Management Of Gastric Outlet Obstruction Research Articles

Is endoscopic ultrasound-guided gastroenterostomy better than surgical gastrojejunostomy or duodenal stenting?

Gastrojejunostomy is a critical procedure for managing gastric outlet obstruction. While surgical gastrojejunostomy has traditionally been the standard approach, endoscopic ultrasound (EUS)-guided gastroenterostomy has emerged as a promising endoscopic alternative. This comprehensive review aims to explore the development, techniques, outcomes, and comparative effectiveness of EUS-guided gastroenterostomy in comparison to duodenal stenting and surgical gastrojejunostomy. A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to April 2024. The search included keywords related to EUS-guided gastrojejunostomy, surgical gastrojejunostomy, and duodenal stenting. Studies reporting on technical success, clinical success, complications, recurrence rates, quality of life, and long-term outcomes were included for analysis. The development of EUS-guided gastroenterostomy has evolved significantly over the years, driven by device advancements and improved endoscopic techniques. Comparative studies have shown that the technique offers several advantages, including the ability to create an anastomosis without the need for surgery, reduced invasiveness, shorter hospital stays, and potentially improved patient outcomes as compared to duodenal stenting and surgical gastrojejunostomy. Endoscopic ultrasound-guided gastroenterostomy represents a promising alternative to surgical gastrojejunostomy and duodenal stenting for the management of gastric outlet obstruction. The technique has evolved significantly, offering a less invasive and more effective treatment option.

Outcomes of Endoscopic Ultrasound-guided Gastroenterostomy Using Lumen-apposing Metal Stent in the Treatment of Malignant and Benign Gastric Outlet Obstruction: A Case Series

Objective: To study the outcomes of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumenapposing metal stent (LAMS) in patients with benign and malignant gastric outlet obstruction (GOO). Materials and Methods: This single-center study retrospectively reviewed the medical records of benign and malignant GOO patients who underwent EUS-GE between May 2019 and September 2023. We evaluated the technical success, adverse events related to the techniques used, clinical success, and recurrence and reintervention rates. Results: A total of twelve patients who underwent three different EUS-GE techniques were included in this study. The first method was the direct over-the-guidewire technique, the second was the wireless-freehand method, and the third was modified endoscopic ultrasound-guided double-balloon occluded gastroenterostomy bypass (M-EPASS). All 3 techniques used preloaded oroenteral catheters in combination. Technical success was achieved in 83.3% (10/12) of patients, and there were 16.6% (2/12) failures due to misdeployment. One (8.3%) severe adverse event occurred resulting in peritonitis during the direct over-the-guidewire method. The second failure, which ensued after use of the wireless-freehand technique, achieved successful stent deployment at the second attempt without any complications. Clinical success was 100% (11/11), and mean follow up was 6.2 months. There was one (9.1 %) incidence of recurrence at 12-month follow up. Conclusion: EUS-GE is effective in the management of GOO, and the wireless-freehand and M-EPASS techniques in combination with oroenteral catheters should be the technique of choice in term of safety and efficacy.

S3314 Novel Use of Tandem Stenting to Create Continuous Patent Channel for Management of Gastric Outlet Obstruction Caused by Diffuse Gastric Adenocarcinoma

S3314 Novel Use of Tandem Stenting to Create Continuous Patent Channel for Management of Gastric Outlet Obstruction Caused by Diffuse Gastric Adenocarcinoma

Endoscopic ultrasound-guided gastrojejunostomy with a direct technique without previous intestinal filling using a tubular fully covered self-expandable metallic stent.

Endoscopic ultrasonography-guided gastrojejunostomy is a minimally invasive method for the management of gastric outlet obstruction. Conventionally, a lumen-apposing metal stent (LAMS) is used to create an anastomosis. However, LAMS is expensive and not widely available. In this report, we described a tubular fully covered self-expandable metallic stent (T-FCSEMS) for this purpose. Twenty-one patients (15 men [71.4%]; median age, 66 years; range, 40-87 years) were included in this study. A total of 19 malignant (12 pancreatic, 6 gastric, and 1 metastatic rectal cancer) and 2 benign cases were observed. The proximal jejunum was punctured with a 19 G needle. The stomach and jejunum walls were dilated with a 6 F cystotome, and a 20×80 mm polytetrafluoroethylene T-FCSEMS (Hilzo) was deployed. Oral feeding was initiated after 12 to 18 hours and solid foods after 48 hours. The median procedure time was 33 minutes (range, 23-55 minutes). After two weeks, 19 patients tolerated oral feeding. In patients with malignancy, the median survival time was 118 days (range, 41-194 days). No serious complications or deaths occurred. All patients with malignancy tolerated oral food intake until they expired. T-FCSEMS is safe and effective. This stent should be considered as an alternative to LAMS for gastric outlet obstruction.

EUS Gastroenterostomy: Primetime for All?

Letter to: Endoscopic ultrasound-guided gastroenterostomy for the management of gastric outlet obstruction: A large comparative study with long-term follow-upEndosc Int Open 2023; 11(01): E60-E66DOI: 10.1055/a-1976-2279

Endoscopy International Open – recently published

Comment on: Outcomes of patients with hepaticojejunostomy anastomotic strictures undergoing endoscopic and percutaneous treatmentEndosc Int Open 2023; 11(01): E24-E31DOI: 10.1055/a-1952-2135 Comment on: Efficacy of the argon plasma coagulation in patients with weight regain after gastric bypass: a randomized control trialEndosc Int Open 2023; 11(01): E43-E51DOI: 10.1055/a-1971-6417 Comment on: Endoscopic ultrasound-guided gastroenterostomy for the management of gastric outlet obstruction: A large comparative study with long-term follow-upEndosc Int Open 2023; 11(01): E60-E66DOI: 10.1055/a-1976-2279

Nasojejunal tube-assisted endoscopic ultrasound-guided gastrojejunostomy for the management of gastric outlet obstruction is safe and effective.

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a therapeutic option for patients with gastric outlet obstruction (GOO), which provides long-term luminal patency without the risk of tumor ingrowth and/or overgrowth and avoids surgical morbidity. The goal of this study was to assess technical success, clinical success, and adverse events associated with a nasojejunal tube-assisted EUS- GJ technique. This was a retrospective study conducted at a single tertiary care center. The nasojejunal tube (14F) was used to perform the EUS-GJ (device-assisted method). During the study period, consecutive GOO patients who underwent EUS-GJ between August 2018 and December 2021 were included. Technical success was defined as adequate positioning and deployment of the stent. The patient's ability to tolerate a normal oral diet without vomiting was defined as clinical success. Thirty patients underwent EUS-GJ during this study period. Twenty-six patients had malignant GOO, while four had a benign obstruction. EUS-GJ was successfully performed in 29 patients, and technical success was 96.67% (29/30). Nasojejunal tube-assisted EUS-GJ technique was used in all patients. Clinical success was achieved in all patients who had technical success (29/29, 100%). The adverse events rate was 6.6%. During the procedure, the median procedure time was 25 min (interquartile range 15-42.5), and the average hospitalization was 4.4 days. Normal meals were tolerated by all patients. After 210 days of median follow-up (range 5-880 days), no recurrence of symptoms was observed. The nasojejunal tube-assisted EUS-GJ is a safe and effective technique to treat GOO symptoms.

A Pragmatic Approach to the Management of Gastric Outlet Obstruction From Pancreaticobiliary Malignancy.

1Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA; 2Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA. Correspondence: Arvind J. Trindade, MD. E-mail: [email protected]. SUPPLEMENTARY MATERIAL accompanies this paper at https://links.lww.com/AJG/C875

Endoscopic ultrasound-guided gastroenterostomy for the management of gastric outlet obstruction: A large comparative study with long-term follow-up.

Background and study aims Gastric outlet obstruction (GOO) is traditionally managed with surgical gastroenterostomy (surgical-GE) and enteral stenting (ES). Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is now a third option. Large studies assessing their relative risks and benefits with adequate follow-up are lacking. We conducted a comparative analysis of patients who underwent EUS-GE, ES, or surgical-GE for GOO. Patients and methods In this retrospective comparative cohort study, consecutive patients presenting with GOO who underwent EUS-GE, ES, or surgical-GE at two academic institutions were reviewed and independently cross-edited to ensure accurate reporting. The primary outcome was need for reintervention. Secondary outcomes were technical and clinical success, length of hospital stay (LOS), and adverse events (AEs). Results A total of 436 patients (232 EUS-GE, 131 ES, 73 surgical-GE) were included. The median duration of follow-up of the entire cohort was 185.5 days (interquartile range 55.25-454.25 days). The rate of reintervention in the EUS-GE group was lower than in the ES and surgical-GE groups (0.9 %, 12.2 %, and 13.7 %, P < 0.0001). Technical success was achieved in 98.3 %, 99.2 %, and 100 % ( P = 0.58), and clinical success was achieved in 98.3 %, 91.6 %, and 90.4 % ( P < 0.0001) in the EUS-GE, ES, and surgical-GE groups, respectively. The EUS-GE group had a shorter LOS (2 days vs. 3 days vs. 5 days, P < 0.0001) and a lower AE rate than the ES and surgical-GE groups (8.6 % vs. 38.9 % vs. 27.4 %, P < 0.0001). Conclusion This large cohort study demonstrates the safety and palliation durability of EUS-GE as an alternative strategy for GOO palliation in select patients.

S2898 A Unique and Challenging Presentation of Abdominal Pain in Patient of Gastric Bypass Anatomy

Introduction: We are presenting an interesting and challenging case of chronic abdominal pain in a patient of gastric bypass surgery. This patient required Endoscopic ultrasound (EUS) directed transgastric Endoscopy (EDGE) for diagnosis and management of pyloric stenosis in a patient with Roux-en-Y gastric bypass anatomy. Case Description/Methods: 61 years old female presented to emergency department with worsening upper abdominal pain for last 2 years. Patient has history of Roux-en-Y gastric bypass surgery in 2002. Patient had multiple prior evaluations with endoscopies and imaging without any significant etiology identified. She underwent repeat endoscopy with finding of a short gastric pouch and normal-appearing gastrojejunal anastomosis and jejunal limbs. An upper gastrointestinal series and small-bowel follow-through showed normal anatomy. A computed tomography of the abdomen significantly distended bypassed stomach (BS) with fluid. Upon further discussion with Radiology, there was abnormal thickening and elongation of the gastric pylorus noted. Subsequently, an EUS directed transgastric endoscopy was performed revealing significantly dilated BS. An AXIOS stent was placed between gastric pouch and BS in order to decompress as well as gaining access to pyloric channel. Tract was dilated and entered with regular gastroscope. Excessive amount of fluid was aspirated from stomach. A severe friable stenosis found at pylorus. This was only traversed with XP190N gastroscope with outer diameter of 5.4mm. Pathology showed benign inflammation. Repeat EGD was performed through the established tract. Pyloric stricture was then dilated up to 12 mm. Patient was subsequently discharged in stable condition and followed up in clinic. She reported significant improvement in symptoms. Discussion: Despite its overall benefit, there are multiple complications associated with Roux-en-Y gastric bypass. EDGE procedure has been routinely performed in order to gain access to biliary tract. Options to gain access to BS include laparoscopic assisted endoscopy versus surgical exploration. EDGE not only provided therapeutic benefit of decompressing significantly distended excluded stomach but also provided access for examining pyloric channel stenosis/thickening concerning for inflammation or neoplasm. After confirming benign nature, repeated endoscopy was performed for dilation. To our knowledge, this is among first few cases of minimally invasive management of gastric outlet obstruction in patient with gastric bypass anatomy.

A CLINICAL STUDY OF GASTRIC OUTLET OBSTRUCTION IN ADULTS

Introduction : Gastric Outlet Obstruction implies complete or incomplete obstruction of the distal stomach, pylorus or proximal duodenum[1]. This may occur as an obstructing mass lesion, external compression or as a result of obstruction from acute edema, chronic scarring and brosis or a combination of both[1,2].Gastric outlet obstruction is not a single entity; it is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying[3]. To Aims Of The Study : determine the relative incidence of benign and malignant gastric outlet obstruction.To study the modes of presentation of gastric outlet obstruction.To study the outcome of management of gastric outlet obstruction. The pat Materials And Methods : ients for this study have been selected from Kurnool medical college, KURNOOL from September 2020 to April 2022. In total, 50 in-patients of gastric outlet obstruction have been studied. An elaborate study of these cases with regard to the history, clinical features, routine and special investigations, pre-operative treatment, operative ndings, postoperative management and complications in post-operative period is done. Of the 50 cases of gastric Results : outlet obstruction 26 had carcinoma antrum, 23 had cicatrized duodenal ulcer and 1 had gastric outlet obstruction secondary to corrosive ingestion. The commonest causes of gastric outlet obstruction in adults are Conclusion : carcinoma stomach with antral growth producing gastric outlet obstruction (52%) and cicatrised duodenal ulcer (46%). Number of cases with cicatrised duodenal ulcer as the chief etiological factor for gastric outlet obstruction is diminishing and the number of cases of antral carcinoma of stomach as the cause of gastric outlet obstruction is increasing.

The First 40 Years of Gastrojejunostomy: From Billroth to Murphy to Mayo.

In the early era of therapeutic laparotomy, surgeons developed operations where the extirpation of pathology only required simple ligation of blood supply, detachment of diseased organs or drainage of infection. In 1881, when sutured anastomosis was in its infancy, a surgeon at Billroth's clinic in Vienna, Anton Wolfler, performed the first successful gastrojejunostomy to treat gastric outlet obstruction. The patient was a 38-year-old male who presented weak and emaciated with an obstructing stomach cancer. After Dr Wolfler's sutured gastrojejunostomy, the patient recovered without complication and was able to eat by mouth. Over the next 40 years, surgeons around the world explored variations in the technique of this operation until it was used in common practice for the management of gastric outlet obstruction. During that same era, gastrojejunostomy severed as a testing ground for sutured anastomosis, which became the accepted method of enteric anastomosis. This article will review the early history of gastrojejunostomy, its origination and the European and American innovators who created modifications of this life-saving operation. The importance that gastrojejunostomy had in the evolution of sutured enteric anastomosis will be highlighted.

EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis.

Background and study aims Surgical gastroenterostomy (SGE) has been the mainstay treatment for gastric outlet obstruction (GOO). The emergence of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) presents a less invasive alternative for palliation of GOO. We conducted a comprehensive review and meta-analysis to compare the effectiveness and safety of EUS-GE compared to SGE. Methods Multiple electronic databases and conference proceedings up to April 2021 were searched to identify studies that reported on safety and effectiveness of EUS-GE in comparison to SGE. Pooled odds ratios (ORs) of technical success, clinical success, adverse events (AE) and recurrence, and pooled standardized mean difference (SMD) of procedure time and post-procedure length of stay (LOS) were calculated. Study heterogeneity was assessed using I 2 and Cochran Q statistics. Results Seven studies including 625 patients (372 EUS-GE and 253 SGE) were included. EUS-GE had lower pooled odds of technical success compared with SGE (OR 0.19, 95 % confidence interval [CI] 0.06–0.60, I 2 0 %). Among the technically successful cases, EUS-GE was superior in terms of clinical success (OR 4.73, 95 % CI 1.83–12.25, I 2 18 %), lower overall AE (OR 0.20, 95 % CI 0.10–0.37, I 2 39 %), and shorter procedure time (SMD –2.4, 95 % CI –4.1, –0.75, I 2 95 %) and post-procedure LOS (SMD –0.49, 95 % CI –0.94, –0.03, I 2 78%). Rates of severe AE (0.89, 95 % CI 0.11–7.36, I 2 67 %) and recurrence (OR 0.49, 95 % CI 0.18–1.38, I 2 49 %) were comparable. Conclusions Our results suggest EUS-GE is a promising alternative to SGE due to its superior clinical success, overall safety, and efficiency. With further evolution EUS-GE could become the intervention of choice in GOO.

70-Year-Old Man With Chronic Nausea and Vomiting

70-Year-Old Man With Chronic Nausea and Vomiting

S1021 Comparison of Endoscopic Ultrasound-Guided Gastroenterostomy to Surgical Gastroenterostomy for the Management of Gastric Outlet Obstruction: A Systematic Review and Meta-Analysis

S1021 Comparison of Endoscopic Ultrasound-Guided Gastroenterostomy to Surgical Gastroenterostomy for the Management of Gastric Outlet Obstruction: A Systematic Review and Meta-Analysis

Novel Uses of Lumen-apposing Metal Stents: A Review of the Literature.

The field of therapeutic endoscopy has seen many recent advancements. One such emerging field is the use of lumen-apposing metal stents (LAMS). Although a few LAMS have been developed, the most commonly reviewed and the only Food and Drug Administration (FDA)-approved LAMS is the Axios stent by Boston Scientific. In 2013, LAMS were initially approved by the FDA for the management of pancreatic fluid collection drainage in the presence walled-off necrosis. Pancreatic fluid collections are traditionally drained with either a plastic stent or a covered biliary self-expanding metal stent. Plastic stents have a double pigtail feature which prevents stent migration. However, their narrow lumen poses limitations as it can lead to early stent occlusion. Fully covered metal stents have larger diameters, allowing improved drainage and decreased stent occlusion but their tubular shape is prone to migration. Consequently, this results in leakage, and frequent retrievals. Over the years, due to their versatility, LAMS now have many off label uses. This includes management of gastric outlet obstruction, superior mesenteric artery syndrome, strictures, gallbladder drainage, and postsurgical collection drainage. In this review, we will be discussing the FDA approved and the nonapproved uses of LAMS.

Endoscopic ultrasound-guided gastroenterostomy using large-diameter (20 mm) lumen apposing metal stent (LLAMS).

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20 mm) LAMS (LLAMS). Patients and methods A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94 %) (mean age: 61.35 ± 16.52 years; 54.84 % males) underwent EUS-GE using LLAMS for malignant (n = 23) and benign (n = 8) GOO. Technical success was achieved in all patients (100 %) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55 % of patients (n = 29). Two patients (6.45 %) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84 ± 160.41 days (median 70, range 4–590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23 %) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.

Laparoscopic versus EUS-guided gastroenterostomy for gastric outlet obstruction: an international multicenter propensity score–matched comparison (with video)

In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic GE (L-GE) are scarce. Our aim was to perform a propensity score-matched comparison between EUS-GE and L-GE. An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of .1 was applied, also considering underlying disease and oncologic staging. Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE-treated patients (94.6%) versus 100% in the L-GE group (P= .493). Clinical success, defined as eating without vomiting or GOO Scoring System≥2, was achieved in 97.1% and 89.2%, respectively (P= .358). Median time to oral intake (1 [interquartile range {IQR}, .3-1.0] vs 3 [IQR, 1.0-5.0] days, P< .001) and median hospital stay (4 [IQR, 2-8] vs 8 [IQR, 5.5-20] days, P< .001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P= .007) and severe (.0% vs 16.2%, P= .025) adverse events were identified more frequently in the L-GE group. For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable.

Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction: Experience from A Tertiary-Care Facility in Pakistan

Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction: Experience from A Tertiary-Care Facility in Pakistan

Clinical characteristics and management of gastric outlet obstruction in acute pancreatitis

ObjectiveThe aim of this study was to describe the clinical characteristics and management of gastric outlet obstruction following acute pancreatitis(AP). BackgroundGastric outlet obstruction (GOO) is not uncommon in acute pancreatitis (AP) and can occur throughout the course. However, the clinical features and related treatment of GOO is rarely reported. MethodsA retrospective review of AP patients with a diagnosis of GOO from March 2017 to June 2020 was performed. The diagnosis and management of GOO, as well as the demographic characteristics and clinical outcomes of the study patients, were collected and analyzed. ResultsOver the three years, there were 60 AP patients developed GOO, constituting an incidence of 5.7%. Thirty-three patients (55.0%, 33/60) developed GOO in the first 4 weeks and 27 patients (45.0%, 27/60) after 4 weeks from onset. Pancreatic necrosis compression (60.6%; 20/33), gastric outlet gastrointestinal edema (27.3%, 9/33) are the main causes of early-onset GOO (≤4 weeks), while wall-off necrosis (92.6%, 25/27) is the leading cause in the late phase (>4 weeks). The management of GOO incorporates both supportive and specific treatment like gastric decompression, gastric juice reinfusion, percutaneous catheter drainage, etc. The mortality of AP patients with GOO (≤4 weeks) was 21.2% and none patients who developed GOO (>4 weeks) died. ConclusionsGOO, as a gastrointestinal complication developed in AP patients, has two peak incidences in the duration of AP and needs to be paid more attention to.