Surgical and Endoscopic Options for Benign and Malignant Gastric Outlet Obstruction

Gastric outlet obstruction in the setting of acute cholecystitis

Acute cholecystitis is a rare cause of gastric outlet obstruction (GOO) and may manifest with nonspecific symptoms which may preclude or delay diagnosis. During the latter part of the 20th century, benign disease was responsible for most cases of GOO in adults with peptic ulcer disease accounting for up to 90% of these cases. Although precise estimates on GOO incidence and prevalence are lacking, as many as 2000 surgical operations were reportedly performed annually for GOO in the United States in the 1990s. We present clinical and imaging findings of a case of a 101-year-old woman with GOO resulting from extrinsic compression from a massively dilated gallbladder related to acute cholecystitis. In addition, we review other rare biliary causes of GOO.

Focal pyloric hypertrophy in adults: a diagnostic pitfall-a case report and review of the literature

Adult hypertrophic pyloric stenosis in the form of focal pyloric hypertrophy is an uncommon but a well-established lesion. In most cases, clinical findings suggest malignancy, and despite advances in imaging techniques, preoperative diagnosis is difficult. Herein, an example of focal pyloric hypertrophy is presented with a review of the literature to emphasize the clinicopathological characteristics of this lesion. In a 43-year-old man with abdominal discomfort, endoscopy showed a 1.5 cm nodular lesion near the pylorus that necessitated surgery to exclude malignancy. Pathological examination allowed the diagnosis of focal pyloric hypertrophy. The present case and the review revealed that focal pyloric hypertrophy is a male dominant lesion in middle-aged patients. The clinical diagnosis is problematic, and its initial diagnosis depends on a high clinical suspicion in patients with upper gastrointestinal system complaints irrespective of the duration of the symptoms. It is not known whether it is a separate entity from the diffuse form. Although both are similar in a clinical point of view, etiopathogenetic studies are required to clarify their differences completely. Moreover, the rare occurrence of focal pyloric hypertrophy and the lack of diagnostic clinical findings do not exclude its consideration in the differential diagnosis, especially in patients with gastric outlet obstruction.

Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome

BACKGROUND

Gastroparesis is a rapidly increasing problem with sometimes devastating consequences. While surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity, they require general anesthesia, advanced skills, and can lead to leaks. Peroral pyloromyotomy is a less invasive alternative; however, this technique is technically demanding and not widely available. We describe a hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow endoluminal stapled pyloroplasty as an alternative treatment option for gastric outlet obstruction.

METHODS

Under general anesthesia, six pigs (mean weight 33 kg) underwent endoscopic placement of intragastric ports using a technique similar to percutaneous endoscopic gastrostomy. A 5 mm laparoscope was used for visualization. A functional lumen imagine probe was used to measure the cross-sectional area (CSA) and diameter of the pylorus before, after, and at 1 week after intervention. Pyloroplasty was performed using a 5 mm articulating laparoscopic stapler. Gastrotomies were closed by endoscopic clips, endoscopic suture, or combination. After 6-8 days, a second evaluation was performed. At the end of the protocol, all animals were euthanized.

RESULTS

Six pyloroplasties were performed. In all cases, this technique was effective in achieving significant pyloric dilatation. The median pre-pyloroplasty pyloric diameter (D) and cross-sectional area (CSA) were 8 mm (4.9-11.6 mm) and 58.6 mm2 (19-107 mm2), respectively. After the procedure, these values increased to 13.41 mm (9.8-17.6 mm) and 147.7 mm2 (76-244 mm2), respectively (p = 0.0152). No important intraoperative events were observed. Postoperatively, all animals did well, with adequate oral intake and no relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent.

CONCLUSIONS

Hybrid endoluminal stapled pyloroplasty is a feasible, safe, and effective alternative method for the treatment of gastric outlet obstruction syndrome.

Modified Devine Exclusion for Unresectable Distal Gastric Cancer in Symptomatic Patients

Background

In patients with outlet obstruction syndrome and/or severe anemia secondary to unresectable gastric cancer (GC), partial stomach-partitioning gastrojejunostomy, or modified Devine exclusion, is a surgical alternative.

Methods

A retrospective study was conducted on patients with unresectable distal GC treated with modified Devine exclusion as palliative surgery between February 2005 and December 2015. It consisted of a series of 10 patients with outlet obstruction syndrome and/or severe anemia. The outcomes of this technique were based on oral tolerance, blood transfusions, postoperative complications, and survival.

Results

Early oral tolerance and a low rate of blood transfusions were observed postoperatively. There was no postoperative mortality and a very low complication rate without anastomotic leakage. Median survival was 9 months.

Conclusions

Partial stomach-partitioning gastrojejunostomy is a safe procedure for unresectable GC which can improve the quality of life of these patients.