RESUMEN
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 re-interventions. 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.
Asunto(s)
Endoscopía Gastrointestinal/métodos , Obstrucción de la Salida Gástrica/cirugía , Gastroenterostomía/métodos , Cuidados Paliativos/métodos , Neoplasias Pancreáticas/complicaciones , Neoplasias Gástricas/complicaciones , Endoscopía Gastrointestinal/efectos adversos , Endoscopía Gastrointestinal/economía , Endoscopía Gastrointestinal/instrumentación , Endosonografía/economía , Endosonografía/instrumentación , Endosonografía/métodos , Obstrucción de la Salida Gástrica/diagnóstico , Obstrucción de la Salida Gástrica/etiología , Gastroenterostomía/efectos adversos , Gastroenterostomía/economía , Gastroenterostomía/instrumentación , Humanos , Yeyuno/cirugía , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Estadificación de Neoplasias , Cuidados Paliativos/economía , Neoplasias Pancreáticas/patología , Neoplasias Pancreáticas/cirugía , Calidad de Vida , Reoperación/economía , Stents Metálicos Autoexpandibles/efectos adversos , Stents Metálicos Autoexpandibles/economía , Estómago/diagnóstico por imagen , Estómago/cirugía , Neoplasias Gástricas/patología , Neoplasias Gástricas/cirugía , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
Introduction: Robotic distal gastrectomy (RDG) is now thought to be less invasive than conventional laparoscopic distal gastrectomy (LDG) for gastric cancer. Although the delta-shaped anastomosis is an established, widely performed procedure for intracorporeal Billroth-I (B-I) gastroduodenostomy after LDG, it has some difficulties and is performed in the ischemic region of the duodenum. We therefore developed a novel overlap B-I gastroduodenostomy after RDG. Materials and Methods: We started using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) for RDG in May 2017. The robotic overlap B-I reconstruction was performed via side-to-side anastomosis, as follows: Two small incisions were made, one on the greater curvature of the remnant stomach, 5 cm from the edge of the remnant gastric stump, and one on the superior edge of the anterior wall of the duodenal stump. A 45-mm EndoWrist linear stapler device (EWLS) loaded with a blue cartridge was inserted through the incision. After the remnant stomach and duodenum were attached to the V-shaped form by the EWLS, the incisions were closed by the EWLS. Results: Seven patients underwent RDG followed by a robotic overlap B-I procedure up to March 2019. Short-term outcomes were determined from medical records and operative videos. No intraoperative complications or conversions to open or conventional laparoscopic surgery occurred. The mean time for the anastomosis was 37 (range 29-45 minutes) minutes. No postoperative complications occurred following the robotic overlap B-I procedure. Discussion: RDG followed by an overlap B-I gastroduodenostomy might be feasible and safe. However, long-term follow-up is required to identify additional benefits.
Asunto(s)
Gastroenterostomía/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Neoplasias Gástricas/cirugía , Anciano , Duodenostomía/métodos , Femenino , Gastrectomía/métodos , Gastroenterostomía/instrumentación , Humanos , Laparoscopía/instrumentación , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Tempo Operativo , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/instrumentación , Engrapadoras QuirúrgicasAsunto(s)
Tratamiento Conservador/métodos , Endoscopía Gastrointestinal/métodos , Obstrucción de la Salida Gástrica/terapia , Stents Metálicos Autoexpandibles , Neoplasias Gástricas/complicaciones , Tratamiento Conservador/instrumentación , Descompresión/instrumentación , Descompresión/métodos , Endoscopía Gastrointestinal/instrumentación , Endosonografía , Fragilidad/etiología , Fragilidad/mortalidad , Obstrucción de la Salida Gástrica/etiología , Gastroenterostomía/instrumentación , Gastroenterostomía/métodos , Humanos , Intubación Gastrointestinal/instrumentación , Intubación Gastrointestinal/métodos , Esperanza de Vida , Selección de Paciente , Neoplasias Gástricas/mortalidad , Resultado del Tratamiento , Ultrasonografía IntervencionalRESUMEN
BACKGROUND/AIMS: Endoscopic retrograde cholangiopancreatography (ERCP) in Billroth II gastrectomy patients is technically demanding and factors affecting its technical difficulty have not yet been clarified. This study aimed to investigate the outcomes of ERCP in Billroth II gastrectomy patients and identify potential factors affecting its technical failure. PATIENTS AND METHODS: A large retrospective study of 308 consecutive patients (391 procedures) with Billroth II gastrectomy-who underwent ERCP from January 2002 to December 2016-was conducted. The outcomes of ERCP and potential factors affecting its technical failure were analyzed. RESULTS: The success rate of duodenal ampullary access, selective duct cannulation and the accomplishment of expected procedures was 81.3% (318/391), 86.5% (275/318) and 97.3% (256/263), respectively, and the technical success rate was 70.3% (275/391). The overall ERCP-related complication rate was 15.3% (60/391). The multivariate analysis indicated that first-time ERCP attempt [odds ratio (OR) 4.29, 95% confidence interval (CI) 2.34-7.85, P < 0.001], Braun anastomosis (OR 3.65, 95% CI 1.38-9.64, P < 0.009), and no cap-assisted gastroscope (OR 3.05, 95% CI 1.69-5.51, P < 0.001) were significantly associated with technical failure. CONCLUSIONS: ERCP is safe, effective and feasible for Billroth II gastrectomy patients. Previous ERCP history, absence of Braun anastomosis and the use of a cap-assisted gastroscope are the predictive factors for its technical success.
Asunto(s)
Colangiopancreatografia Retrógrada Endoscópica/métodos , Duodeno/cirugía , Gastrectomía/métodos , Gastroenterostomía/instrumentación , Anciano , Anastomosis en-Y de Roux/métodos , Colangiopancreatografia Retrógrada Endoscópica/efectos adversos , Conducto Colédoco/cirugía , Femenino , Cálculos Biliares/cirugía , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Insuficiencia del Tratamiento , Resultado del TratamientoAsunto(s)
Endosonografía/métodos , Obstrucción de la Salida Gástrica/diagnóstico por imagen , Obstrucción de la Salida Gástrica/cirugía , Gastroenterostomía/métodos , Stents , Cirugía Asistida por Computador/métodos , Femenino , Obstrucción de la Salida Gástrica/etiología , Gastroenterostomía/instrumentación , Humanos , Persona de Mediana Edad , Pancreatitis/complicaciones , Pancreatitis/diagnóstico , Punciones/instrumentación , Medición de Riesgo , Cirugía Asistida por Computador/instrumentación , Resultado del TratamientoAsunto(s)
Obstrucción de la Salida Gástrica/cirugía , Gastroenterostomía/métodos , Recurrencia Local de Neoplasia/cirugía , Neoplasias Pancreáticas/cirugía , Pancreaticoduodenectomía/efectos adversos , Obstrucción de la Salida Gástrica/diagnóstico por imagen , Obstrucción de la Salida Gástrica/etiología , Gastroenterostomía/instrumentación , Humanos , Yeyuno/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia/complicaciones , Recurrencia Local de Neoplasia/diagnóstico por imagen , Neoplasias Pancreáticas/complicaciones , Neoplasias Pancreáticas/diagnóstico por imagen , Pancreaticoduodenectomía/métodos , Stents , Estómago/diagnóstico por imagen , Estómago/cirugía , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Ultrasonografía Intervencional , Vómitos/etiologíaRESUMEN
Traditionally, restoration of normal bowel continuity after resection and bypass of a diseased or obstructed gastrointestinal tract can only be achieved through surgery, which can be technically challenging and comes with a risk of adverse events. Here, we describe our institutions' experience with endoscopic-guided gastroenterostomy or enteroenterostomy with lumen-apposing metal stent (LAMS) from March 2015 to August 2016. Ten patients had gastrogastrostomy (gastric pouch to gastric remnant) and three patients had jejunogastrostomy (Roux limb to gastric remnant) for the reversal of Roux-en-Y bariatric surgery. One patient had gastroduodenostomy (stomach to duodenal bulb) post antrectomy and one patient had jejunojejunostomy for distal obstruction following Roux-en-Y reconstruction. Technical and clinical success were achieved in all patients, save for delayed anastomotic stenosis following stent removal in one patient, with a mean follow-up of 126 days (3-318 days) with minimal complications in two patients. Endoscopic gastrointestinal anastomosis therefore may be a safe and feasible technique to re-establish continuity of the digestive system following bypass in the short-term.
Asunto(s)
Endosonografía , Muñón Gástrico/cirugía , Gastroenterostomía/métodos , Reoperación/métodos , Adulto , Anciano , Anastomosis en-Y de Roux , Anastomosis Quirúrgica , Constricción Patológica , Endoscopía Gastrointestinal/instrumentación , Estudios de Factibilidad , Femenino , Gastrectomía , Muñón Gástrico/diagnóstico por imagen , Gastroenterostomía/instrumentación , Humanos , Masculino , Metales , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/etiología , Reoperación/efectos adversos , Estudios Retrospectivos , StentsRESUMEN
INTRODUCTION: Proximal gastric leak is one of the most common complications after laparoscopic sleeve gastrectomy (LSG). Endoscopy is the gold standard treatment for acute staple-line leaks. Surgery is the most effective treatment modality in case of chronic fistula. MATERIAL AND METHODS: A 55-year- old man presented an acute leak after LSG. The leak was treated with metal stent deployment with temporary closure. After 6 months, he presented leak recurrence with general sepsis, perigastric-infected collection, and gastro-jejunal fistula. RESULTS: Endoscopic internal drainage (EID) was performed; however, due to fistula persistence, a surgical procedure was proposed. The patient refused revisional surgery; therefore, endoscopic salvage procedure was decided. A fully covered metal stent was deployed in order to bypass the perigastric collection creating an endoscopic gastro-jejunal anastomosis. CONCLUSION: Revisional surgery is the gold standard treatment for chronic fistula after SG. Endoscopic treatment with SEMS deployment may be a sound option in selected cases especially after failure of other endoscopic techniques or refusal of revisional surgery.
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Fuga Anastomótica/etiología , Gastrectomía/efectos adversos , Fístula Gástrica/etiología , Gastroenterostomía/métodos , Fístula Intestinal/etiología , Fuga Anastomótica/cirugía , Enfermedad Crónica , Drenaje/métodos , Endoscopía/efectos adversos , Gastrectomía/métodos , Fístula Gástrica/cirugía , Gastroenterostomía/instrumentación , Humanos , Fístula Intestinal/cirugía , Yeyuno/cirugía , Masculino , Persona de Mediana Edad , Obesidad Mórbida/cirugía , Stents , Estómago/cirugía , Grapado Quirúrgico/efectos adversos , Resultado del TratamientoAsunto(s)
Remoción de Dispositivos/métodos , Endosonografía , Migración de Cuerpo Extraño/cirugía , Gastroenterostomía/instrumentación , Cirugía Endoscópica por Orificios Naturales , Stents , Anciano , Migración de Cuerpo Extraño/diagnóstico por imagen , Migración de Cuerpo Extraño/etiología , Gastroenterostomía/efectos adversos , Gastroenterostomía/métodos , Humanos , Masculino , Resultado del TratamientoRESUMEN
BACKGROUND: We developed a modified delta-shaped gastroduodenostomy technique in totally laparoscopic distal gastrectomy. This novel technique, which effectively reduces the required quantity of linear stapler [1-3], was named as self-pulling and latter transected delta-shaped anastomosis (Delta SPLT) [4]. METHODS: Delta SPLT was performed on 15 patients with stage cT1-2 antral cancer. We ligated the duodenum with a rope instead of transecting it and used the ligature rope to pull the duodenum during the whole progress of gastroduodenostomy. When closing the entry hole, the duodenum was transected at the same time, which saved one linear stapler. Data of clinicopathologic characteristics, surgical and postoperative outcomes were collected and expressed as means ± standard deviations. RESULTS: All the operations were successfully performed by using no more than four 60-mm linear staplers. The mean BMI of the patients is 23.0 ± 2.5 kg/m2 (range 17.0-26.0 kg/m2), and duration of the operation was 115.0 ± 33.4 min (range 75-215 min), including 22.3 ± 6.7 min (range 15-35 min) of reconstruction. Mean blood loss was 82.7 ± 71.3 mL (range 10-300 mL), and mean times to first flatus was 2.3 ± 1.1 days (range 1-5 days). A mean number of 27.5 ± 5.4 (range 18-38) lymph nodes was retrieved. Overall postoperative morbidity rate was 6.7% (1/15). There was no anastomosis-related complication, but one case of pneumonia developed on postoperative day (POD) 2 which was successfully managed by conservative methods. Patients were discharged (POD mean 5.8 ± 1.3, range 4-9) when their bowel movements recovered and no discomfort with soft diet was claimed. CONCLUSION: Delta SPLT is a safe and feasible technique and requires less clinical costs.
Asunto(s)
Gastroenterostomía/instrumentación , Laparoscopía/instrumentación , Neoplasias Gástricas/cirugía , Duodeno/cirugía , Gastroenterostomía/métodos , Humanos , Laparoscopía/métodos , Estudios Retrospectivos , Técnicas de Sutura , Resultado del Tratamiento , Grabación en VideoAsunto(s)
Anastomosis en-Y de Roux/efectos adversos , Neoplasias de los Conductos Biliares/cirugía , Colangiocarcinoma/cirugía , Endoscopía del Sistema Digestivo , Gastroenterostomía , Anastomosis en-Y de Roux/métodos , Neoplasias de los Conductos Biliares/patología , Colangiocarcinoma/patología , Endoscopía del Sistema Digestivo/instrumentación , Endoscopía del Sistema Digestivo/métodos , Femenino , Obstrucción de la Salida Gástrica/etiología , Gastroenterostomía/instrumentación , Gastroenterostomía/métodos , Humanos , Persona de Mediana Edad , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/cirugía , Stents , Cirugía Asistida por Computador/instrumentación , Cirugía Asistida por Computador/métodos , Resultado del TratamientoRESUMEN
BACKGROUND: A delta-shaped anastomosis in totally laparoscopic Billroth I gastrectomy could be performed easily and sufficiently using only laparoscopic linear staplers. However, the restricted maneuverability and severe blurring of these staplers along with their limited hemostability induced strain. In this study, we determined the feasibility and safety of performing delta-shaped anastomosis using the Endo GIA™ Reloads with Tri-Staple™ Technology combined with Endo GIA™ Ultra Universal stapler (Tri-Staple) with a particular focus on short-term surgical outcomes. METHODS: We performed a single-institutional prospective interventional study (UMIN 000008014). The Tri-Staple was prospectively used on 23 consecutive patients who underwent a curative totally laparoscopic Billroth I gastrectomy with delta-shaped anastomosis. These patients were matched with the 19 patients previously treated using the ENDOPATH(®) ETS Articulating Linear Cutters (ETS) on clinical and demographic characteristics. RESULTS: There were no differences between the groups in anastomosis-related local complications, morbidity, non-anastomosis-related local complications, total systemic complications, and short-term outcomes with the exception of significantly reduced blood loss in the Tri-Staple group (ETS vs. Tri-Staple: 37 [10-306] vs. 15 [5-210] mL, p = 0.02). Intraoperative bleeding from the staple line was significantly reduced in the Tri-Staple group. The postoperative drain indwelling period (ETS vs. Tri-Staple, 6 [4-10] vs. 4 [2-43] days, p = 0.032), fasting period (5 [3-7] vs. 3 [3-24] days, p = 0.022), and hospital stay (14 [10-47] vs. 11 [6-58] days, p = 0.025) were significantly shorter in the Tri-Staple group. There was no mortality in this series. Acceleration assessed as indices of blurring of stapler tip might have a significant adverse influence on staple-line bleeding at stapling sites. CONCLUSION: Totally laparoscopic Billroth I distal gastrectomy using Tri-Staple was feasible and safe with favorable short-term surgical outcomes. Reduced blurring while stapling may be a novel endpoint which newly developed stapling devices should target.
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Gastrectomía/métodos , Gastroenterostomía/instrumentación , Laparoscopía/métodos , Neoplasias Gástricas/cirugía , Engrapadoras Quirúrgicas , Grapado Quirúrgico/instrumentación , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Gastrectomía/instrumentación , Gastroenterostomía/métodos , Humanos , Laparoscopía/instrumentación , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Grapado Quirúrgico/métodos , Resultado del TratamientoRESUMEN
BACKGROUND/AIMS: We presented our preliminary clinical data for totally laparoscopic D2 radical distal gastrectomy using delta-shaped anastomosis (TLG-DSA) to evaluate its effectiveness in terms of minimal invasiveness, technical feasibility, and safety for resection of early gastric cancer. METHODOLOGY: Five consecutive patients who underwent TLG-DSA in our institution from October 22th 2013 to November 29th 2013 were enrolled in this study. In all five cases, only laparoscopic linear staplers were used for intra-corporeal anastomosis. RESULTS: There were 3 men and 2 women, with a mean age of 67.6 years and a mean body mass index (BMI) of 21.4. All the patients with early gastric cancer were received TLG-DSA. No postoperative complications were found in all five patients, and no postoperative mortality occurred. CONCLUSIONS: TLG-DSA using laparoscopic linear staplers for early gastric cancer was safe and feasible. Delta-shaped anastomosis is a simple, easy and safe method of intracorporeal gastroduodenostomy.
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Gastrectomía/métodos , Gastroenterostomía , Laparoscopía , Neoplasias Gástricas/cirugía , Grapado Quirúrgico , Anciano , Diseño de Equipo , Estudios de Factibilidad , Femenino , Gastrectomía/instrumentación , Gastroenterostomía/instrumentación , Humanos , Laparoscopía/instrumentación , Masculino , Persona de Mediana Edad , Estadificación de Neoplasias , Neoplasias Gástricas/patología , Engrapadoras Quirúrgicas , Grapado Quirúrgico/instrumentación , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
The main goal of this study was to numerically quantify risk of duodenal stump blowout after Billroth II (BII) gastric resection. Our hypothesis was that the geometry of the reconstructed tract after BII resection is one of the key factors that can lead to duodenal dehiscence. We used computational fluid dynamics (CFD) with finite element (FE) simulations of various models of BII reconstructed gastrointestinal (GI) tract, as well as non-perfused, ex vivo, porcine experimental models. As main geometrical parameters for FE postoperative models we have used duodenal stump length and inclination between gastric remnant and duodenal stump. Virtual gastric resection was performed on each of 3D FE models based on multislice Computer Tomography (CT) DICOM. According to our computer simulation the difference between maximal duodenal stump pressures for models with most and least preferable geometry of reconstructed GI tract is about 30%. We compared the resulting postoperative duodenal pressure from computer simulations with duodenal stump dehiscence pressure from the experiment. Pressure at duodenal stump after BII resection obtained by computer simulation is 4-5 times lower than the dehiscence pressure according to our experiment on isolated bowel segment. Our conclusion is that if the surgery is performed technically correct, geometry variations of the reconstructed GI tract by themselves are not sufficient to cause duodenal stump blowout. Pressure that develops in the duodenal stump after BII resection using omega loop, only in the conjunction with other risk factors can cause duodenal dehiscence. Increased duodenal pressure after BII resection is risk factor. Hence we recommend the routine use of Roux en Y anastomosis as a safer solution in terms of resulting intraluminal pressure. However, if the surgeon decides to perform BII reconstruction, results obtained with this methodology can be valuable.
Asunto(s)
Duodeno/fisiopatología , Gastroenterostomía/efectos adversos , Modelos Biológicos , Estómago/fisiopatología , Dehiscencia de la Herida Operatoria/etiología , Dehiscencia de la Herida Operatoria/fisiopatología , Suturas/efectos adversos , Animales , Simulación por Computador , Duodeno/cirugía , Femenino , Gastroenterostomía/instrumentación , Humanos , Masculino , Medición de Riesgo/métodos , Estómago/cirugía , PorcinosRESUMEN
OBJECTIVE: To explore the safety and feasibility of biodegradable magnesium alloy stapler based on the result of animal experimental study for gastrointestinal anastomosis. METHODS: Sixteen beagle dogs were equally and randomly divided into experimental (magnesium alloy) group and control (titanium alloy) group. A gastrojejunal and a colonic anastomosis were performed in each beagle dog. The anastomosis time, postoperative complications, body weight, blasting pressure of anastomosis and serum glutamic pyruvic transaminase, glutamic oxaloacetic transaminase, creatinine, blood urea nitrogen, and serum magnesium were compared between the two groups. The healing of anastomosis and degradation of magnesium alloy were observed. The histopathological features of heart, liver, spleen and kidney were examined in the two groups. RESULTS: There were no significant differences in anastomosis time, body weight, postoperative complications, anastomotic bursting pressure between the two groups. The anastomosis was healed well, and no dramatic inflammatory cell infiltration was observed. Magnesium alloy could be degraded completely in the animal body within 90 days. There were no significant differences in serum glutamic pyruvic transaminase, glutamic oxaloacetic transaminase, creatinine, blood urea nitrogen and serum magnesium between the two groups. Histopathological examination showed that the degradation of magnesium alloy did not harm the important organs (liver, kidney, heart, brain and spleen). CONCLUSIONS: Magnesium alloy stapler is safe and feasible for gastrointestinal anastomosis in beagle dogs. The degradation of magnesium alloy does not harm the healing of anastomosis and other important organs. Magnesium alloy stapler may be a candidate of biodegradable and safe material of stapler for gastrointestinal anastomosis in human.
Asunto(s)
Implantes Absorbibles , Gastroenterostomía/instrumentación , Magnesio , Suturas , Aleaciones , Animales , Perros , Femenino , Masculino , TitanioRESUMEN
BACKGROUND AND STUDY AIMS: The use of natural oriï¬ce transluminal endoscopic surgery (NOTES) for gastroenterostomy has been previously reported, but it remains technically challenging and additional assistance is often needed. The aim of this study was to develop and evaluate a novel method for the creation of a gastroenterostomy using NOTES with an occluder. METHODS: Transgastric endoscopic gastroenterostomy was performed in 12 healthy female dogs using a therapeutic upper gastrointestinal endoscope and a partially covered occluder. The occluder was removed with a snare 1 week later. The patency of the gastroenterostomy was confirmed by endoscopy, contrast radiological study, necropsy, and histological examination after 2 weeks. RESULTS: NOTES gastroenterostomy with an occluder was successful in all 12 dogs. The mean operative time was 32.3 ± 10.3 min (range 20.3 - 53.5). One dog (the first; 8.3 %) died 4 days after the operation of severe intra-abdominal infection due to incorrect deployment of the occluder and poor bowel preparation. Minor bleeding occurred at the anastomosis after removal of the occluder in two of the remaining dogs (18.2 %). Necropsy revealed postoperative adhesions that had developed at the anastomotic site in one dog (9.1 %). No anastomotic leakage or intestinal obstruction was observed. Complete healing of the anastomosis was confirmed on histological evaluation. CONCLUSION: Gastroenterostomy performed entirely by NOTES using an occluder was technically feasible in this survival animal model.
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Gastroenterostomía/instrumentación , Cirugía Endoscópica por Orificios Naturales/métodos , Animales , Perros , Endoscopios Gastrointestinales , Estudios de Factibilidad , Femenino , Gastroenterostomía/métodos , Cirugía Endoscópica por Orificios Naturales/instrumentaciónRESUMEN
BACKGROUND AND STUDY AIMS: Surgical gastroenterostomy is associated with appreciable morbidity and mortality. We evaluated the technical feasibility and outcomes of a new method of endoscopic ultrasound (EUS)-guided gastroenterostomy using novel tools designed for transluminal therapy. METHODS: In one acute and four survival female pigs, a gastroenterostomy was created under EUS guidance. Novel tools used included: (i) an anchor wire; (ii) an access device; (iii) a fully covered metal stent with bilateral lumen-apposing anchors. The anchor guide wire was inserted through a standard 19-G fine needle aspiration (FNA) needle to appose the small-bowel and stomach walls. The access device created a 3.5-mm fistula opening for insertion of the stent delivery catheter. The stent lumen was dilated to 10 mm to pass a gastroscope into the small bowel. RESULTS: The procedure was technically successful in all animals. No bleeding occurred. In one acute animal, necropsy showed good stent position and no tissue injury. In four survival animals, the stents remained fully patent and all animals showed normal eating behavior without signs of infection. Stents were easily removed without tissue trauma at 4.5 weeks (n = 3) or 5.5 weeks (n = 1). After stent removal, the tracts appeared mature and were easily intubated with the gastroscope. Necropsy and histopathology showed complete fusion of the stomach and small-bowel wall layers at the site of gastroenterostomy. CONCLUSIONS: EUS-guided gastroenterostomy is feasible using novel tools with no adverse outcomes in a survival porcine model. Further study of this is indicated as an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction in appropriately selected patients.