Endoscopic gastroenterostomy: techniques and review.

PURPOSE OF REVIEW: Gastric outlet obstruction (GOO) can result from benign and malignant causes. Until recently, surgical gastrojejunostomy was the treatment of choice for patient with benign and malignant GOO with a good functional status. Endoscopic placement of luminal self-expandable metal stents is currently widely accepted as the first line of treatment for malignant GOO because of its effectiveness and minimally invasive nature. The main shortcoming of luminal stents is the high incidence of recurrent GOO most commonly because of tumor ingrowth/overgrowth. More recently, endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) has emerged as an alternative to both luminal stent placement and surgical gastrojejunostomy. Advantages of EUS-GE include its minimally invasive nature, efficacy and low incidence of recurrent GOO in cancer patient. We will describe five different techniques to perform this novel and rapidly evolving procedure using a biflanged, lumen-apposing metal stent and compare benefits and risks of each approach. These approaches include antegrade EUS-GE or 'traditional/downstream' and 'rendezvous' methods, retrograde EUS-GE or 'enterogastrostomy,'17 (EPASS), and antegrade EUS-GE 'direct' method. RECENT FINDINGS: A preprocedural computed tomography scan allows the proximity of the duodenum or jejunum to the stomach to be determined and to assess for the presence of significant ascites, which is a contraindication to EUS-GE. Technical success rates even in the early studies approximate 90%, regardless of the technique used. Clinical success rates have been exceptionally high as well, with only a minority of patients experiencing persistent symptoms despite technical success. One procedure-related death has been reported so far with an overall low morbidity. Pain, bleeding, pneumoperitoneum and peritonitis have been reported in one patient each. However, duration of follow-up in these studies has been short. SUMMARY: We describe five different techniques to performing EUS-GE. Early studies show excellent efficacy. Stent misdeployment/displacement is the most frequent relevant adverse event. Prospective and preferably randomized trials with comparison to endoluminal enteral stents and surgical gastroenterostomy are needed.

[The influence of draining on the quality of the intestinal suture].

The Billroth II gastric resection with mechanical suture of the gastro-jejunoanastomosis was performed in 8 dogs. The amount of E.coli and neutrophiles in tissue edges were registered morphometrically within 30 days. The important defencive role of the mucosa was proved. The inverted and everted mechanical intestinal suture were accessed from the positions of draining possibility.

[Centralization on fewer surgeons--an example from gastric surgery]. / Centralisering på den enkelte kirurg--et eksempel fra ventrikelkirurgi.

INTRODUCTION: Previous studies have shown an association between surgical volume and a decreased mortality rate for departments as a whole as well as for individual surgeons. The background for this study was to investigate whether it would be beneficial to centralize gastric surgery, not only in fewer departments but also in fewer hands in the department. MATERIALS AND METHODS: The study was based on the patient records of the 93 patients operated between 1 January 2000 and 1 September 2005. The surgeons were divided into two groups based on whether they had performed more than 15 or less than 5 operations during the period. RESULTS: Of the 93 operations, 3 surgeons performed 80 and 7 surgeons performed the remaining 13 operations. The mortality was significantly increased in patients operated by surgeons with a low operation volume, p = 0.0004. The 12 acute operations were performed as often by a surgeon with low operation volume as by a surgeon with high operation volume. Again, mortality increased when the operation was performed by a surgeon with low operation volume, p = 0.015. CONCLUSION: The results argue for a centralization of gastric resections on a few surgeons and for an organisation of acute surgery so that these procedures are performed by only a few experienced surgeons.

Combined laparoscopic/endoscopic anvil placement for the performance of the gastroenterostomy.

BACKGROUND: We developed the laparoscopic gastric bypass in 1993 and first reported the technique and results in 1994. The technique for the gastroenterostomy was derived from the method used in the percutaneous endoscopic gastrostomy tube placement. Some have questioned the safety of this technique, and alternatives have been proposed. METHOD: Prospectively, we have followed and recorded the results of our laparoscopic patients. To date we have performed over 1,400 laparoscopic gastric bypass operations using the same technique of anvil placement: pulling the anvil down from the mouth to the stomach pouch with a percutaneously placed wire. All patients underwent upper GI endoscopy following the anvil placement, and a water-soluble upper GI series was obtained on the first postoperative day. RESULTS: There have been no esophageal injuries in the first 1400 patients on whom this technique was done. CONCLUSION: The percutaneous pull-wire technique is a safe and effective method to place the 21-mm circular stapler anvil for the performance of a laparoscopic gastroenterostomy.

[Efficient accomplishment of anastomosis in gastrointestinal operations]. / Pretsizionnoe formirovanie anastomozov pri operatsiiakh na zheludke i kishechnike.

In experimental study (40 dogs) variant of precisional (microsurgical) suture and anastomosis was developed, which was successfully carried out in clinical practice in 72 patients with various diseases of gastro-intestinal tract. For precisional formation of gastro-intestinal and bowel anastomoses magnifying optics, atraumatic suturing material and microsurgical instruments were used. Separately were sutured by knot sutures gastric or bowel serosa (external layer) and musculosubcutaneos layer of these organs together with mucous membrane tangentially, without its penetrating puncture (internal layer). The developed precisional method of formation of the anastomoses promotes healing of gastro-intestinal wound by primary intention and may be recommended for wider practical application.

[Is total pancreatectomy still responsible treatment for chronic pancreatitis? (author's transl)]. / Ist die totale Pankreatektomie zur Behandlung der chronischen Pankreatitis noch zu verantworten?

A total of 61 pancreatectomies for chronic pancreatitis are reported. The operative mortality rate was 21% and the later mortality rate 29%, although caused by diabetes. The results are so poor that this method should only be performed in extreme situations. Left or right resection of the main inflammation site is proposed as an alternative. To prevent recurrence of the pancreatitis, the in situ remaining part of the pancreas should be sclerosed by occlusion of the pancreatic duct system.