Endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for palliation of malignant gastric outlet obstruction (ENDURO): study protocol for a randomized controlled trial.

BACKGROUND: Malignant gastric outlet obstruction (GOO) is a debilitating condition that frequently occurs in patients with malignancies of the distal stomach and (peri)ampullary region. The standard palliative treatment for patients with a reasonable life expectancy and adequate performance status is a laparoscopic surgical gastrojejunostomy (SGJ). Recently, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) emerged as a promising alternative to the surgical approach. The present study aims to compare these treatment modalities in terms of efficacy, safety, and costs. METHODS: The ENDURO-study is a multicentre, open-label, parallel-group randomized controlled trial. In total, ninety-six patients with gastric outlet obstruction caused by an irresectable or metastasized malignancy will be 1:1 randomized to either SGJ or EUS-GE. The primary endpoint is time to tolerate at least soft solids. The co-primary endpoint is the proportion of patients with persisting or recurring symptoms of gastric outlet obstruction for which a reintervention is required. Secondary endpoints are technical and clinical success, quality of life, gastroenterostomy dysfunction, reinterventions, time to reintervention, adverse events, quality of life, time to start chemotherapy, length of hospital stay, readmissions, weight, survival, and costs. DISCUSSION: The ENDURO-study assesses whether EUS-GE, as compared to SGJ, results in a faster resumption of solid oral intake and is non-inferior regarding reinterventions for persistent or recurrent obstructive symptoms in patients with malignant GOO. This trial aims to guide future treatment strategies and to improve quality of life in a palliative setting. TRIAL REGISTRATION: International Clinical Trials Registry Platform (ICTRP): NL9592. Registered on 07 July 2021.

Early Lumen-Apposing Metal Stent Dysfunction Complicating Endoscopic Ultrasound-Guided Gastroenterostomy: A Report of Two Cases.

Endoscopic ultrasonography-guided gastroenterostomy using a lumen-apposing metal stent has emerged as a novel technique in the palliative treatment of malignant gastric outlet obstruction. Endoscopic ultrasonography-guided gastroenterostomy seems to have the potential to provide long-lasting patency in a minimally invasive manner. Low reintervention rates have been described. We report two cases with early lumen-apposing metal stent dysfunction, compromising patency. One case showed food impaction after three weeks, and hyperplastic tissue overgrowth with a buried distal flange six weeks after stent placement. The latter was successfully treated by argon plasma coagulation, stent removal, and deployment of a larger-diameter lumen-apposing metal stent. The second case showed a narrowed luminal diameter of the stent and jejunal pressure ulcerations after three weeks. The narrowing was successfully treated by balloon dilation. Eight weeks later, hyperplastic tissue overgrowth at the distal flange of the stent and a gastro-colonic fistula were diagnosed, followed by extensive reconstructive surgery.

Colon ischemia: Right-sided colon involvement has a different presentation, etiology and worse outcome. A large retrospective cohort study in histology proven patients.

BACKGROUND: Colon ischemia (CI), is generally considered a non-occlusive mesenteric ischemia disorder that usually runs a benign course, but right-sided involvement (RCI) has been associated with worse outcome. The poor outcome of RCI has been associated with comorbidity, but more recently also with occlusions of the mesenteric arteries. We performed a retrospective analysis of a large cohort of CI-patients to assess differences in presentation, etiology, and comorbidity between right-sided colon ischemia (RCI) and non-right-sided colon ischemia (NRCI), and their relation to outcome. METHODS: We performed a retrospective cohort study in two centers from 2000 to 2011 for CI and analyzed clinical presentation, etiology, treatment and outcome. Diagnosis was based on full colonoscopy and/or surgical findings and confirmed by histopathology. RESULTS: 239 patients were included (mean age 69, 52% female). RCI was found in 48% and NRCI in 52%. Patients with NRCI presented more often with rectal bleeding (87% vs. 45%; p<0.001). In RCI more nausea (58% vs. 39%; p=0.013), weight loss (56% vs. 19%; p<0.001), paralytic ileus (32% vs. 18%; p=0.018) and peritoneal signs (27% vs. 7%; p<0.001) was observed compared to NRCI. The cause of CI was more often idiopathic in NRCI (46% vs. 26%; p=0.002); an occlusive cause was seen more often in RCI (26.3 vs 2.4%, p<0.0001). RCI patients had longer hospital stay (15 vs. 8 days, p<0.001), need for surgery (61% vs. 34%, p<0.001), and trend toward higher 30-day in-hospital mortality (20% vs. 12%, p=0.084). CONCLUSIONS: RCI ischemia has different etiology, presentation, and outcome. The series shows a high proportion of - treatable - vessel occlusion. It reinforces the advice to perform CT angiography in RCI as means to improve its poor outcome.

A black perforated esophagus treated with surgery: Report of a case.

A case of a perforated black esophagus treated with minimal invasive surgery is presented. A 68-year-old women underwent a right-sided hemihepatectomy and radio frequency ablation of two metastasis in the left liver lobe. Previous history revealed a hemicolectomy for an obstructive colon carcinoma with post-operative chemotherapy. Postoperatively she developed severe dyspnea due to a perforation of the esophagus with leakage to the pleural space. Video-assisted thoracoscopic surgery (VATS) to adequately drain the perforation was performed. Gastroscopy revealed a perforated black esophagus. The black esophagus, acute esophageal necrosis or Gurvits syndrome is a rare entity with an unknown aetiology which is likely to be multifactorial. The estimated mortality rate is high. To our knowledge, this is the first case published of early VATS used in a case of perforated black esophagus.