EUS-guided gastroenterostomy using a novel electrocautery lumen apposing metal stent for treatment of gastric outlet obstruction (with video)

BACKGROUND AND AIM

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for the treatment of gastric outlet obstruction (GOO) has been actually performed only with one type of electrocautery lumen-apposing metal stents (EC-LAMS). We aimed to evaluate the safety, technical and clinical effectiveness of EUS-GE using a newly available EC-LAMS in patients with malignant and benign GOO.

MATERIALS AND METHODS

Consecutive patients who underwent EUS-GE for GOO using the new EC-LAMS at five endoscopic referral centers were retrospectively evaluated. Clinical efficacy was determined utilizing the Gastric Outlet Obstruction Scoring System (GOOSS).

RESULTS

Twenty-five patients (64% male, mean age 68.7 ± 9.3 years) met the inclusion criteria; 21 (84%) had malignant etiology. Technically, EUS-GE was successful in all patients, with a mean procedural time of 35 ± 5 min. Clinical success was 68% at 7 days and 100% at 30 days. The mean time to resume oral diet was 11.4 ± 5.8 h, with an improvement of at least one point of GOOSS score observed in all patients. The median hospital stay was 4 days. No procedure-related adverse events occurred. After a mean follow-up of 7.6 months (95% CI 4.6-9.2), no stent dysfunctions were observed.

CONCLUSION

This study suggests EUS-GE can be performed safely and successfully using the new EC-LAMS. Future large multicenter prospective studies are needed to confirm our preliminary data.

Double anchor lock fixing method to prevent stent displacement in endoscopic ultrasound-guided gastroenterostomy: a porcine study

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is widely used in patients with gastric outlet obstruction (GOO). Recurrence of obstruction symptoms caused by stent migration is the major reason for reintervention in EUS-GE. To solve this problem, we proposed developing a double anchor lock (DAL) fixing stent method for EUS-GE. The safety and efficacy of the DAL fixing stent method were evaluated in this study.

METHODS

Sixteen Bama miniature pigs were randomly divided into an experimental group (n = 8) and a control group (n = 8). A gastric outlet obstruction model was established for all the pigs. The experimental group was treated with the DAL fixing stent method for EUS-GE, while the control group was treated with EUS-GE. Three-month stent migration rate, remission rate of GOO, re-occlusion intervention rate, weight change, and incidence of procedure-related complications of EUS-GE were analyzed and estimated in the two groups.

RESULTS

EUS-GE was successfully completed in every subject in both groups. Symptoms of digestive tract obstruction can be relieved in all animals. The stent existence rate in the 3 months was higher in the experimental group than in the control group (87.5% vs. 12.5%, P = 0.012). Except for one animal in the experimental group in which there was pneumoperitoneum due to a stent insertion failure, no animal experienced bleeding or perforation.

CONCLUSION

The DAL fixing stent method, which can effectively prevent stent migration, is safe and simple. EUS-GE can effectively relieve the symptoms of digestive tract obstruction.

Primary acquired gastric outlet obstruction in children: A retrospective single center study

BACKGROUND/ PURPOSE

Idiopathic hypertrophic pyloric stenosis is by far the most common cause of gastric outlet obstruction (GOO) in young infants, with more than 90% of cases presenting between 3 and 10 weeks after birth. While cases of late onset pyloric stenosis beyond infancy have been reported, the etiology is poorly understood. We report our experience of 5 cases, describing the similarities and differences in management of our patient population which happens to be the second largest reported in literature.

METHODS

From July 2014 to June 2018 (4 years) a total of five patients of primary acquired GOO were encountered at our center.

RESULTS

The age range was 3 to 6 years and only one of them was a female. All presented with characteristic nonbilious vomiting that was recurrent and episodic. Upper GI (gastrointestinal) contrast study series revealed a dilated stomach and delayed gastric emptying. Upper GI endoscopy also demonstrated a dilated stomach without any intraluminal polyp, ulcer or any other pathology. Intraoperatively the pylorus had no evidence of scarring, inflammation, external compression or any mass in and around the pylorus. A retrocolic gastrojejunostomy was curative in all patients.

CONCLUSION

Though rare, one must maintain a high index of suspicion for primary acquired GOO in the differential diagnosis of older children with nonbilious vomiting and failure to thrive. Following appropriate diagnostic workup, surgical interventions should be performed expeditiously because adequate nutrition is key to proper physical and mental development of the child. Further research will hopefully elucidate the underlying pathophysiology in order to guide clinical options for both prevention and treatment.

TYPE OF STUDY

Retrospective single center study.

LEVEL OF EVIDENCE

Level 4.

Stomach-partitioning gastrojejunostomy is better than conventional gastrojejunostomy in palliative care of gastric outlet obstruction for gastric or pancreatic cancer: a meta-analysis

Background

Unresectable gastric or pancreatic malignancies are the most common cause of gastric outlet obstruction (GOO). Although several authors reported better outcomes in patients submitted to gastric partitioning gastrojejunostomy (GPGJ) compared to conventional gastrojejunostomy (CGJ), clinical experience with GPGJ is poor, studies comparing the two techniques are few and no randomized trials were performed. Our systematic review aimed at comparing GPGJ (partial or complete) with CGJ in patients operated for GOO for gastric or pancreatic cancer.

Methods

A computerized literature search was performed on Medline until January 2017. The studies included were 8 with a total of 226 patients. Study outcomes included delayed gastric emptying (DGE), nutrition by oral intake, length of hospital stay and survival time. The pooled effects were estimated using a fixed effect model or random effect model based on the heterogeneity test. Results were expressed as odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes. For continuous outcomes, the mean of the measures of central tendency was calculated.

Results

The GPGJ group had lower rates of DGE (OR =4.997, 95% CI: 2.310-10.810) and length of hospital stay (19.7 versus 23.3 days) and higher rates of nutrition by oral intake (OR =0.156, 95% CI: 0.055-0.442) and survival time (189.2 versus 115.2 days).

Conclusions

GPGJ is associated with lower rates of DGE and higher rates of normal oral intake compared to CGJ with a tendency towards better survival in the GPGJ group. Multicenter randomized controlled trials would be required to confirm these results.

Recent advancements in stent therapy in patients with malignant gastroduodenal outlet obstruction

Gastric outlet obstruction (GOO) is one of severe comorbidities caused by many kinds of malignant diseases and is associated with not only degradation of patients' quality of life but also mortality. Although surgical bypass is one of the main therapies for malignant GOO, it is often difficult to perform in end-stage patients. The deployment of self-expandable metallic stents (SEMSs) has recently become a viable alternative to surgical bypass for malignant GOO. This technique is less invasive and more effective, particularly in patients with poor prognoses. Many reports have referred to the feasibility, effectiveness, and safety of the placement of SEMSs for malignant GOO. According to these reports, the rates of technical and clinical success were reported to be relatively high and the rate of adverse events to be acceptable. However, precautions against severe adverse events such as massive bleeding and perforation are necessary. Several reports have described the differences in clinical results among different kinds of SEMSs. The presence of a covered design for SEMSs may affect the patency of SEMSs and the rate of stent dysfunction. Selection of the SEMS according to axial force may affect successful achievement of long patency of SEMSs and avoidance of gastroduodenal perforation at the bending site of the duodenum. Compared with high technical success rates nearing 100%, clinical success rates were usually lower than technical success. Therefore, determination of predictive factors for failure of clinical success is important. Several papers reported that low performance status could be associated with failure of clinical success. However, the association of clinical success with other factors such as carcinomatosa and ascites remains controversial, which is a problem to be solved. Reintervention with SEMS using the stent-in-stent method after stent dysfunction can be performed effectively as well as placement of the first SEMS.

Self-expandable metallic stent placement for palliation in gastric outlet obstruction

Malignant gastric outlet obstruction (GOO) often has a markedly adverse impact on the quality of life (QOL) of patients. Procedures in affected patients should aim to reduce obstructive symptoms and enable oral ingestion. Surgical gastrojejunostomy (GJJ) has been performed as a conventional palliative procedure. Enteral stenting has been increasingly used as an alternative to surgical palliation because of its lower invasiveness. Enteral stents used for GOO are made of a metal alloy mesh in a cylindrical shape, and are termed self-expandable metallic stent (SEMS). Of the two placement techniques, over-the-wire (OTW) and through-the-scope (TTS) deployment, TTS is easier and is now more frequently used. In general, the technical success rate is extremely high, at nearly 100%, and the clinical success rate is about 90%, but complications after placement can occur, most frequently late-developing stent dysfunction due to stent obstruction and migration. Biliary obstruction can occur concurrently with GOO, or before or after GOO, particularly in patients with pancreaticobiliary malignancies. Considering accessibility to the bile duct, biliary stenting should generally be conducted prior to enteral stenting. Transhepatic or transmural biliary stenting may be required if transpapillary stenting is not possible. Because enteral stenting is more commonly associated with late-developing stent dysfunction, it is better suited than GJJ for patients with a short life expectancy and poorer performance score. Chemotherapy may be beneficial in reducing the risk of stent obstruction, despite the possible risk of migration, particularly in patients with GOO due to gastric cancer. Many enteral stents with different structures are now commercially available, but the association between the design and mechanical properties of a stent and clinical outcomes is still poorly understood. Further, no consensus on the benefits of covered SEMS has yet been obtained. Further study to verify which types of SEMS are most suited for GOO is warranted.

Retroperitoneal nodular fasciitis: a benign etiology on the differential diagnosis of malignant gastric outlet obstruction

Nodular fasciitis is a relatively rare, benign and proliferative lesion that is not typically found in the retroperitoneal (RP) space and has not been previously reported as a cause of gastric outlet obstruction (GOO). GOOs are frequently associated with malignancies, however, benign etiologies should be considered as well. We report the first case of GOO secondary to nodular fasciitis in the form of a spontaneously regressing RP mass that was initially concerning for malignancy.