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.

Endoscopic ultrasound guided gastroenterostomy:Technical details updates,clinical outcomes,and adverse events

Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has been transformed from an innovative technique,into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction.Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed,giving patients more less invasive options.However,EUS-GE is still a technically challenging procedure.In order to improve EUS-GE,several techniques have been reported to improve the technical details.With EUS-GE widely performed,more data about EUS-GE’s clinical outcomes have been reported.The aim of the current review is to describe technical details updates,clinical outcomes,and adverse events of EUS-GE.

Retrievable puncture anchor traction method for endoscopic ultrasound-guided gastroenterostomy: A porcine study

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)is an alternative method for the surgical treatment of gastric outlet obstruction,but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away.Thus,the technique requires superb skill.In order to improve EUS-GE,we have developed a retrievable puncture anchor traction(RPAT)device for EUSGE to address the issue of bowel tenting.AIM To evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.METHODS Six Bama mini pigs each weighing between 15 and 20 kg underwent the RPATassisted EUS-GE procedure.Care was taken to ensure that the animals experienced minimal pain and discomfort.Two days prior to the procedure the animals were limited to a liquid diet.No oral intake was allowed on the day before the procedure.A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method.Infection in the animals was determined.Four weeks after the procedure,a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia.The pig was euthanized after examination.RESULTS The RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals.All the pigs tolerated a regular diet within hours of the procedure.The animals were monitored for four weeks after the RPATassisted EUS-GE,during which time all of the animals exhibited normal eating behavior and no signs of infection were observed.Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals.No tissue overgrowth or ingrowth was observed in any case.Each animal had a mature fistula,and the stents were removed without significant bleeding.Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.CONCLUSION The RPAT method helps reduce mobility of the bowel.Therefore,the RPATassisted EUS-GE method is a minimally invasive treatment modality.

Nomogram for predicting early complications after distal gastrectomy

BACKGROUND Reducing or preventing postoperative morbidity in patients with gastric cancer(GC)is particularly important in perioperative treatment plans.AIM To identify risk factors for early postoperative complications of GC post-distal gastrectomy and to establish a nomogram prediction model.METHODS This retrospective study included 131 patients with GC who underwent distal gastrectomy at the Second Hospital of Shandong University between January 2019 and February 2023.The factors influencing the development of complications after distal gastrectomy in these patients were evaluated using univariate and multivariate logistic regression analysis.Based on the results obtained,a predictive nomogram was established.The nomogram was validated using internal and external(n=45)datasets.Its sensitivity and specificity were established by receiver operating characteristic curve analysis.Decision curve(DCA)analysis was used to determine its clinical benefit and ten-fold overfitting was used to establish its accuracy and stability.RESULTS Multivariate logistic regression analysis showed that hypertension,diabetes,history of abdominal surgery,and perioperative blood transfusion were independent predictors of postoperative complications of distal gastrectomy.The modeling and validation sets showed that the area under the curve was 0.843[95%confidence interval(CI):0.746-0.940]and 0.877(95%CI:0.719-1.000),the sensitivity was 0.762 and 0.778,respectively,and the specificity was 0.809 and 0.944,respectively,indicating that the model had good sensitivity and specificity.The C-indexes of the modeling and validation datasets were 0.843(95%CI:0.746-0.940)and 0.877(95%CI:0.719-1.000),respectively.The calibration curve(Hosmer Lemeshow test:χ^(2)=7.33)showed that the model had good consistency.The results of the DCA analysis indicated that this model offered good clinical benefits.The accuracy of 10-fold cross-validation was 0.878,indicating that the model had good accuracy and stability.CONCLUSION The nomogram prediction model based on independent risk factors related to postoperative complications of distal gastrectomy can facilitate perioperative intervention for high-risk populations and reduce the incidence of postoperative complications.

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.

Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasoundguided gastroentero-anastomosis

Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be caused by mechanical obstruction,either benign or malignant,or by motility disorders.In this review we will focus on malignant GOO and on its endoscopic ultrasound(EUS)-guided palliative treatment.The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas;other causes include duodenal or ampullary neoplasms,gastric lymphomas,retroperitoneal lymphadenopathies and,more infrequently,gallbladder and bile duct cancers.Surgery represents the treatment of choice when radical and curative resection is potentially feasible;if the malignant cause is not likely to be completely resected,palliative treatments should be proposed.Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent.Both treatments are effective;however,endoscopic stent placement is less invasive and it is associated with good short-term results,while surgery provides longer-lasting effects with a lower frequency of reintervention.In the last few years,EUS-guided gastroenterostomy(GE)has been proposed as palliative treatment for malignant GOO.This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction,through the deployment of a lumen-apposing metal stent under EUS-view.EUS-GE has the advantage of being as minimally invasive as enteral stent placement,and of guaranteeing long-term results similar to those of surgery.

Annular pancreas producing duodenal obstruction: A case report

Annular pancreas is a rare congenital anomaly characterized by the presence of ectopic pancreatic tissue surrounding the duodenum. This malformation is usually asymptomatic in adults, but can manifests as pancreatitis, duodenal stenosis, or duodenal or gastric ulceration. We report the case of a young patient of 18 years old hospitalized for epigastric pain and vomiting, in whom radiological investigations showed an annular pancreas. At operation, a complete obstruction of the duodenum between its first and second parts was found, caused by an annular pancreas. No other congenital anomaly of the intra abdominal organs was noted. A gastroenterostomy was performed. Both the rarity of this congenital abnormality and its successful correction by surgical means have prompted us to make the following presentation.

Unveiling hidden outcomes in malignant gastric outlet obstruction research–insights from a"Pancreas 2000"review

Malignant gastric outlet obstruction(mGOO)is a major condition affecting patients with periampullary tumors,including pancreatic cancer.The current treatment options include surgical gastroenterostomy,endoscopic stenting and more recently EUS-guided gastroenterostomy.Most studies comparing the outcomes of the three procedures focus on technical success,clinical success and safety.Several“occult”outcomes relevant to the patient’s viewpoints and perspective may ultimately impact on cancer-related and overall survival,such as body mass composition,nutritional biomarkers,chemotherapy tolerance and patient-reported quality of life.The aim of this review is to provide an overview of potential key outcomes that should be explored in future comparative research around mGOO treatment options.