy who developed recurrent disease resulting in obstruction of the afferent limb. The patient developed biliary obstruction and cholangitis at presentation. Her biliary tree failed to dilate which precluded safe percu-taneous biliary decompression. During surgical explo-ration, she was found to have a dilated afferent limb at the level of the transverse mesocolon. The patient underwent decompression of the afferent limb as well as the biliary tree using a venting gastrojejunostomy to the blind loop. This represents a novel surgical ap-proach for management of this complicated and diffi-cult problem.

Efferent limb of gastrojejunostomy obstruction by a whole okra phytobezoar:Case report and brief review

A phytobezoar is one of the intraluminal causes of gastric outlet obstruction,especially in patients with previous gastric surgery and/or gastric motility disorders.Before the proton pump inhibitor era,vagotomy,pyloroplasty,gastrectomy and gastrojejunostomy were commonly performed procedures in peptic ulcer patients.One of the sequelae of gastrojejunostomy is phytobezoar formation.However,a bezoar causing gastric outlet obstruction is rare even with giant gastric bezoars.We report a rare case of gastric outlet obstruction due to a phytobezoar obstructing the efferent limb of the gastrojejunostomy site.This phytobezoar which consisted of a whole piece of okra(lady finger vegetable) was successfully removed by endoscopic snare.To the best of our knowledge,this is the first case of okra bezoar-related gastrojejunostomy efferent limb obstruction reported in the literature.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction(GOO)is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum.GOO can be caused by either benign or malignant etiologies,often resulting in early satiety,nausea,vomiting and poor oral intake.GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies.Traditional treatment options for GOO can be broadly divided into surgical[surgical gastrojejunostomy(GJ)]and endoscopic interventions(dilation and/or placement of luminal self-expanding metal stents).While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting,it has also been associated with a higher rate of adverse events.Furthermore,many patients with advanced metastatic disease are not good surgical candidates.More recently,endoscopic ultrasound(EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches.This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Gastrojejunostomy followed by induction chemotherapy for incurable gastric cancer with outlet obstruction

A 72-year-old male gastric cancer patient with outlet obstruction underwent laparoscopic exploration. The examination disclosed intraperitoneal free cancer cells with no overt peritoneal, lymphatic, or hepatic metastasis. The patient underwent laparoscopy-assisted gastroje-junostomy (LAGJ) and started chemotherapy with S-1 plus cisplatin on postoperative day 13. Three course of the chemotherapy shrank the tumor markedly. Then, the patient underwent gastrectomy with a curative intent. Laparotomy revealed no intraperitoneal free cancer cells, and microscopically complete resection was achieved. The patient received S-1 chemotherapy as postoperative adjuvant treatment for 1 year, and is still alive with no evidence of peritoneal recurrence. LAGJ followed by S-1 plus cisplatin is one of the optional treatments that should be considered for patients with outlet obstruction as it may widen opportunities for potentially curative resection.

Bowel intussusception caused by a percutaneously placed endoscopic gastrojejunostomy catheter: A case report

BACKGROUND In adults,bowel intussusception is a rare diagnosis and is mostly due to an organic bowel disorder.In rare cases,this is a complication of a percutaneously placed endoscopic gastro(jejunostomy)catheter.CASE SUMMARY We describe a case of a 73-year-old patient with a history of myocardial infarction,chronic idiopathic constipation and Parkinson’s disease.For the admission of his Parkinson’s medication,a percutaneous endoscopic gastrostomy with jejunal extension(PEG-J)was placed.The patient presented three times at the emergency department of the hospital with intermittent abdominal pain with nausea and vomiting.There were no distinctive abnormalities from the physical and laboratory examinations.An abdominal computed tomography scan showed a small bowel intussusception.By push endoscopy,a jejunal bezoar at the tip of the PEG-J catheter was found to be the cause of small bowel intussusception.The intussusception was resolved after removing the bezoar during push enteroscopy.CONCLUSION Endoscopic treatment of bowel intussusception caused by PEG-J catheter bezoar.

Surgical Management of Perforated Peptic Ulcer;Closure with Omental Patch versus Definitive Repair with Vagotomy and Gastrojejunostomy: A Comparative Study

Background: The perforation of peptic ulcer is a common and serious life threatening surgical emergency. Up-till now no consensus was reached regarding the best practice in management of perforated peptic ulcer. The aim of this study is to evaluate and compare between both management strategies of perforated peptic ulcer;performing simple closure of the perforation with an omental patch then H. pylori eradication and inhibition of acid secretion using long time proton pump inhibitors versus performing definitive repair of perforated peptic ulcer (closure of the perforation with an omental patch, truncal vagotomy and gastrojejunostomy to discover a proper management strategy of perforated peptic ulcer. Patients and Methods: In the current study we included 30 patients which were divided into 2 groups: group 1 included 15 patients where we managed them by simple closure of the perforation with an omental patch then H. pylori eradication and inhibition of acid secretion using long time proton pump inhibitors and group 2 included 15 patients where we performed closure of the perforation with an omental patch, truncal vagotomy and gastrojejunostomy. Results: We found that younger patient underwent vagotomy and gastro-jejunostomy technique (p Conclusions: Peptic ulcer perforation could be safely managed by primary closure and covering by omentum in addition to medical treatment of H. pylori infection and inhibition of acid secretion especially in old patients with comorbid condition who presented late or with shock.

Application of Percutaneous Endoscopic Gastrojejunostomy in Duodenal Crohn’s Disease-Associated Strictures

Background Duodenal Crohn’s disease(CD)-associated strictures are related to a high risk of malnutrition,and effective methods of enteral nutrition(EN)are needed to support these patients.The purpose of this study was to evaluate the efficacy and safety of percutaneous endoscopic gastrojejunostomy(PEG-J)for the treatment of duodenal CD-associated strictures.Methods Patients with strictures associated with duodenal CD were recruited.The clinical data,stricture characteristics,nutritional status,duration of PEG-J tube placement,complications,and follow up periods were recorded.Results A total of 24 patients with duodenal CD-associated strictures underwent PEG-J tube placement.The PEG-J tubes were successfully placed in 100%of the patients within an average of 19.04±2.94 minutes.There were no procedure-related complications.There were no major complications after PEG-J tube placement,and only two minor complications(8.33%)occurred.PEG-J was well tolerated in all patients.The mean Karnofsky score was 67.50±7.94 points and 83.33±7.02 points(P=0.000),the mean body mass index was 17.02±1.85 kg/m^(2)and 18.10±1.78 kg/m^(2)(P=0.045),and the mean Alb level was 35.28±5.35 g/dl and 38.68±5.10 g/dl(P=0.029)before PEG-J and 3 months after PEG-J,respectively.The median CD Activity Index(CDAI score)was 144(range 87-280)and the median C-reactive protein(CRP)was 1.90 mg/L(0.5-67.9 mg/L)after PEG-J,which were significantly lower than the respective 196 mg/L(range 114-331 mg/L)(P=0.044)and 3.75 mg/L(range 0.5-67 mg/L)(P=0.033)before PEG-J.Conclusion PEG-J was a safe,well-tolerated and effective method for the treatment of duodenal CD-associated strictures.PEG-J improved the patient’s nutritional status and reduced disease CD activity.These findings suggest that PEG-J is an option for EN in patients with duodenal CD-associated strictures.

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.

Palliative Therapy for Gastric Outlet Obstruction Caused by Unresectable Gastric Cancer： A Meta-analysis Comparison of Gastrojejunostomy with Endoscopic Stenting

Background： Gastrojejunostomy （G J J） and endoscopic stenting （ES） are palliative treatments for gastric outlet obstruction （GO0） caused by gastric cancer. We compared the outcomes of GJJ with ES by performing a meta-analysis. Methods： Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis. Procedure time, time to resumption of oral intake, duration of hospital stay, patency duration, and overall survival days were compared using weighted mean differences （WMDs）. Technical success, clinical success, procedure-related mortality, complications, the rate of re-obstruction, postoperative chemotherapy, and reintervention were compared using odds ratios （ORs）.Results： Nine studies were included in the analysis. Technical success and clinical success were not significantly different between the ES and GJJ groups. The ES group had a shorter procedure time （WMD = -80.89 min, 95% confidence interval [CI] = -93.99 to -67.78, P 〈 0.001）, faster resumption of oral intake （WMD = -3.45 days, 95% CI = -5.25 to -1.65, P 〈 0.001）, and shorter duration of hospital stay （WMD = -7.67 days, 95% CI = -11.02 to -4.33, P 〈 0.001）. The rate of minor complications was significantly higher in the GJJ group （OR = 0.13, 95% CI = 0.04-0.40, P 〈 0.001）. However, the rates of major complications （OR = 6.91, 95% CI = 3.90-12.25, P 〈 0.001）, re-obstruction （OR = 7.75, 95% CI = 4.06-14.78, P 〈 0.001）, and reintervention （OR = 6.27, 95% CI = 3.36-11.68, P 〈 0.001） were significantly lower in the GJJ group than that in the E S group. Moreover, GJJ was significantly associated with a longer patency duration （WMD = -167.16 days, 95% CI = -254.01 to -89.31, P 〈 0.001） and overall survival （WMD = -103.20 days, 95% CI = -161.49 to -44.91, P = 0.001）. Conclusions： Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer. ES is associated with better short-term outcomes. GJJ is preferable to ES in terms of its lower rate of stent-related complications, re-obstruction, and reintervention. GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.

Experimental research of stent anastomosis of gastrojejunostomy in a porcine model

Background Gastrojejunostomy is one of the most frequently used procedures for general surgeons. The creation of anastomosis between various parts of the gastrointestinal tract is a basic technical component and major task in the daily practice of almost all gastrointestinal procedures. This research evaluated a new procedure of making gastrointestinal anastomosis with stent.Methods Twenty experimental mini-pigs were randomized into two groups. In stent anastomosis group （SA）, the anastomoses were constructed with a poly-levolactic acid stent. In hand-sewn group （HA）, the anastomoses were performed with a single-layer continuous suture. Abdominal X-ray with intraluminal contrast was performed on the 10th postoperative day. Five pigs of each group were sacrificed on the postoperative days 3 and 14 to determine anastomotic bursting pressure in situ, hydroxyproline concentration, and histopathological evaluation of the anastomotic sites.Results There was no intraoperative morbidity or mortality. The median time needed for the sutured anastomosis was （21.7±2.3） minutes and for the stent anastomosis was （11.9±1.9） minutes （P 〈0.001）. Abdominal X-ray with intraluminal contrast demonstrated normal gas distribution and showed no evidence of leakage or obstruction. Macroscopic appearance at the longitudinal opening of anastomosis was always good in both groups. The median anastomotic bursting pressure was （18.2±1.6） kPa in SA group on postoperative day 3, compared with （11.7±3.2） kPa in HA group （P=0.003）. The anastomotic bursting pressure on day 14 was not significantly different between SA group （（27.1±2.6）kPa） and HA group （（28.3±1.7） kPa） （P=0.388）. The hydroxyproline concentrations were not significantly different.Conclusions The stent anastomosis was not considered to be more difficult than a sutured anastomosis. This method is proved to be safe and feasible compared with the traditional hand-sewn method in the porcine model. The method increases early anastomotic strength in this study.

Stapled gastro/duodenojejunostomy shortens reconstruction time during pylorus-preserving pancreaticoduodenectomy

AIM:To investigate whether a stapled technique is superior to the conventional hand-sewn technique for gastro/duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy(PpPD).METHODS:In October 2010,we introduced a mechanical anastomotic technique of gastro-or duodenojejunostomy using staplers during PpPD.We compared clinical outcomes between 19 patients who underwent PpPD with a stapled gastro/duodenojejunostomy(stapled anastomosis group)and 19 patients who underwent PpPD with a conventional hand-sewn duodenojejunostomy(hand-sewn anastomosis group).RESULTS:The time required for reconstruction was significantly shorter in the stapled anastomosis group than in the hand-sewn anastomosis group(186.0±29.4 min vs 219.7±50.0 min,P=0.02).In addition,intraoperative blood loss was significantly less(391.0±212.0 mL vs 647.1±482.1 mL,P=0.03)and the time to oral intake was significantly shorter(5.4±1.7d vs 11.3±7.9 d,P=0.002)in the stapled anastomosis group than in the hand-sewn anastomosis group.There were no differences in the incidences of delayed gastric emptying and other postoperative complications between the groups.CONCLUSION:These results suggest that stapled gastro/duodenojejunostomy shortens reconstruction time during PpPD without affecting the incidence of delayed gastric emptying.

Application of side-to-side anastomosis of the lesser curvature of stomach and jejunum in gastric bypass

AIM To evaluate the feasibility of side-to-side anastomosis of the lesser curvature of stomach and jejunum in laparoscopic Roux-en-Y gastric bypass(LRYGB).METHODS Seventy-seven patients received side-to-side anastomosis of the lesser curvature of stomach and jejunum by utilization of linear stapler in LRYGB from April 2012 to July 2015 were retrospectively analyzed.RESULTS All patients were successfully completed laparoscopic gastric bypass with the side-to-side anastomosis of the lesser curvature of stomach and jejunum. No patient was switched to laparotomy during operation. No early complications including gastrointestinal anastomotic bleeding, fistula, obstruction, deep vein thrombosis, incision infections, intra-abdominal hernia complications were found. One patient complicated with stricture of gastrojejunal anastomosis(1.3%) and six patients complicated with incomplete intestinal obstruction(7.8%). BMI and Hb A1 c determined at 3, 6, 12, 24 mo during follow up period were significantly reduced compared with preoperative baselines respectively. The percentage of patients who maintain HbA 1c(%) < 6.5% without taking antidiabetic drugs reached to 61.0%, 63.6%, 75.0%, and 63.6% respectively. The outcome parameters of concomitant diseases were significantly improved too.CONCLUSION Present surgery is a safety and feasibility procedure. It is effective to lighten the body weight of patients and improve type 2 diabetes and related complications.

Initial experience of single-incision plus one port left-side approach totally laparoscopic distal gastrectomy with uncut Roux-en-Y reconstruction

BACKGROUND Single incision plus one port left-side approach(SILS+1/L)totally laparoscopic distal gastrectomy(TLDG)is an emerging technique for the treatment of gastric cancer.Reduced port laparoscopic gastrectomy has a number of potential advantages for patients compared with conventional laparoscopic gastrectomy:relieving postoperative pain,shortening hospital stay and offering a better cosmetic outcome.Nevertheless,there are no previous reports on the use of SILS+1/L TLDG with uncut Roux-en-Y(uncut R-Y)reconstruction.AIM To investigate the initial feasibility of SILS+1/L TLDG with uncut Roux-en-Y digestive tract reconstruction(uncut R-Y reconstruction)to treat distal gastric cancer.METHODS A total of 21 patients who underwent SILS+1/L TLDG with uncut R-Y reconstruction for gastric cancer were enrolled.All patients were treated at The Second Hospital of Shandong University.Reconstructions were performed intracorporeally with 60 mm endoscopic linear stapler and 45 mm no-knife stapler.The clinicopathological characteristics,surgical details,postoperative short-term outcomes,postoperative follow-up upper gastrointestinal radiography findings and endoscopy results were analyzed retrospectively.RESULTS All SILS+1/L operations were performed by SILS+1/L TLDG successfully.The patient population included 13 men and 8 women with a mean age of 48.2 years(ranged from 40 years to 70 years)and median body mass index of 22.8 kg/m^2.There were no conversions to open laparotomy,and no other port was placed.The mean operation time was 146 min(ranged 130-180 min),and the estimated mean blood loss was 54 mL(ranged 20-110 mL).The mean duration to flatus and discharge was 2.3(ranged 1-3.5)and 7.3(ranged 6-9)d,respectively.The mean number of retrieved lymph nodes was 42(ranged 30-47).Two patients experienced mild postoperative complications,including surgical site infection(wound at the navel incision)and mild postoperative pancreatic fistula(grade A).Follow-up upper gastrointestinal radiography and endoscopy were carried out at 3 mo postoperatively.No patients experienced moderate or severe food stasis,alkaline gastritis or bile reflux during the follow-up period.No recanalization of the biliopancreatic limb was found.CONCLUSION SILS+1/L TLDG with uncut R-Y reconstruction could be safely performed as a reduced port surgery.

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.

Current role of palliative interventions in advanced pancreatic cancer

Pancreatic adenocarcinoma is the third leading cause of cancer death in the United States. Unfortunately, at diagnosis, most patients are not candidates for curative resection. Surgical palliation, a procedure performed with the intention of relieving symptoms or improving quality of life, comes to the forefront of management. This article reviews the palliative management of unresectable pancreatic cancer, including obstructive jaundice, duodenal obstruction and pain control with celiac plexus block. Although surgical bypasses for both biliary and duodenal obstructions usually achieve good technical success, they result in considerable perioperative morbidity and mortality, even when performed laparoscopically. The effectiveness of selfexpanding metal stents for biliary drainage is excellent with low morbidity. Surgical gastrojejunostomy for duodenal obstruction appears to be best for patients with a life expectancy of greater than 2 mo while endoscopic stenting has been shown to be feasible with good symptom relief in those with a shorter life expectancy. Regardless of the palliative procedure performed, all physicians involved must be adequately trained in end of life management to ensure the best possible care for patients.

Small bowel perforation after duodenal stent migration:An interesting case of a rare complication

Duodenal stents are frequently used for palliating malignant gastric outlet obstruction.Successful stent placement relieves obstructive symptoms,is cost effective,and has a relatively low complication rate.However,enteral stents have the potential of migrating distally and rarely,even lead to bowel perforation.We present a rare case of a duodenal stent placed as a palliative measure for gastric outlet obstruction due to unresectable pancreatic cancer that migrated distally after a gastrojejunostomy resulting in small bowel perforation.