Combined laser and mechanical lithotripsy for endoscopic management of Bouveret's syndrome: A case report.

Bouveret's syndrome (BS) represents an exceedingly rare clinical entity characterized by gastric outlet obstruction induced by a gallstone passing through a cholecystoduodenal, cholecystogastric or choledochoduodenal fistula and impacting in the duodenum or pylorus. Endoscopy is the preferred first-line therapy. It has a favorable safety profile, but requires high level of expertise to achieve stone clearance.

[Upper gastro-intestinal tumour stenosis treated by a new endoscopic approach]. / Sténose digestive tumorale haute traitée par une nouvelle approche endoscopique.

Gastric outlet obstruction (GOO) is a mechanical obstruction of the distal stomach or proximal duodenum. Surgical gastro-jejunostomy and self-expanding metal duodenal stents were the conventional treatments for GOO. In recent years, a new treatment option emerged using echo-guided endoscopic gastroenterostomy (EUS-GE). It appears to be a safe and effective technique with a clinical success rate of 85-90 % and a side effect rate of less than 18 %. Compared to metal duodenal prostheses, the risk of recurrence of GOO and of re-intervention is lower with EUS-GE. The rate of side effects also appears to be lower than with the surgical technique, with a shorter length of hospital stay. Randomised studies comparing these different techniques are still needed to determine a new treatment algorithm for GOO. We report a case of successful EUS-GE performed at our institution.

La «gastric outlet obstruction¼ (GOO) est une obstruction mécanique de l'estomac distal ou du duodénum proximal. La gastro-jéjunostomie chirurgicale et les endoprothèses métalliques auto-expansibles duodénales étaient les traitements conventionnels de la GOO. Ces dernières années, une nouvelle option thérapeutique est apparue utilisant la gastro-entéro-anastomose par voie endoscopique écho-guidée (GE-EEG). Elle semble être une technique sûre et efficace avec un taux de succès clinique de 85 à 90 % et un taux d'effets secondaires de moins de 18 %. Comparé aux prothèses duodénales métalliques, le risque de récidive de la GOO et de réintervention est plus faible avec la GE-EEG. Le taux de manifestations indésirables semble également être plus faible qu'avec la technique chirurgicale, avec une durée de séjour hospitalier plus courte. Des études randomisées comparant ces différentes techniques sont encore nécessaires pour déterminer un nouvel algorithme de traitement pour la GOO. Nous rapportons un cas de GE-EEG réalisée avec succès dans notre institution.

Benign pyloric adenomyoma presented as gastric outlet obstruction: a case report and review of the literature.

BACKGROUND: Gastric adenomyoma is a rare benign tumor composed of glandular structures and smooth muscle fibers. While some classify gastric adenomyoma as a hamartoma, others view it as an abortive form of heterotopic pancreas. Despite its benign nature, there is a risk of malignant transformation. Predominantly found in the antrum, gastric adenomyoma affects all ages but is most common in adults aged 40-60 years. Symptoms are nonspecific, and its similarity to other lesions complicates diagnosis. This paper aims to provide a review of medical literature on gastric adenomyoma and its diagnosis and treatment methods, along with presenting an additional case report on the same topic. CASE PRESENTATION: We present the case of a 55-year-old Syrian man who experienced vomiting, weight loss, and chronic partial constipation. An obstructing mass in the pylorus was detected, and then an open surgery was performed to excise the lesion. A biopsy of the resected mass was obtained for histopathological examination. The final diagnosis of the lesion was pyloric-region adenomyoma with severe pyloric stenosis. After the successful surgery, the patient recovered without any recurrence or complications. CONCLUSIONS: Several diagnostic approaches are available, including radiological studies, endoscopic examination, and fine needle aspiration guided by endoscopic ultrasonography. Treatment options involve endoscopic submucosal dissection and complete laparotomy resection. Further studies and thorough reviews are recommended to better understand the best clinical practices. Practitioners should consider gastric adenomyoma when encountering a mural gastric lesion.

A Classification for Gastric Outlet Obstruction in Childhood: Extending Beyond Infantile Hypertrophic Pyloric Stenosis.

BACKGROUND/AIMS:  Gastric outlet obstruction (GOO) is a rare condition in childhood, with the exception of infantile hypertrophic pyloric stenosis (IHPS). However, no classification exists from a pediatric gastroenterologist's perspective. MATERIALS AND METHODS:  The patients with a diagnosis of GOO between 2009 and 2020 were reviewed retrospectively. We classified the patients according to GOO: presence of clinical findings accompanied by radiological and/or endoscopic findings; clinical status: intractable nonbilious postprandial vomiting alone or with abdominal pain, early satiety, weight loss, postprandial abdominal distension, and malnutrition; radiology: delayed gastric emptying and dilated stomach; endoscopy: nonbilious gastric contents after 6-8 hours of emptying and/or failed pyloric intubation; physical examination: visible gastric peristalsis. RESULTS:  A total of 30 GOO patients (15 patients with IHPS, 1 patient with annular pancreas, 4 patients with gastric volvulus, 2 patients with duodenal atresia, 2 patients with antral web, 1 patient with late-onset hypertrophic pyloric stenosis (LHPS) had surgical treatment, and remaining 5 patients had medical treatment) were enrolled to the study. The median age was 8 months (range: 3 months-16 years), and 14 patients were female. Mitochondrial disorders, LHPS, metabolic disorders, and eosinophilic gastrointestinal system diseases were added to Sharma's GOO classification, and the classification has been expanded. CONCLUSION:  This is the first and largest study of GOO in children. From the perspective of pediatric gastroenterology, new diseases will be addressed, and definitions will be highlighted with our classification for GOO in childhood.

This is a successful removal of more than 450 pieces of metal objects from a patient's stomach: a case report.

BACKGROUND: Ingestion of foreign bodies may be seen unconsciously or intentionally in patients with mental health problems. Most cases pass through the esophagus slowly; however, in some cases, the tumor may be located in narrower areas of the digestive tract that require endoscopic or surgical intervention. This study describes a rare case of successful removal of more than 450 pieces of metal objects from the stomach of a 36-year-old man via ingestion of foreign bodies at Imam Khomeini Hospital in Ahvaz. CASE PRESENTATION: A 36-year-old male patient (Aryan race) presented with complaints of chronic abdominal pain, frequent vomiting, and intolerance to liquids and food. The patient's companions mentioned a history of gradual ingestion of small metal objects 3 months prior. The patient was conscious and had stable vital signs. In the patient's X-ray and endoscopy, multiple metal objects inside the patient's stomach were observed, causing gastric outlet obstruction. The patient underwent gastrostomy surgery, and 452 screws, nuts, keys, stones, and other metal parts weighing 2900 g were removed from the stomach. Five days after the operation, the patient was transferred to the psychiatric service in good general condition and was diagnosed with psychosis, and her condition returned to normal at follow-up. CONCLUSION: Successful removal of this foreign body is rare. In chronic abdominal pain, especially in the context of psychiatric disorders, attention should be given to the ingestion of foreign bodies. In swallowing large amounts of sharp and metallic foreign objects, surgical intervention is necessary, especially in cases of obstruction, and saves the patient's life.

IgG4-related disease presenting with gastric outlet obstruction.

A woman in her 20s presented with 6 weeks of fever, persistent vomiting and 28% loss of body weight. Symptoms were refractory to treatment with antiemetics and broad spectrum antibiotics.Further investigation via oesophageogastroduedenoscopy revealed a large gastric ulcer and pyloric stricture, causing gastric outlet obstruction (GOO). Biopsies of the stomach and duodenum showed plasma cell infiltration with a large proportion being IgG4 positive.Treatment with methylprednisolone, and later prednisolone, quickly improved inflammatory markers and symptoms. Balloon dilatation of the pyloric stricture also improved vomiting, allowing eventual re-establishment of oral nutrition. The patient made a full recovery with maintenance treatment on mycophenolate mofetil.IgG4-related disease (IgG4-RD) is a multisystem disorder with unpredictable presentation. The case highlights diagnostic challenges in IgG4-RD and identifies it as a rare differential in upper gastrointestinal symptoms. To our knowledge this is the first published case of IgG4-RD in the duodenum causing GOO.

Efficacy and safety of self-expandable metallic stents for management of benign gastric outlet obstruction-A prospective study.

INTRODUCTION: We aimed at evaluating the safety and efficacy of self-expandable metallic stent (SEMS) insertion for managing patients with benign gastric outlet obstruction (GOO). METHODS: This prospective interventional study included 23 patients. All consecutive treatment-naïve symptomatic patients with benign GOO were recruited. Fully covered SEMS were deployed across the stricture under fluoroscopic and endoscopic guidance. Technical success, clinical success and sustained treatment response (STR) were assessed. Technical success was defined as the successful deployment of SEMS at the desired anatomic location. Clinical success was defined as the resolution of symptoms and an increase in Gastric Outlet Obstruction Scoring System (GOOSS) of at least 1 point from the baseline score on Day 7. STR was assessed at four and eight weeks post stent removal in patients who had a response at week four. Factors associated with stent migration and non-response at week four were also assessed. RESULTS: The median age of the study population was 30 years (range 19-65 years). Males constituted 65.22%. Most patients presented with vomiting (100%) and abdominal pain (95.65%). Peptic stricture was most common etiology for GOO (60.9%) followed by tubercular (26.1%) and corrosive (13%). Most common site of obstruction was junction of first and second part of duodenum (69.57%) followed by pyloric (30.43%). Median length of stricture was 2 cm (range 1.5-4). Technical success was achieved in all 23 patients (100%). Clinical success was achieved in 21 patients (91.3%). Response at Day 28 was seen in 20 patients (86.95%). Eighteen of 20 (90%) patients who had a response at week four had STR at week four and week eight after stent removal. Stent migration occurred in five (21.7%) patients. On univariate analysis, stricture length, calibre and stent length were found to predict migration. CONCLUSIONS: Fully covered SEMS was an effective and safe management modality in patients with benign GOO. Stent migration remains a troublesome disadvantage.

Congenital pyloric atresia associated with epidermolysis bullosa junctionalis: a novel lethal variant.

A term male baby was born vaginally to a primi mother. An antenatal ultrasound revealed polyhydramnios and a distended stomach in the baby. At birth, the baby had well-defined areas of peeling skin on the face and blisters on the forearm region. The abdominal X-ray revealed a single gastric bubble, which is consistent with pyloric atresia and needs surgery. Pyloroplasty was initially performed, but it was unsuccessful. Therefore, a feeding jejunostomy and gastrostomy were performed. However, the baby developed sepsis and septic shock and died at about 2 months of age. Skin biopsy revealed cleavage above the lamina densa, and genetic analysis indicated heterozygosity in ITGB4 exons 10 and 16, which are associated with epidermolysis bullosa junctionalis and pyloric atresia.

Laparoscopic Gastrojejunostomy Versus Endoscopic Stenting as a Palliative Treatment for Gastric Outlet Obstruction.

Introduction: Gastric outlet obstruction (GOO) is a common complication in advanced stage upper gastrointestinal malignancies. The symptoms of severe nausea and protracted vomiting can lead to a decline in quality of life and cachexia. Symptoms of GOO can be effectively managed with either operative or nonoperative palliative interventions. In our article, we aim to compare laparoscopic gastrojejunostomy (GJ) to endoscopic stenting as palliative interventions for GOO. Methods: We retrospectively evaluated the charts of patients who underwent palliative procedure for gastric outlet obstruction. Group I included patients who underwent endoscopic stenting, and group II patients underwent Laparoscopic GJ. The groups' demographics (age, gender), length of procedure, length of stay, days to oral intake, overall survival, complications rate, and 30-day mortality rates were compared. Results: Overall, 38 patients were included in the study. Nineteen patients underwent endoscopic stenting and 19 underwent laparoscopic GJ. Comparing the groups, no significant differences were noted. Surgical time was significantly longer than the endoscopic procedures (83 minutes versus 25 minutes, P = .001). No significant differences were noted in days of oral intake initiation, overall survival and 30-day mortality rates. Five patients in the stenting group had complications (26.3%) versus none in the surgical group (P = .046). No postoperative complications were noted. Conclusion: Laparoscopic GJ is a safe and feasible treatment for GOO, demonstrating early resumption of oral intake. The relative short hospital stay, combined with an encouraging postoperative complications profile and low reintervention rate, should be kept in mind especially among patients with longer life expectancy.

[Treatment Strategies for Gastric Cancer Patients with Gastric Outlet Obstruction].

Gastric cancer frequently leads to gastric outlet obstruction (GOO), causing significant symptoms and complications. Surgical bypass and stenting are two representative palliative treatments for GOO by gastric cancer. This study reviews clinical guidelines for malignant GOO treatment, highlighting differences in recommendations based on patient survival expectations and systemic health. A meta-analysis of surgical bypass and stenting in gastric cancer patients revealed no significant difference in technical and clinical success rates between the two treatments. However, stenting allowed faster resumption of oral intake and shorter hospital stays but had higher rates of major complications and reobstruction. Despite these differences, overall survival did not significantly differ between the two groups. Emerging techniques like EUS-guided gastrojejunostomy show promise but require further research and experienced practitioners. Ultimately, treatment should be tailored to patient preferences and the specific benefits and drawbacks of each method to improve quality of life and outcomes.

Prepyloric gastric antral muscular ring in an infant.

We present a unique case of a prepyloric gastric muscular ring, a pathology distinct from a gastric web. There is scarcity of literature on this topic, nearly all cases of prepyloric antral rings or webs published in literature are mucosal or submucosal in nature with no evidence of muscle hypertrophy. Given the prevalence of pyloric stenosis as the most common gastric outlet malformation in neonates, gastric rings and webs are not readily considered in the differential diagnosis of gastric outlet obstruction. While most cases of gastric outlet obstruction are diagnosed radiologically, less common pathologies will be confirmed with direct visual inspection during surgery. The term "congenital gastric outlet obstruction" has been used to encompass rare cases, making it appropriate to include a muscular ring in this category. We propose the term "gastric ring" be used with a semantic modifier of "muscular" versus "submucosal/mucosal" to avoid confusion.

Systematic review of long-term effectiveness of endoscopic gastrojejunostomy in patients presenting with gastric outlet obstruction from periampullary malignancies.

BACKGROUND: Recently, endoscopic ultrasound-guided (EUS) gastrojejunostomy (GJ) has emerged as an alternative option to surgical palliation and endoscopic duodenal stenting for malignant gastric outlet obstruction (GOO). Although early success rates are commonly reported with the technique, there is a paucity of data regarding the long-term efficacy of this approach. In this study, we investigated long-term outcomes in patients that underwent EUS-guided GJ for palliation of periampullary malignancies. METHODS: From a total of 192 studies that were reviewed, 6 studies with a follow-up time frame of a minimum of 5 months were analyzed, totaling 238 patients. Outcome variables included technical success rate, clinical success rate, adverse events, symptom recurrence, and re-intervention rates. RESULTS: The cohort of 238 patients had a technical success rate of 93.7% and a clinical success rate of 92.9%. A total of 25 patients (10.5%) experienced adverse events associated with EUS-GJ. A total of 14 patients (5.9%) experienced recurrence of GOO symptoms within 5 months. A total of 14 patients (5.9%) underwent re-intervention with the first 5 months. CONCLUSIONS: This systematic review shows that data are scarce regarding long-term effectiveness of EUS-guided GJ. Even though early success rates have been reported, further studies are needed to focus on long-term efficacy of this approach. Until such studies become available, surgical palliation should continue to be the treatment of choice for patients with malignant GOO with a prolonged life expectancy.

Bouveret Syndrome: A Curious Simultaneous Presentation of Two Cases: Comparison of Clinical Observations and Surgical Management.

Gallstone ileus is an uncommon occurrence and accounts for about 0.3-0.5% of complications of cholelithiasis in elderly patients. Bouveret syndrome is an uncommon medical condition resulting from the blockage of the duodenal bulb by a stone, which consequently obstructs the outlet of the stomach. Until now, a comparison of two different presentations of Bouveret syndrome has not been published in the literature due to the rarity of this pathology. The curious simultaneous occurrence of the two cases discussed here made it possible for us to compare the different diagnostic and therapeutic pathways. In fact, both cases differ not only in their presenting symptoms, but also in the management adopted by the same surgical team.

Management of complicated Bouveret's syndrome.

Bouveret's syndrome is an uncommon cause of gastric outlet obstruction caused by the impaction of large gallstones in the duodenal lumen. The gallstones pass into the duodenal lumen through a cholecystogastric or a cholecystoduodenal fistula. Endoscopic retrieval with or without lithotripsy is the first line of management, often with variable success. We present a case of a woman in her 70s who presented with signs of gastric outlet obstruction and was diagnosed with Bouveret's syndrome with a 5 cm diameter gallstone in the third part of her duodenum. Following several unsuccessful attempts of endoscopic extraction, she underwent successful jejunal enterotomy with fragmentation and extraction of the calculus using an Allis tissue holding forceps. Postoperative recovery was uneventful.

Unusual case of Niemeier type II gallbladder perforation: case report and literature review.

Niemeier type II gallbladder perforation (GBP) is caused by inflammation and necrosis of the gallbladder wall followed by bile spilling into the abdominal cavity after perforation. The gallbladder then becomes adhered to the surrounding inflammatory tissue to form a purulent envelope, which communicates with the gallbladder. At present, the clinical characteristics and treatment of type II GBP are not well understood and management of GBP remains controversial. Type II GBP with gastric outlet obstruction is rare and prone to misdiagnosis and delayed treatment. Recent systematic reviews report that percutaneous drainage does not influence outcomes. In this current case, due to the high risk of bleeding and accidental injury, as well as a lack of access to safely visualize the Calot's triangle, the patient could not undergo laparoscopic cholecystectomy, which would have been the ideal option. This current case report presents the use of percutaneous laparoscopic drainage combined with percutaneous transhepatic gallbladder drainage in a patient with type II GBP associated with gastric outlet obstruction. A review of the relevant literature has been provided in addition to a summary of the clinical manifestations and treatments for type II GBP.

Surgical versus endoscopic gastroenterostomy for gastric outlet obstruction: a retrospective multicentric comparative study of technical and clinical success.

PURPOSE: Gastric outlet obstruction (GOO) is mainly due to advanced malignant disease. GOO can be treated by surgical gastroenterostomy (SGE), endoscopic enteral stenting (EES), or endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to improve the quality of life. METHODS: Between 2009 and 2022, patients undergoing SGE or EUS-GE for GOO were included at three centers. Technical and clinical success rates, post-procedure adverse events (AEs), length of hospital stay (LOS), 30-day all-cause mortality, and recurrence of GOO were retrospectively analyzed and compared between SGE and EUS-GE. Predictive factors for technical and clinical failure after SGE and EUS-GE were identified. RESULTS: Of the 97 patients included, 56 (57.7%) had an EUS-GE and 41 (42.3%) had an SGE for GOO, with 62 (63.9%) GOO due to malignancy and 35 (36.1%) to benign disease. The median follow-up time was 13,4 months (range 1 days-106 months), with no difference between the two groups (p = 0.962). Technical (p = 0.133) and clinical (p = 0.229) success rates, severe morbidity (p = 0.708), 30-day all-cause mortality (p = 0.277) and GOO recurrence (p = 1) were similar. EUS-GE had shorter median procedure duration (p < 0.001), lower post-procedure ileus rate (p < 0.001), and shorter median LOS (p < 0.001) than SGE. In univariate analysis, no risk factors for technical or clinical failure in SGE were identified and abdominal pain reported before the procedure was a risk factor for technical failure in the EUS-GE group. No risk factor for clinical failure was identified for EUS-GE. In the subgroup of GOO due to benign disease, SGE was associated with better technical success (p = 0.035) with no difference in clinical success rate compared to EUS-GE (p = 1). CONCLUSION: EUS-GE provides similar long-lasting symptom relief as SGE for GOO whether for benign or malignant disease. SGE may still be indicated in centers with limited experience with EUS-GE or may be reserved for patients in whom endoscopic technique fails.

Endoscopic ultrasound-guided gastrojejunostomy for benign gastric outlet obstruction (GOO): a retrospective analysis of patients and outcomes.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) has been well utilized in treating malignant gastric outlet obstructions (GOO) given its efficacy and lower risk profile compared to surgery. However, its efficacy and potential for use in patients with benign GOO who are poor surgical candidates is not well documented. The aim of this study was to examine the role of EUS-GJ in treatment of benign GOO in select patients. PATIENTS AND METHODS: This is a single-center, open-label, retrospective descriptive study that included all consecutive patients undergoing EUS-GJ to treat benign causes of GOO. Direct antegrade and direct retrograde methods were utilized. RESULTS: A total of 18 patients were included, 38.9% female with an average age of 63.3 years. Extrinsic GOO was present in (10 of 18) 55.5% of patients and intrinsic etiology was present in (8 of 18) 45.5% of patients. Technical success was achieved in 100% (18 of 18) patients and clinical success was achieved in 94% (17 of 18) patients. In total, 13 patients had follow-up endoscopy, 2 patients were treated relatively recently in time, 1 patient was lost to follow-up, and 2 patients died of other chronic illnesses. Stents remained in place for a median of 286 days (range 88-1444 days). In patients whose stents were removed, 75% (3 of 4) had extrinsic etiologies of GOO. CONCLUSIONS: This study reports a favorable long-term patency with excellent technical and clinical success of EUS-GJ in patients with benign GOO. Despite the limitations of sample size and retrospective nature, it adds to the extremely limited literature of EUS-GJ in management of patients with benign GOO.

Alarming Incidence of Gastric Outlet Obstruction Related to NSAIDS and Synthetic Opioid in North West India.

BACKGROUND: In recent years, there has been an alarming increase in cases of gastric outlet obstruction (GOO) at our center due to drug abuse. So, we conducted this study to know the incidence of nonsteroidal anti-inflammatory drugs (NSAIDs) and synthetic opioid abuse in cases of GOO. METHODS: This was an observational study involving consecutive cases of GOO diagnosed from September 2017 to February 2019. A detailed history, including drug addiction history and clinical examination, was done. Investigations included routine biochemical and hematological tests, upper gastrointestinal endoscopy (UGIE), ultrasonography, rapid urease test (RUT), and histopathology of the diseased area. RESULTS: Among the 102 cases diagnosed with GOO, 62 (60.78%) cases had a history of drug addiction. The drug addiction history was as follows: NSAIDs and opioids in 56, opioids alone in four, and NSAIDs alone in two cases. The most common site of stricture was the second part of the duodenum. The features on histopathology were ulcerations of the mucosa infiltrated by eosinophils, plasma cells, and lymphocytes. CONCLUSION: There is an alarming increase in the incidence of GOO due to NSAIDs and opioid abuse at our center. Efforts should be made to control the indiscriminate use of these over-the-counter drugs to prevent dreaded complications.