Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy.

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

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.

Bouveret syndrome: a rare complication of gallstone disease.

A Caucasian man in his late 80s was admitted with central abdominal pain, abdominal distension and continuous vomiting, on the background of a recent admission for acute cholecystitis. The patient was managed for subacute bowel obstruction and was admitted to general surgery for further investigation. His blood tests showed raised inflammatory markers and deranged liver function tests. A CT scan showed the migration of a large gallstone, previously seen in the neck of the gallbladder on prior admission, to the proximal duodenum causing a degree of gastric outlet obstruction. A diagnosis of Bouveret syndrome was made, and although initially managed conservatively, the patient ultimately underwent surgery to remove the gallstone which had relocated again to the terminal ileum. Our case highlights the importance of considering rare complications such as Bouveret syndrome in patients presenting with bowel obstruction, particularly in the context of recent or chronic cholecystitis.

Endoscopic Ultrasound Gastro-Enteroanastomosis for Benign Gastric Outlet Obstruction due to Large Duodenal Diverticula.

Gastric outlet obstruction is a condition characterized by inadequate gastric emptying due to benign or malignant conditions inducing an inadequate oral intake. In recent years, a novel therapeutic treatment for this condition is given by the use of electrocautery lumen-apposing metal stents. In this case report, we want to present an example of a benign condition treated by endoscopic ultrasound-guided gastroenterostomy with the bi-flanged SpaxusTM stent (Taewoong Medical Co.) mounted on electrocautery catheter.

The Significance of Staging Laparoscopy in Detection of Radiologically Occult Peritoneal Carcinomatosis in Gastric Cancer With Gastric Outlet Obstruction: Consideration of The Optimal Treatment Approach.

BACKGROUND/AIM: Gastric cancer with gastric outlet obstruction (GOO) is generally found at an advanced stage and with an unfavorable prognosis. This study was performed to examine the prevalence of radiologically occult peritoneal carcinomatosis in GOO and determine the optimal treatment strategy. PATIENTS AND METHODS: This single-center study was a retrospective review of the clinical data of 186 patients with locally advanced gastric cancer at the distal stomach who underwent surgery from 2008 to 2016. These patients were divided into two groups according to the presence or absence of GOO due to cancer progression: With GOO (n=71) and without GOO (n=115). RESULTS: The incidence of peritoneal carcinomatosis [with macroscopic peritoneal deposits (P1)/positive peritoneal cytology (CY1)] detected at laparotomy/laparoscopy was significantly higher in the group with GOO than in the group without (32.4% vs. 9.6%, p<0.01). The R0 resection rate was lower in the group with GOO (62.0% vs. 87.0%, p<0.01). The 5-year overall survival rate was also lower in the group with GOO (43.9% vs. 68.5%, p<0.01). However, in the subset of patients who underwent R0 surgery, the 5-year rates were similar for the two groups (67.4% vs. 73.1%, p=0.91). The multivariable analysis showed that a type 3 tumor appearance (odds ratio=3.66) and presence of GOO (odds ratio=2.87) were predictors of peritoneal carcinomatosis. CONCLUSION: The prevalence of radiologically occult peritoneal carcinomatosis in gastric cancer with GOO exceeded 30%. Staging laparoscopy (gastrojejunal bypass, if needed) should be performed to determine the optimal treatment plan.

Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in different sites: A single-center retrospective study.

OBJECTIVES: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently been employed as a novel treatment for gastric outlet obstruction (GOO). The aim of this study was to evaluate the safety and efficacy of EUS-GE for GOO at different sites. METHODS: Consecutive hospitalized patients who underwent EUS-GE for GOO at the Department of Gastroenterology, Nanjing Drum Tower Hospital from March 2017 to April 2020 were recruited in this retrospective study. Patients were divided into three groups depending on the obstruction site. The primary outcomes included technical success and clinical success. The secondary outcomes were operation time, post-procedure length of stay (LOS), hospitalization cost, and complications such as peritonitis, bleeding, pneumoperitoneum, abdominal pain, and infection. RESULTS: A total of 51 patients were included. Technical success achieved in 100% patients with proximal GOO and in 88.9% with distal GOO (P = 0.176). Clinical success declined from the oral side to the anal side (P = 0.510). Operation time, hospitalization costs, and post-procedural LOS were similar among groups (P = 0.532, 0.520, and 0.144, respectively). Complications were observed in 28 (54.9%) patients. In approaching the mature phase of the endosopist, clinical success improved, while the secondary outcomes showed no statistically significant difference compared with the initial phase. CONCLUSIONS: EUS-GE may be challenging for distal GOO; however, it is safe and effective when carried out by experienced endoscopists. A complete preoperative evaluation to assess the difficulty of the procedure is necessary. Prospective studies with large sample size are needed to further validate our findings.

Crack cocaine abuse as an undescribed cause of gastric outlet obstruction.

A 32-year-old male with crack-cocaine abuse for 10 years, 300 g/day. He started with epigastric abdominal pain, intensity 10/10, he went to another hospital where a perforated peptic ulcer was suspected and a laparotomy was performed, with no findings. Subsequently, he started with vomiting and weight loss, on admission, a gastric outlet obstruction (GOO) was suspected and CT scan showed a concentric duodenal growth. An upper endoscopy identified a duodenal bulb stenosis with a Forrest-III ulcer. Roux-en-Y gastrojejunal anastomosis was performed, identifying duodenal thickening, without malignancy.