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Martinet E, Gonzalez JM, Thobois M, Hamouda I, Hardwigsen J, Chopinet S, Pauleau G, Vanbiervliet G, Onana P, Moutardier V, Gasmi M, Barthet M, Birnbaum DJ. Surgical versus endoscopic gastroenterostomy for gastric outlet obstruction: a retrospective multicentric comparative study of technical and clinical success. Langenbecks Arch Surg 2024; 409:192. [PMID: 38900214 DOI: 10.1007/s00423-024-03365-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Gastric outlet obstruction (GOO) is mainly due to advanced malignant disease. GOO can be treated by surgical gastroenterostomy (SGE), endoscopic enteral stenting (EES), or endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to improve the quality of life. METHODS Between 2009 and 2022, patients undergoing SGE or EUS-GE for GOO were included at three centers. Technical and clinical success rates, post-procedure adverse events (AEs), length of hospital stay (LOS), 30-day all-cause mortality, and recurrence of GOO were retrospectively analyzed and compared between SGE and EUS-GE. Predictive factors for technical and clinical failure after SGE and EUS-GE were identified. RESULTS Of the 97 patients included, 56 (57.7%) had an EUS-GE and 41 (42.3%) had an SGE for GOO, with 62 (63.9%) GOO due to malignancy and 35 (36.1%) to benign disease. The median follow-up time was 13,4 months (range 1 days-106 months), with no difference between the two groups (p = 0.962). Technical (p = 0.133) and clinical (p = 0.229) success rates, severe morbidity (p = 0.708), 30-day all-cause mortality (p = 0.277) and GOO recurrence (p = 1) were similar. EUS-GE had shorter median procedure duration (p < 0.001), lower post-procedure ileus rate (p < 0.001), and shorter median LOS (p < 0.001) than SGE. In univariate analysis, no risk factors for technical or clinical failure in SGE were identified and abdominal pain reported before the procedure was a risk factor for technical failure in the EUS-GE group. No risk factor for clinical failure was identified for EUS-GE. In the subgroup of GOO due to benign disease, SGE was associated with better technical success (p = 0.035) with no difference in clinical success rate compared to EUS-GE (p = 1). CONCLUSION EUS-GE provides similar long-lasting symptom relief as SGE for GOO whether for benign or malignant disease. SGE may still be indicated in centers with limited experience with EUS-GE or may be reserved for patients in whom endoscopic technique fails.
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Affiliation(s)
- Eugénie Martinet
- Department of Digestive Surgery, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | | | - Maxime Thobois
- Department of Gastroenterology and Hepatology, Hôpital L'Archet 2, Nice, France
| | - Ilyes Hamouda
- Public Health Laboratory of the Faculty of Medical and Paramedical Sciences; Epidemiology and Health Economics Department, Hôpital Timone, Marseille, France
| | | | | | - Ghislain Pauleau
- Department of Digestive Surgery, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | | | - Philippe Onana
- Department of Gastroenterology and Hepatology, Hôpital L'Archet 2, Nice, France
| | | | | | | | - David Jérémie Birnbaum
- APHM Digestive Department, Marseille, France.
- Hôpital Nord, Chemin des Bourrely, Marseille cedex 20, 13915, France.
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Fujisawa T, Ishii S, Nakai Y, Kogure H, Tomishima K, Takasaki Y, Ito K, Takahashi S, Suzuki A, Isayama H. Dedicated Echoendoscope for Interventional Endoscopic Ultrasound: Comparison with a Conventional Echoendoscope. J Clin Med 2024; 13:2840. [PMID: 38792381 PMCID: PMC11121945 DOI: 10.3390/jcm13102840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objective: Interventional endoscopic ultrasound (I-EUS) is technically difficult and has risks of severe adverse events due to the scarcity of dedicated endoscopes and tools. A new EUS scope was developed for I-EUS and was modified to increase the puncture range, reduce the blind area, and overcome guidewire difficulties. We evaluated the usefulness and safety of a new EUS scope compared to a conventional EUS scope. Methods: All I-EUS procedures were performed at Juntendo University Hospital from April 2020 to April 2022. The primary outcomes included the procedure time and fluoroscopy time. The secondary outcomes included the technical success rate and the rates of procedure-related adverse events. Clinical data were retrospectively reviewed and statistically analyzed between the new and conventional EUS scopes. Results: In total, 143 procedures in 120 patients were analyzed. The procedure time was significantly shorter with the new EUS scope, but the fluoroscopy time was not different. Among the patients only undergoing EUS-guided biliary drainage (EUS-BD), 79 procedures in 74 patients were analyzed. Both the procedure time and fluoroscopy time were significantly shorter with the new EUS scope. Multivariate analysis revealed that a new EUS scope and use of covered metal stents could reduce the fluoroscopy time. The technical success rate and the adverse event rate were not significantly different between the total I-EUS and the EUS-BD only groups. However, the conventional scope showed stent deviation during stent placement, which did not happen with the new scope. Conclusions: The new EUS scope reduced procedure time for total I-EUS and fluoroscopy time for EUS-BD compared to a conventional EUS scope because of the improvement suitable for I-EUS.
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Affiliation(s)
- Toshio Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Shigeto Ishii
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo 113-8655, Japan
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo 162-8666, Japan
| | - Hirofumi Kogure
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan;
| | - Ko Tomishima
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Yusuke Takasaki
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Koichi Ito
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Sho Takahashi
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Akinori Suzuki
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan; (T.F.); (S.I.); (K.T.); (Y.T.); (K.I.); (S.T.); (A.S.)
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Fugazza A, Andreozzi M, Asadzadeh Aghdaei H, Insausti A, Spadaccini M, Colombo M, Carrara S, Terrin M, De Marco A, Franchellucci G, Khalaf K, Ketabi Moghadam P, Ferrari C, Anderloni A, Capretti G, Nappo G, Zerbi A, Repici A. Management of Malignant Gastric Outlet Obstruction: A Comprehensive Review on the Old, the Classic and the Innovative Approaches. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:638. [PMID: 38674284 PMCID: PMC11052138 DOI: 10.3390/medicina60040638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/31/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024]
Abstract
Gastrojejunostomy is the principal method of palliation for unresectable malignant gastric outlet obstructions (GOO). Gastrojejunostomy was traditionally performed as a surgical procedure with an open approach butrecently, notable progress in the development of minimally invasive procedures such as laparoscopic gastrojejunostomies have emerged. Additionally, advancements in endoscopic techniques, including endoscopic stenting (ES) and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are becoming more prominent. ES involves the placement of self-expandable metal stents (SEMS) to restore luminal patency. ES is commonly the first choice for patients deemed unfit for surgery or at high surgical risk. However, although ES leads to rapid improvement of symptoms, it carries limitations like higher stent dysfunction rates and the need for frequent re-interventions. Recently, EUS-GE has emerged as a potential alternative, combining the minimally invasive nature of the endoscopic approach with the long-lasting effects of a gastrojejunostomy. Having reviewed the advantages and disadvantages of these different techniques, this article aims to provide a comprehensive review regarding the management of unresectable malignant GOO.
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Affiliation(s)
- Alessandro Fugazza
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Marta Andreozzi
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Hamid Asadzadeh Aghdaei
- Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Agustin Insausti
- Department of Gastroenterology and Digestive Endoscopy, Medical Association Hospital, IGEA Institute, Patricios 347, Bahia Blanca B8000, Argentina;
| | - Marco Spadaccini
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Matteo Colombo
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Silvia Carrara
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
| | - Maria Terrin
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Alessandro De Marco
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Gianluca Franchellucci
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
| | - Kareem Khalaf
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B 1T8, Canada;
| | - Pardis Ketabi Moghadam
- Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran P.O. Box 19875-17411, Iran;
| | - Chiara Ferrari
- Division of Anaesthesiology, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy;
| | - Andrea Anderloni
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Giovanni Capretti
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Gennaro Nappo
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Zerbi
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
- Pancreatic Unit, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Alessandro Repici
- Division of Gastroenterology and Digestive Endoscopy, Humanitas Research Hospital-IRCCS, Via Manzoni 56, Rozzano, 20089 Milan, Italy; (A.F.); (M.A.); (M.C.); (S.C.); (M.T.); (A.D.M.); (G.F.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20090 Milan, Italy; (G.C.); (G.N.); (A.Z.)
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Teoh AYB, Lakhtakia S, Tarantino I, Perez-Miranda M, Kunda R, Maluf-Filho F, Dhir V, Basha J, Chan SM, Ligresti D, Ma MTW, de la Serna-Higuera C, Yip HC, Ng EKW, Chiu PWY, Itoi T. Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9:124-132. [PMID: 38061378 DOI: 10.1016/s2468-1253(23)00242-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel endoscopic method to palliate malignant gastric outlet obstruction. We aimed to assess whether the use of EUS-GE with a double balloon occluder for malignant gastric outlet obstruction could reduce the need for reintervention within 6 months compared with conventional duodenal stenting. METHODS The was an international, multicentre, randomised, controlled trial conducted at seven sites in Hong Kong, Belgium, Brazil, India, Italy, and Spain. Consecutive patients (aged ≥18 years) with malignant gastric outlet obstruction due to unresectable primary gastroduodenal or pancreatobiliary malignancies, a gastric outlet obstruction score (GOOS) of 0 (indicating an inability in intake food or liquids orally), and an Eastern Cooperative Oncology Group performance status score of 3 or lower were included and randomly allocated (1:1) to receive either EUS-GE or duodenal stenting. The primary outcome was the 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction (ie, restenosis of the stent due to tumour ingrowth, tumour overgrowth, or food residue; stent migration; or stent fracture) within 6 months, analysed in the intention-to-treat population. Prespecified secondary outcomes were technical success (successful placement of a stent), clinical success (1-point improvement in gastric outlet obstruction score [GOOS] within 3 days), adverse events within 30 days, death within 30 days, duration of stent patency, GOOS at 1 month, and quality-of-life scores. This study is registered with ClinicalTrials.gov (NCT03823690) and is completed. FINDINGS Between Dec 1, 2020, and Feb 28, 2022, 185 patients were screened and 97 (46 men and 51 women) were recruited and randomly allocated (48 to the EUS-GE group and 49 to the duodenal stent group). Mean age was 69·5 years (SD 12·6) in the EUS-GE group and 64·8 years (13·0) in the duodenal stent group. All randomly allocated patients completed follow-up and were analysed. Reintervention within 6 months was required in two (4%) patients in the EUS-GE group and 14 (29%) in the duodenal stent group [p=0·0020; risk ratio 0·15 [95% CI 0·04-0·61]). Stent patency was longer in the EUS-GE group (median not reached in either group; HR 0·13 [95% CI 0·08-0·22], log-rank p<0·0001). 1-month GOOS was significantly better in the EUS-GE group (mean 2·41 [SD 0·7]) than the duodenal stent group (1·91 [0·9], p=0·012). There were no statistically significant differences between the EUS-GE and duodenal stent groups in death within 30 days (ten [21%] vs six [12%] patients, respectively, p=0·286), technical success, clinical success, or quality-of-life scores at 1 month. Adverse events occurred 11 (23%) patients in the EUS-GE group and 12 (24%) in the duodenal stent group within 30 days (p=1·00); three cases of pneumonia (two in the EUS-GE group and one in the duodenal stent group) were considered to be procedure related. INTERPRETATION In patients with malignant gastric outlet obstruction, EUS-GE can reduce the frequency of reintervention, improve stent patency, and result in better patient-reported eating habits compared with duodenal stenting, and the procedure should be used preferentially over duodenal stenting when expertise and required devices are available. FUNDING Research Grants Council (Hong Kong Special Administrative Region, China) and Sociedad Española de Endoscopia Digestiva.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China.
| | - Sundeep Lakhtakia
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Ilaria Tarantino
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Manuel Perez-Miranda
- Department of Gastroenterology and Hepatology, University Hospital Rio Hortega, Valladolid, Spain
| | - Rastislav Kunda
- Department of Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Department of Gastroenterology-Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium; Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Fauze Maluf-Filho
- Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil; Department of Gastroenterology of University of São Paulo, São Paulo, Brazil; National Council for Scientific and Technological Development-CNPq, Brazil
| | - Vinay Dhir
- Institute of Digestive and Liver Care, SL Raheja Hospital, Mumbai, India
| | - Jahangeer Basha
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Shannon Melissa Chan
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
| | - Mark Tsz Wah Ma
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | | | - Hon Chi Yip
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Enders Kwok Wai Ng
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Philip Wai Yan Chiu
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
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Singh S, Sawal A. Comprehensive Review on Pancreatic Head Cancer: Pathogenesis, Diagnosis, and Treatment Challenges in the Quest for Improved Survival. Cureus 2024; 16:e54290. [PMID: 38500905 PMCID: PMC10945288 DOI: 10.7759/cureus.54290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
This comprehensive review explores the complexities surrounding pancreatic head cancer, a highly fatal and challenging-to-treat illness with a survival rate of less than five years. Despite being a major contributor to cancer-related deaths, pancreatic head malignancy often eludes early detection due to its posterior location and high metastatic potential. The review delves into the associated symptoms, including gastric outlet obstruction and obstructive jaundice, highlighting the impact on the patient's eligibility for surgery. Examining recent advancements, the article discusses fast-track surgery recovery programs and emerging immunotherapeutic approaches, acknowledging the unique challenges posed by the immunosuppressive environment of pancreatic head cancer. Additionally, the review elucidates the intricate relationship between pancreatic cancer and glucose levels, emphasizing the role of islets of Langerhans in insulin production. The pathogenesis section explores lifestyle and genetic factors contributing to pancreatic head carcinoma, shedding light on risk factors such as smoking, obesity, diabetes, and hereditary predispositions. The extensive analysis of pancreatic cancer diagnosis methods encompasses imaging techniques, biopsies, and biomarkers, emphasizing the challenges posed by late-stage diagnoses. Addressing treatment modalities, the review emphasizes the significance of surgery, chemotherapy, radiotherapy, and targeted therapy. The intricate details of neoadjuvant, immunotherapy, and microbial therapy provide a comprehensive understanding of evolving treatment strategies. The review concludes by highlighting promising areas of research, including oncolytic viral therapy and gene editing technology, aiming to enhance the limited treatment options for this devastating disease.
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Affiliation(s)
- Shreya Singh
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Anupama Sawal
- Anatomy, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Canakis A, Irani SS. Endoscopic Treatment of Gastric Outlet Obstruction. Gastrointest Endosc Clin N Am 2024; 34:111-125. [PMID: 37973223 DOI: 10.1016/j.giec.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Endoscopic management of gastric outlet obstruction includes balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to relieve mechanical blockage and reestablish per oral intake. Based on the degree of obstruction, patients may experience debilitating symptoms that can quickly lead to malnutrition and delays in chemotherapy. Compared with surgery, minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations. EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates. This article aims to describe endoscopic treatment options and future considerations.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Mailstop: C3-GAS, Seattle, WA 98101, USA.
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7
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Wang J, Hu JL, Sun SY. Endoscopic ultrasound guided gastroenterostomy: Technical details updates, clinical outcomes, and adverse events. World J Gastrointest Endosc 2023; 15:634-640. [DOI: 10.4253/wjge.v15.i11.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/12/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has been transformed from an innovative technique, into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction. Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed, giving patients more less invasive options. However, EUS-GE is still a technically challenging procedure. In order to improve EUS-GE, several techniques have been reported to improve the technical details. With EUS-GE widely performed, more data about EUS-GE’s clinical outcomes have been reported. The aim of the current review is to describe technical details updates, clinical outcomes, and adverse events of EUS-GE.
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Affiliation(s)
- Jian Wang
- Department of Gastroenterology, People's Hospital of Shenyang Economic and Technological Development Zone, Shenyang 110001, Liaoning Province, China
| | - Jin-Long Hu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Si-Yu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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8
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Bronswijk M, Vanella G, van Wanrooij RLJ, Samanta J, Lauwereys J, Pérez-Cuadrado-Robles E, Dell'Anna G, Dhar J, Gupta V, van Malenstein H, Laleman W, Jaekers J, Topal H, Topal B, Crippa S, Falconi M, Besselink MG, Messaoudi N, Arcidiacono PG, Kunda R, Van der Merwe S. Same-session double EUS-guided bypass versus surgical gastroenterostomy and hepaticojejunostomy: an international multicenter comparison. Gastrointest Endosc 2023; 98:225-236.e1. [PMID: 36990124 DOI: 10.1016/j.gie.2023.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/16/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND AND AIMS Gastric outlet and biliary obstruction are common manifestations of GI malignancies and some benign diseases for which standard treatment would be surgical gastroenterostomy and hepaticojejunostomy (ie, "double bypass"). Therapeutic EUS has allowed for the creation of an EUS-guided double bypass. However, same-session double EUS-guided bypass has only been described in small proof-of-concept series and lacks a comparison with surgical double bypass. METHODS A retrospective multicenter analysis was performed of all consecutive same-session double EUS-guided bypass procedures performed in 5 academic centers. Surgical comparators were extracted from these centers' databases from the same time interval. Efficacy, safety, hospital stay, nutrition and chemotherapy resumption, long-term patency, and survival were compared. RESULTS Of 154 identified patients, 53 (34.4%) received treatment with EUS and 101 (65.6%) with surgery. At baseline, patients undergoing EUS exhibited higher American Society of Anesthesiologists scores and a higher median Charlson Comorbidity Index (9.0 [interquartile range {IQR}, 7.0-10.0] vs 7.0 [IQR, 5.0-9.0], P < .001). Technical success (96.2% vs 100%, P = .117) and clinical success rates (90.6% vs 82.2%, P = .234) were similar when comparing EUS and surgery. Overall (11.3% vs 34.7%, P = .002) and severe adverse events (3.8% vs 19.8%, P = .007) occurred more frequently in the surgical group. In the EUS group, median time to oral intake (0 days [IQR, 0-1] vs 6 days [IQR, 3-7], P < .001) and hospital stay (4.0 days [IQR, 3-9] vs 13 days [IQR, 9-22], P < .001) were significantly shorter. CONCLUSIONS Despite being used in a patient population with more comorbidities, same-session double EUS-guided bypass achieved similar technical and clinical success and was associated with fewer overall and severe adverse events when compared with surgical gastroenterostomy and hepaticojejunostomy.
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Affiliation(s)
- Michiel Bronswijk
- Department of Gastroenterology and Hepatology; Department of Gastroenterology and Hepatology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | | | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Jayanta Samanta
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Jonas Lauwereys
- Department of Gastroenterology and Hepatology; Department of Gastroenterology and Hepatology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, APHP, Centre, University of Paris Cité, Paris, France
| | | | - Jahnvi Dhar
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Vikas Gupta
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | | | - Wim Laleman
- Department of Gastroenterology and Hepatology
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Nouredin Messaoudi
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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9
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Razzak FA, Ghazi R, Brunaldi VO, Mahmoud T, Rapaka B, Al Annan K, Kerbage A, Abu Dayyeh BK. Pitfalls of EUS-guided gastrojejunostomy in a patient with history of Roux-en-Y gastric bypass and a frozen abdomen. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:263-266. [PMID: 37456224 PMCID: PMC10339041 DOI: 10.1016/j.vgie.2023.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Video 1Case of EUS-guided gastrojejunostomy in a patient with a history of Roux-en-Y gastric bypass and a frozen abdomen.
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Affiliation(s)
- Farah Abdul Razzak
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Vitor O Brunaldi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Karim Al Annan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Anthony Kerbage
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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10
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Huang TL, Zhong WQ, Shen YH, Ni MH, Xu GF, Lyu Y, Li W, Zhou XL, Cai W, Wang L, Zou XP. Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in different sites: A single-center retrospective study. J Dig Dis 2022; 23:358-364. [PMID: 35880323 DOI: 10.1111/1751-2980.13118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 05/31/2022] [Accepted: 07/22/2022] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Tian Lu Huang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Wen Qi Zhong
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Yong Hua Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Mu Han Ni
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Gui Fang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Ying Lyu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Wen Li
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Xiao Liang Zhou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Wei Cai
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Xiao Ping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
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11
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Duarte-Chavez R, Kahaleh M. Therapeutic endoscopic ultrasound. Transl Gastroenterol Hepatol 2022; 7:20. [PMID: 35548470 PMCID: PMC9081917 DOI: 10.21037/tgh-2020-12] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/12/2020] [Indexed: 08/30/2023] Open
Abstract
Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
| | - Michel Kahaleh
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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12
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Kumar A, Chandan S, Mohan BP, Atla PR, McCabe EJ, Robbins DH, Trindade AJ, Benias PC. EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E448-E458. [PMID: 35433208 PMCID: PMC9010090 DOI: 10.1055/a-1765-4035] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022] Open
Abstract
Background and study aims Surgical gastroenterostomy (SGE) has been the mainstay treatment for gastric outlet obstruction (GOO). The emergence of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) presents a less invasive alternative for palliation of GOO. We conducted a comprehensive review and meta-analysis to compare the effectiveness and safety of EUS-GE compared to SGE. Methods Multiple electronic databases and conference proceedings up to April 2021 were searched to identify studies that reported on safety and effectiveness of EUS-GE in comparison to SGE. Pooled odds ratios (ORs) of technical success, clinical success, adverse events (AE) and recurrence, and pooled standardized mean difference (SMD) of procedure time and post-procedure length of stay (LOS) were calculated. Study heterogeneity was assessed using I 2 and Cochran Q statistics. Results Seven studies including 625 patients (372 EUS-GE and 253 SGE) were included. EUS-GE had lower pooled odds of technical success compared with SGE (OR 0.19, 95 % confidence interval [CI] 0.06-0.60, I 2 0 %). Among the technically successful cases, EUS-GE was superior in terms of clinical success (OR 4.73, 95 % CI 1.83-12.25, I 2 18 %), lower overall AE (OR 0.20, 95 % CI 0.10-0.37, I 2 39 %), and shorter procedure time (SMD -2.4, 95 % CI -4.1, -0.75, I 2 95 %) and post-procedure LOS (SMD -0.49, 95 % CI -0.94, -0.03, I 2 78%). Rates of severe AE (0.89, 95 % CI 0.11-7.36, I 2 67 %) and recurrence (OR 0.49, 95 % CI 0.18-1.38, I 2 49 %) were comparable. Conclusions Our results suggest EUS-GE is a promising alternative to SGE due to its superior clinical success, overall safety, and efficiency. With further evolution EUS-GE could become the intervention of choice in GOO.
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Affiliation(s)
- Anand Kumar
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Saurabh Chandan
- Division of Gastroenterology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Pradeep R. Atla
- Palmdale Regional Medical Center, Palmdale, California, United States
| | - Evin J. McCabe
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - David H. Robbins
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Arvind J. Trindade
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States
| | - Petros C. Benias
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States
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13
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Fabbri C, Binda C, Fugazzola P, Sbrancia M, Tomasoni M, Coluccio C, Jung CFM, Prosperi E, Agnoletti V, Ansaloni L. Hybrid gastroenterostomy using a lumen-apposing metal stent: a case report focusing on misdeployment and systematic review of the current literature. World J Emerg Surg 2022; 17:6. [PMID: 35065661 PMCID: PMC8783442 DOI: 10.1186/s13017-022-00409-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background Gastric outlet obstruction can result from several benign and malignant diseases, in particular gastric, duodenal or pancreatic tumors. Surgical gastroenterostomy and enteral endoscopic stenting have represented effective therapeutic options, although recently endoscopic ultrasound-guided gastroenterostomy using lumen-apposing metal stent (LAMS) is spreading improving the outcome of this condition. However, this procedure, although mini-invasive, is burdened with not negligible complications, including misdeployment.
Main body We report the case of a 60-year-old male with gastric outlet obstruction who underwent ultrasound-guided gastroenterostomy using LAMS. The procedure was complicated by LAMS misdeployment being managed by laparoscopy-assisted placement of a second LAMS. We performed a systematic review in order to identify all reported cases of misdeployment in EUS-GE and their management. The literature shows that misdeployment occurs in up to 10% of all EUS-GE procedures with a wide spectrum of possible strategies of treatment. Conclusion The here reported hybrid technique may offer an innovative strategy to manage LAMS misdeployment when this occurs. Moreover, a hybrid approach may be valuable to overcome this complication, especially in early phases of training of EUS-guided gastroenterostomy. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-022-00409-z.
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Affiliation(s)
- Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy.
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, M. Bufalini Hospital, Cesena, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, M. Bufalini Hospital, Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, M. Bufalini Hospital, Cesena, Italy
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14
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Mukai S, Itoi T, Tsuchiya T, Ishii K, Tanaka R, Tonozuka R, Furuichi Y, Joyama E, Miyazawa H, Sofuni A. Experimental study of a physician-controlled electrocautery-enhanced delivery system incorporating a newly developed lumen-apposing metal stent for interventional endoscopic ultrasound (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:817-824. [PMID: 35030302 DOI: 10.1002/jhbp.1113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/09/2021] [Accepted: 12/16/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND/PURPOSE Although the lumen-apposing metal stent (LAMS) is useful for interventional endoscopic ultrasound (EUS) procedures, there has been some concern about the potential for stent-induced adverse events because of the high lumen-apposing force. A newly designed LAMS with less lumen-apposing force has been developed for use with a physician-controlled electrocautery-enhanced delivery system. The aim of this animal study was to evaluate the feasibility of performing interventional EUS using this newly designed LAMS system. METHODS EUS-guided cystogastrostomy was performed using the novel LAMS 3 times in a wet simulation model. EUS-guided gastroenterostomy and EUS-guided gallbladder drainage were then performed using the system in 4 pigs. RESULTS The LAMS was successfully placed in all 3 EUS-guided cystogastrostomy procedures using the wet simulation model and in all 4 EUS-guided gastroenterostomy and gallbladder drainage procedures in the animal model. In the 3 weeks following the procedure, eating behavior was normal in all animals and there were no adverse events. The stents remained patent during this time and were removed without difficulty. The fistula was mature in all cases and a standard upper gastrointestinal endoscope was easily advanced via the fistula to observe the afferent and efferent loops or the lumen of the gallbladder. Necropsy confirmed complete adhesion between the stomach and the wall of the jejunum or gallbladder. CONCLUSIONS Our study findings demonstrate the feasibility of this new LAMS system and its potential clinical value for interventional EUS.
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Affiliation(s)
- Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yoshihiro Furuichi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Eri Joyama
- Department of International Medical Care, Tokyo Medical University, Tokyo, Japan
| | - Hideaki Miyazawa
- Department of Gastroenterology, Tokyo Kamata Medical Center, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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15
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Basha J, Lakhtakia S, Yarlagadda R, Nabi Z, Gupta R, Ramchandani M, Chavan R, Jagtap N, Asif S, Rao GV, Reddy N. Gastric outlet obstruction with ascites: EUS-guided gastro-enterostomy is feasible. Endosc Int Open 2021; 9:E1918-E1923. [PMID: 34917463 PMCID: PMC8670992 DOI: 10.1055/a-1642-7892] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/23/2021] [Indexed: 01/13/2023] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastro-enterostomy(EUS-GE) is a recently described novel minimally invasive endoscopic procedure for patients having malignant gastric outlet obstruction (GOO). The safety of EUS-GE in the presence of ascites with GOO is not known. The objective of the study was to evaluate the feasibility and safety of EUS-GE in patients with GOO and ascites. Patients and methods Consecutive patients with GOO who underwent EUS-GE between January 2019 and March 2021 constituted the study population. EUS-GE was performed using either EPASS or free-hand technique. The technical success, clinical success, adverse events, and survival times were evaluated. The outcomes were compared between patients with and without ascites. Results A total of 31 patients with GOO underwent EUS-GE of whom 29 (93.5 %) had malignant and two (6.4 %) had benign etiologies. Ascites was observed in 12 out of 31 (38.7%) patients and all had underlying malignancy. Majority (27, 87 %) of the EUS-GE procedures were performed using EPASS technique, and 4 (13 %) underwent free-hand technique. Eleven of 12 patients with ascites and GOO underwent EUS GE using EPASS technique. The technical success (91.6 % vs. 89.4 %; P = 0.841), clinical success (83.3 % vs. 89.4 %; P = 0.619), mean procedure time (32 vs. 31.6 min; P = 0.968) and adverse events (0 % vs. 10.5 %; P = 0.245) were not significantly different between patients with or without ascites. However, the median survival time was significantly low in patients with ascites when compared to without ascites (36 vs. 290 days; P < 001 ). Conclusions Ascites is a common occurrence in patients with malignant GOO. EUS GE is feasible in presence of ascites with EPASS technique.
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Affiliation(s)
| | | | | | - Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Rajesh Gupta
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | | | - Nitin Jagtap
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Shujaath Asif
- Asian Institute of Gastroenterology, Hyderabad, India
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16
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Nutahara D, Nagai K, Sofuni A, Tsuchiya T, Ishii K, Furuichi Y, Kitamura K, Itoh M, Miyazawa H, Itoi T. Morphological study of the gastrointestinal tract around the ligament of Treitz using upper gastrointestinal radiography: Fundamental data for EUS-guided gastrojejunostomy. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2021; 28:1023-1029. [PMID: 34181825 DOI: 10.1002/jhbp.1018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND/PURPOSE We developed EUS-guided double-balloon occluded gastrojejunostomy (EPASS) for gastric drainage tract obstruction. The success of EPASS depends on the proximity of the stomach and the gastrointestinal (GI) tract near the ligament of Treitz. The aim of this study is to clarify the GI anatomy near the ligament of Treitz. METHODS One thousand and sixteen cases imaged upper GI radiography using barium were retrospectively evaluated. Morphologically, the GI tract running near the ligament of Treitz was divided in three types: Type I: The 4th portion of the duodenum (D4) approaches the stomach; Type II: D4 does not approach the stomach; Type III: D4 forms a loop to the jejunum. The minimum distance between the stomach and the GI tract near the ligament of Treitz was measured. RESULTS Based on the morphological classification, 74.6% in the study group was classified in Type I, 22.0% in Type II, and 3.3% in Type III, respectively. The median minimum distance in Type II/III group were significantly longer, compared with the Type I (P < .01). CONCLUSIONS The GI anatomy near the ligament of Treitz was clarified using upper GI radiography. It is divided into three patterns, and one-fourth of cases may have difficulty in EUS-guided gastrojejunostomy.
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Affiliation(s)
- Daisuke Nutahara
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
- Department of Gastroenterology and Hepatology, Hachioji Medical Center, Tokyo Medical University, Shinjuku-ku, Japan
| | - Kazumasa Nagai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
- Department of Gastroenterology and Hepatology, Hachioji Medical Center, Tokyo Medical University, Shinjuku-ku, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Yoshihiro Furuichi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
| | - Katsuya Kitamura
- Department of Gastroenterology and Hepatology, Hachioji Medical Center, Tokyo Medical University, Shinjuku-ku, Japan
| | - Masahiro Itoh
- Department of Anatomy, Tokyo Medical University, Shinjuku-ku, Japan
| | - Hideaki Miyazawa
- Department of Gastroenterology, Tokyo Kamata Medical Center, Ota-ku, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Shinjuku-ku, Japan
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Cominardi A, Tamanini G, Brighi N, Fusaroli P, Lisotti A. Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasound-guided gastroentero-anastomosis. World J Gastrointest Oncol 2021; 13:1086-1098. [PMID: 34616514 PMCID: PMC8465451 DOI: 10.4251/wjgo.v13.i9.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/16/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by postprandial vomiting, abdominal pain, bloating and, in advanced cases, by weight loss secondary to inadequate oral intake. This clinical entity may be caused by mechanical obstruction, either benign or malignant, or by motility disorders. In this review we will focus on malignant GOO and on its endoscopic ultrasound (EUS)-guided palliative treatment. The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas; other causes include duodenal or ampullary neoplasms, gastric lymphomas, retroperitoneal lymphadenopathies and, more infrequently, gallbladder and bile duct cancers. Surgery represents the treatment of choice when radical and curative resection is potentially feasible; if the malignant cause is not likely to be completely resected, palliative treatments should be proposed. Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent. Both treatments are effective; however, endoscopic stent placement is less invasive and it is associated with good short-term results, while surgery provides longer-lasting effects with a lower frequency of reintervention. In the last few years, EUS-guided gastroenterostomy (GE) has been proposed as palliative treatment for malignant GOO. This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction, through the deployment of a lumen-apposing metal stent under EUS-view. EUS-GE has the advantage of being as minimally invasive as enteral stent placement, and of guaranteeing long-term results similar to those of surgery.
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Affiliation(s)
- Anna Cominardi
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Giacomo Tamanini
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Nicole Brighi
- Department of Medical Oncology, Istituto Scientifico Romagnolo Per Lo Studio Dei Tumori “Dino Amadori” (IRST) IRCCS, Meldola 47014, FC, Italy
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, University of Bologna/Hospital of Imola, Bologna 40121, Italy
| | - Andrea Lisotti
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
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Sobani ZA, Paleti S, Rustagi T. Endoscopic ultrasound-guided gastroenterostomy using large-diameter (20 mm) lumen apposing metal stent (LLAMS). Endosc Int Open 2021; 9:E895-E900. [PMID: 34079873 PMCID: PMC8159608 DOI: 10.1055/a-1399-8442] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 12/15/2022] Open
Abstract
Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20 mm) LAMS (LLAMS). Patients and methods A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94 %) (mean age: 61.35 ± 16.52 years; 54.84 % males) underwent EUS-GE using LLAMS for malignant (n = 23) and benign (n = 8) GOO. Technical success was achieved in all patients (100 %) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55 % of patients (n = 29). Two patients (6.45 %) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84 ± 160.41 days (median 70, range 4-590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23 %) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.
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Affiliation(s)
- Zain A. Sobani
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Swathi Paleti
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
| | - Tarun Rustagi
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico, United States
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Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2021. [PMID: 32390697 DOI: 10.3748/wjg.v26.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2022] Open
Abstract
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.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome "Tor Vergata", Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy.
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20
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Endoscopic gastrointestinal anastomosis: a review of established techniques. Gastrointest Endosc 2021; 93:34-46. [PMID: 32593687 DOI: 10.1016/j.gie.2020.06.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/11/2020] [Indexed: 02/08/2023]
Abstract
Technologic advancements in the field of therapeutic endoscopy have led to the development of minimally invasive techniques to create GI anastomosis without requiring surgery. Examples of the potential clinical applications include bypassing malignant and benign gastric outlet obstruction, providing access to the pancreatobiliary tree in those who have undergone Roux-en-Y gastric bypass, and relieving pancreatobiliary symptoms in afferent loop syndrome. Endoscopic GI anastomosis is less invasive and less expensive than surgical approaches, result in improved outcomes, and therefore are more appealing to patients and providers. The aim of this review is to present the evolution of luminal endoscopic gastroenteric and enteroenteric anastomosis dating back to the first compression devices and to describe the clinical techniques being used today, such as magnets, natural orifice transluminal endoscopic surgery, and EUS-guided techniques. Through continued innovation, endoscopic interventions will rise to the forefront of the therapeutic arsenal available for patients requiring GI anastomosis.
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Oliveira JFD, Cordero MAC, Lima GRDA, Paulo GAD, Lima MSD, Martins BDC, Ribeiro U, Maluf-Filho F. EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center. ACTA ACUST UNITED AC 2020; 66:1521-1525. [PMID: 33295403 DOI: 10.1590/1806-9282.66.11.1521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/02/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION EUS-GE is a promising treatment for patients with GOO.
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Affiliation(s)
- Joel Fernandez de Oliveira
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Martin Andres Coronel Cordero
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Gustavo Rosa de Almeida Lima
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Gustavo Andrade de Paulo
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Marcelo Simas de Lima
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Bruno da Costa Martins
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Ulysses Ribeiro
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
| | - Fauze Maluf-Filho
- Instituto do Câncer do Estado de São Paulo (Icesp) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), Serviço de Endoscopia Gastrointestinal, São Paulo, SP, Brasil
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22
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Xu G, Shen Y, Lv Y, Zhou X, Li W, Wang Y, Hassan S, Wang L, Zou X. Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy using double balloon occlusion methods: a clinical retrospective study in 36 patients with malignant gastric outlet obstruction. Endosc Int Open 2020; 8:E1690-E1697. [PMID: 33140026 PMCID: PMC7581485 DOI: 10.1055/a-1221-9656] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Gastric outlet obstruction (GOO) is common in the late stage of many malignant tumors of the digestive system. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is commonly used for palliative treatment of malignant GOO. The objective of this study was to investigate the safety, efficacy, and prognosis of EUS-GE in treatment of malignant GOO in Chinese patients. Patients and methods This was a retrospective, single-center study with 36 consecutive patients with malignant GOO who were treated with EUS-GE. The main outcome measures were technical success rate, clinical success rate, incidence of adverse events (AEs), and median survival time. Results A total of 36 patients with malignant GOO underwent double-balloon-assisted EUS-GE between March 2017 and June 2019 in our hospital. GOO occurred mainly in elderly men (mean age 69.0 years, M:F 0.89). The most common etiology of GOO was pancreatic cancer (41.7 %). The most common obstruction site was the second part of the duodenum (63.9 %). The technical success rate was 100 % (36/36). The clinical success rate was 94.4 % (34/36). Median time for the total procedure was 52 minutes (range 34 - 156 min). Median time for determination of puncture site was 20 minutes (range 15 - 28 min). Median time between puncture and successful delivery of the stent was 38 minutes (range 19 - 128 min). The GOOSS score was 0.2 before EUS-GE. The GOO Scoring System (GOOSS) score was 2.2 at 15 days after the EUS-GE ( P = 0.001). The GOOSS score was still higher than 2 during a median follow-up period of 89 days. AEs were observed in nine patients (25.0 %) and 13 total AEs occurred. One patient died as a result of delayed stent migration and bleeding. Mean length of hospital stay was 5.8 ± 4.7 days. The median survival period was 103 days. The rate of GOO recurrence was 2.7 % (1/36). Conclusion EUS-GE was associated with increased safety and efficacy for treatment of malignant GOO in Chinese Mainland.
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Affiliation(s)
- Guifang Xu
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Yonghua Shen
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Ying Lv
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Xiaoliang Zhou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Wen Li
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Yi Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Shahzeb Hassan
- Northwestern University Feinberg School of Medicine, Chicago 60611, IL, United States
| | - Lei Wang
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
| | - Xiaoping Zou
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School
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23
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Yamamoto K, Itoi T. Recent developments in endoscopic ultrasonography-guided gastroenterostomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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25
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Tonozuka R, Tsuchiya T, Mukai S, Nagakawa Y, Itoi T. Endoscopic Ultrasonography-Guided Gastroenterostomy Techniques for Treatment of Malignant Gastric Outlet Obstruction. Clin Endosc 2020; 53:510-518. [PMID: 32962331 PMCID: PMC7548149 DOI: 10.5946/ce.2020.151] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022] Open
Abstract
Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.
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Affiliation(s)
- Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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26
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Wang GX, Zhang K, Sun SY. Retrievable puncture anchor traction method for endoscopic ultrasound-guided gastroenterostomy: A porcine study. World J Gastroenterol 2020; 26:3603-3610. [PMID: 32742129 PMCID: PMC7366053 DOI: 10.3748/wjg.v26.i25.3603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/30/2020] [Accepted: 05/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an alternative method for the surgical treatment of gastric outlet obstruction, but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away. Thus, the technique requires superb skill. In order to improve EUS-GE, we have developed a retrievable puncture anchor traction (RPAT) device for EUS-GE to address the issue of bowel tenting.
AIM To evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.
METHODS Six Bama mini pigs each weighing between 15 and 20 kg underwent the RPAT-assisted EUS-GE procedure. Care was taken to ensure that the animals experienced minimal pain and discomfort. Two days prior to the procedure the animals were limited to a liquid diet. No oral intake was allowed on the day before the procedure. A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method. Infection in the animals was determined. Four weeks after the procedure, a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia. The pig was euthanized after examination.
RESULTS The RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals. All the pigs tolerated a regular diet within hours of the procedure. The animals were monitored for four weeks after the RPAT-assisted EUS-GE, during which time all of the animals exhibited normal eating behavior and no signs of infection were observed. Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals. No tissue overgrowth or ingrowth was observed in any case. Each animal had a mature fistula, and the stents were removed without significant bleeding. Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.
CONCLUSION The RPAT method helps reduce mobility of the bowel. Therefore, the RPAT-assisted EUS-GE method is a minimally invasive treatment modality.
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Affiliation(s)
- Guo-Xin Wang
- Department of Gastroenterology, Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Kai Zhang
- Department of Gastroenterology, Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Si-Yu Sun
- Department of Gastroenterology, Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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27
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Ichkhanian Y, Runge T, Gutierrez OIB, Khashab MA. Simultaneous double gastrojejunostomy for afferent and efferent limb syndromes. VideoGIE 2020; 5:294-295. [PMID: 32642616 PMCID: PMC7332759 DOI: 10.1016/j.vgie.2020.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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28
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Troncone E, Fugazza A, Cappello A, Blanco GDV, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol 2020; 26:1847-1860. [PMID: 32390697 PMCID: PMC7201143 DOI: 10.3748/wjg.v26.i16.1847] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/06/2020] [Accepted: 04/16/2020] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Edoardo Troncone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | - Annalisa Cappello
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
| | | | - Giovanni Monteleone
- Department of Systems Medicine, University of Rome “Tor Vergata”, Napoli 80129, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
- Humanitas University, Department of Biomedical Sciences, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Milan, Italy
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong 999077, China
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Humanitas Clinical and Research Center – IRCCS -, via Manzoni 56, 20089 Rozzano (Mi), Italy
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Chavan R, Ramchandani M, Nabi Z, Lakhtakia S, Reddy DN. Luminal and extraluminal bleeding during EUS-guided double-balloon-occluded gastrojejunostomy bypass in benign gastric outlet obstruction with portal hypertension. VideoGIE 2020; 5:64-67. [PMID: 32051912 PMCID: PMC7003061 DOI: 10.1016/j.vgie.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
| | | | - Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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Ratone JP, Caillol F, Zemmour C, Bories E, Pesenti C, Lestelle V, Godat S, Hoibian S, Proux A, Capodano G, Giovannini M. Outcomes of duodenal stenting: Experience in a French tertiary center with 220 cases. Dig Liver Dis 2020; 52:51-56. [PMID: 31401023 DOI: 10.1016/j.dld.2019.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/19/2019] [Accepted: 06/30/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Endoscopic stenting for malignant gastroduodenal outlet obstruction (MGOO) is described as ineffective and not long-lasting despite a few favorable studies. This study aimed to evaluate the clinical outcomes of a large series of patients in a tertiary center. METHODS A single-center retrospective study was performed using data collected from all patients who received palliative duodenal self-expandable metal stents between January 2011 and December 2016. The primary endpoints were patient diet after the first duodenal procedure (Gastric Outlet Obstruction Scoring System, GOOSS) and clinical success. The secondary endpoints were the median patency duration (calculated according to the Kaplan-Meier method) and the cumulative incidence of reintervention. RESULTS Two-hundred twenty patients were included. The increase in the GOOSS score was significant (p < 0.001), and the clinical success rate was 86.3%. The median estimated patency duration was 9.0 months [6.5-29.1]. Patients with pancreatic adenocarcinoma had significantly longer patency durations (p = 0.02). The estimated cumulative probability of a second duodenal procedure after 4 months was 13%. CONCLUSIONS In this large series of patients who underwent duodenal stenting for MGOO, we observed significant changes in GOOSS scores, a relatively long patency duration compared to findings in previous series, and a low probability of subsequent duodenal procedures, primarily due to a low median overall survival time (4 months).
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Affiliation(s)
| | - Fabrice Caillol
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | - Christophe Zemmour
- Inst Paoli Calmettes, Dept Clin Res & Invest, Biostat & Methodolo Unit, Marseille, France; Aix Marseille Univ, INSERM, IRD, SESSTIM, Marseille, France.
| | - Erwan Bories
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | | | | | - Sébastien Godat
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | - Solène Hoibian
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
| | - Aurélien Proux
- Paoli-Calmettes Institute, Palliative Unit, Marseille, France.
| | | | - Marc Giovannini
- Paoli-Calmettes Institute, Endoscopy Unit, Marseille, France.
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Song TJ, Moon JH, Lee YN, Lee SS. Design considerations of the novel lumen-apposing metal stents (Niti-S SPAXUS). ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.tgie.2019.150637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Gastric outlet obstruction (GOO) refers to mechanical obstruction of the distal stomach or proximal duodenum and it is associated with a significant decrease in quality of life. Surgical gastrojejunostomy and self-expandable metal stents were the traditional treatment for GOO. Recently, endoscopic ultrasound guided gastroenterostomy (EUS-GE) has emerged as a third therapeutic option for patients with GOO. Most EUS-GE techniques utilize the placement of a lumen-apposing metal stent under echoendoscopy but differ in the method of localizing the jejunal loop prior to EUS puncture. Data supporting EUS-GE have been promising. Case series including 10 or more cases showed the technical success rate to be approximately 90%. Clinical success is achieved in approximately 85-90% and a less than 18% risk of adverse events is reported. EUS-GE was associated with a lower recurrence of GOO and need for re-intervention when compared to enteral stenting. In addition, EUS-GE shows significantly fewer adverse events compared with surgical gastrojejunostomy. In conclusion, EUS-GE provides symptom relief without the risks of surgical intervention and the limited patency of enteral SEMS placement. EUS-GE is an exciting new option in the management of GOO. Despite the excellent results, randomized studies comparing these different modalities of treatment for GOO are needed before EUS-GE can be accepted as standard of care.
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Xu MM, Dawod E, Gaidhane M, Tyberg A, Kahaleh M. Reverse Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Superior Mesenteric Artery Syndrome: A New Concept. Clin Endosc 2019; 53:94-96. [PMID: 31794656 PMCID: PMC7003011 DOI: 10.5946/ce.2018.196] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/08/2019] [Indexed: 12/11/2022] Open
Abstract
Superior mesenteric artery syndrome (SMAS) causes compression and partial or complete obstruction of the duodenum, resulting in abdominal pain, nausea, vomiting, and weight loss. If conservative therapy fails, the patient is typically referred for enteral feeding or laparoscopic gastrojejunostomy. The last few years have seen increasing use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for gastric obstruction indications. EUS-GJ involves the creation of a gastric bypass via an echoendoscope in cases in which the small intestine can be punctured under ultrasonographic visualization, resulting in an incision-free, efficient, and safe procedure. In this case report, we present the first case of SMAS treated using a reverse EUS-GJ, and describe the steps and advantages of the procedure in this particular case.
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Affiliation(s)
- Ming-Ming Xu
- Division of Gastroenterology, Kaiser Permanente, Los Angeles, CA, USA
| | - Enad Dawod
- Division of Gastroenterology, Weill Cornell Medical College, New York, NY, USA
| | - Monica Gaidhane
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Amy Tyberg
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute at Virginia Mason Medical Center, Seattle, Washington, USA
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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35
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Tontini GE, Manfredi G, Orlando S, Neumann H, Vecchi M, Buscarini E, Elli L. Endoscopic ultrasonography and small-bowel endoscopy: Present and future. Dig Endosc 2019; 31:627-643. [PMID: 31090965 DOI: 10.1111/den.13429] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022]
Abstract
Over the last decade, impressive technological advances have occurred in ultrasonography and small-bowel endoscopy. Nowadays, endoscopic ultrasonography is an essential diagnostic tool and a therapeutic weapon for pancreatobiliary disorders. Capsule endoscopy and device-assisted enteroscopy have quickly become the reference standard for the diagnosis of small-bowel luminal diseases, thereby leading to radical changes in diagnostic and therapeutic pathways. We herein provide an up-to-date overview of the latest advances in endoscopic ultrasonography and small-bowel endoscopy, focusing on the emerging paradigms and technological innovations that might improve clinical practice in the near future.
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Affiliation(s)
- Gian Eugenio Tontini
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Stefania Orlando
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Digestive Endoscopy and Gastroenterology Unit, ASST of Cremona, Cremona, Italy
| | - Helmut Neumann
- Department of Medicine I, University Medical Center Mainz, Mainz, Germany
| | - Maurizio Vecchi
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Luca Elli
- Gastroenterology and Endoscopy Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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36
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Moutinho-Ribeiro P, Liberal R, Macedo G. Endoscopic ultrasound in pancreatic cancer treatment: Facts and hopes. Clin Res Hepatol Gastroenterol 2019; 43:513-521. [PMID: 30935904 DOI: 10.1016/j.clinre.2019.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/12/2019] [Accepted: 02/16/2019] [Indexed: 02/04/2023]
Abstract
Pancreatic ductal adenocarcinoma is one of the most common causes of cancer-related deaths. Since most patients present with advanced disease, its prognosis is dismal. New and more effective therapeutic strategies are needed. Endoscopic ultrasound is currently an indispensable tool for the diagnosis and staging of pancreatic ductal adenocarcinoma. In recent years, endoscopic ultrasound has evolved to become also a therapeutic procedure. On one hand, the role of endoscopic ultrasound in the management of pancreatic cancer-related symptoms (pain, obstructive jaundice, and gastric outlet obstruction) is now well established. On the other hand, its use as a mean to the delivery of anti-tumor therapies (injecting anti-tumor agents, assisting in radiotherapy, and guiding ablative therapies) is still mostly experimental, despite growing evidence supporting its feasibility, safety and efficacy.
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Affiliation(s)
- Pedro Moutinho-Ribeiro
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal.
| | - Rodrigo Liberal
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal
| | - Guilherme Macedo
- Gastroenterology and Hepatology Department, Centro Hospitalar Sao Joao and World Gastroenterology Organisation (WGO) Porto Training Center, Porto, Portugal
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Amateau SK, Lim CH, McDonald NM, Arain M, Ikramuddin S, Leslie DB. EUS-Guided Endoscopic Gastrointestinal Anastomosis with Lumen-Apposing Metal Stent: Feasibility, Safety, and Efficacy. Obes Surg 2019; 28:1445-1451. [PMID: 29500673 DOI: 10.1007/s11695-018-3171-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Stuart K Amateau
- Interventional and Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Department of Medicine, University of Minnesota Medical Center, MMC 36-420 Delaware St SE, Minneapolis, MN, 55455, USA.
| | - Chin Hong Lim
- Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Nicholas M McDonald
- Interventional and Therapeutic Endoscopy, Division of Gastroenterology and Hepatology, Department of Medicine, University of Minnesota Medical Center, MMC 36-420 Delaware St SE, Minneapolis, MN, 55455, USA
| | - Mustafa Arain
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Sayeed Ikramuddin
- Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Daniel B Leslie
- Division of Minimally Invasive Gastrointestinal Surgery and Medicine, Department of Surgery, University of Minnesota Medical Center, Minneapolis, MN, USA
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Tringali A, Giannetti A, Adler DG. Endoscopic management of gastric outlet obstruction disease. Ann Gastroenterol 2019. [PMID: 31263354 DOI: 10.20524/aog.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient's prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti)
| | - Aurora Giannetti
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti).,Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (DI.BI.M.I.S.), University of Palermo, Palermo, Italy (Aurora Giannetti)
| | - Douglas G Adler
- Gastroenterology, and Hepatology Department, University of Utah School of Medicine, Salt Lake City, Utah USA (Douglas G. Adler)
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Tringali A, Giannetti A, Adler DG. Endoscopic management of gastric outlet obstruction disease. Ann Gastroenterol 2019; 32:330-337. [PMID: 31263354 PMCID: PMC6595925 DOI: 10.20524/aog.2019.0390] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/07/2019] [Indexed: 12/14/2022] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms. It may be caused by motor disorders and by benign or malignant mechanical disease. Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy. Surgery remains the last resort. Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method. The use of a covered or uncovered stent depends on patient-related variables, which include the stricture site, concomitant involvement of the bile duct, the patient’s prognosis, probably the tumor type, and the use of chemotherapy. EUS-GE is a promising technique but needs more studies with longer follow up before any firm conclusions can be drawn.
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Affiliation(s)
- Alberto Tringali
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti)
| | - Aurora Giannetti
- Endoscopy Unit Surgical Department, ASST GOM Niguarda, Milan, Italy (Alberto Tringali, Aurora Giannetti).,Section of Gastroenterology, Biomedical Department of Internal and Specialized Medicine (DI.BI.M.I.S.), University of Palermo, Palermo, Italy (Aurora Giannetti)
| | - Douglas G Adler
- Gastroenterology, and Hepatology Department, University of Utah School of Medicine, Salt Lake City, Utah USA (Douglas G. Adler)
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Lou X, Yu D, Li J, Feng S, Sun JJ. Efficacy of endoscopic ultrasound-guided and endoscopic retrograde cholangiopancreatography-guided biliary drainage for malignant biliary obstruction: a systematic review and meta-analysis. Minerva Med 2019; 110:564-574. [PMID: 30994320 DOI: 10.23736/s0026-4806.19.05981-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Endoscopic ultrasound-guided (EUS) biliary drainage was used as an alternative method for patients who failed endoscopic retrograde cholangiopancreatography (ERCP). In recent years, an increasing number of patients was treated with EUS-biliary drainage (BD), but lack of data was available to value the efficacy and safety between EUS and ERCP. Therefore, a review was needed to evaluate the similarities and differences between the two methods and explored whether EUS-guided biliary drainage could be considered as first-line treatment. EVIDENCE ACQUISITION We searched the Pubmed/Medline, Embase, Web of science, Google scholar, the Cochrane Library and Clinical trials of electronic databases till October 2018 for all English language. Primary outcomes to comparison included technical success, clinical success and adverse events. Secondary outcomes consisted of stent dysfunction requiring reintervention and procedure duration, Data from selected studies were collected to calculate the odds ratios (OR) and standard mean difference (SMD). EVIDENCE SINTHESIS We searched 469 studies and at last identified 4 eligible trials. These included a total of 428 patients, 215 in the EUS group and 213 in the ERCP group. There was no difference in technical success (OR, 0.95; 95% CI: 0.45-2.02; I2=0%), clinical success (OR, 0.87; 95% CI: 0.42-1.79; I2=0%) and adverse events between 2 procedures (OR, 0.76; 95% CI: 0.29-2.00; I2=55%) but EUS-BD consisted of lower rate of reintervention (OR, 0.30; 95% CI: 0.14-0.63; I2=0%),and fewer procedure-related adverse events in pancreatitis and cholangitis (OR, 0.14; 95% CI: 0.04-0.51; I2=0%).There was no difference in length of procedure duration, with a pooled standard mean difference of 0.26 (95% CI: -0.15 to 0.66). CONCLUSIONS EUS-BD and ERCP-BD in terms of relief of malignant biliary obstruction presented the similarity rate of technical success, clinical success and there is no significant difference in adverse events of two procedures. EUS-BD could be used as a substitute for ERCP-BD, even considered as first-line treatment.
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Affiliation(s)
- Xin Lou
- Department of Hepatopancreatobiliary Surgery, Tianjin Medical University Second Hospital, Tianjin Medical University, Tianjin, China
| | - Dong Yu
- Department of Hepatopancreatobiliary Surgery, Tianjin Medical University Second Hospital, Tianjin Medical University, Tianjin, China
| | - Jun Li
- Department of Hepatopancreatobiliary Surgery, Tianjin Medical University Second Hospital, Tianjin Medical University, Tianjin, China
| | - Shuang Feng
- Department of Hepatopancreatobiliary Surgery, Tianjin Medical University Second Hospital, Tianjin Medical University, Tianjin, China
| | - Jin-Jin Sun
- Department of Hepatopancreatobiliary Surgery, Tianjin Medical University Second Hospital, Tianjin Medical University, Tianjin, China -
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Ge PS, Young JY, Dong W, Thompson CC. EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction. Surg Endosc 2019; 33:3404-3411. [PMID: 30725254 DOI: 10.1007/s00464-018-06636-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 12/19/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO); however, data comparing EUS-GE to enteral stent placement are limited. We aimed to compare clinical outcomes between EUS-GE and enteral stent placement in the palliation of malignant GOO. METHODS Retrospective analysis of a prospectively collected database on patients who underwent EUS-GE or enteral stent placement for palliation of malignant GOO from 2014 to 2017 was conducted. Primary outcome was the rate of stent failure requiring repeat intervention. Secondary outcomes included technical and clinical success, time to repeat intervention, length of hospital stay, and adverse events. RESULTS A total of 100 consecutive patients (mean age 65.9 ± 11.9 years, 44.0% female) were identified, of which 78 underwent enteral stent placement, and 22 underwent EUS-GE. Rate of stent failure requiring repeat intervention was higher in the enteral stent group than the EUS-GE group (32.0% vs. 8.3%, p = 0.021). Technical success was achieved in 100% in both groups. Higher initial clinical success was attained in the EUS-GE group than the enteral stent group (95.8% vs. 76.3%, p = 0.042). Mean length of hospital stay following stent placement was similar between groups (p = 0.821). The enteral stent group trended towards increased adverse events (40.2% vs. 20.8%, p = 0.098). Kaplan-Meier analysis showed decreased stent function in the enteral stent group (p = 0.013). CONCLUSION Compared to enteral stent placement, EUS-GE has a higher rate of initial clinical success and lower rate of stent failure requiring repeat intervention. EUS-GE may be offered for selected patients with malignant GOO in centers with extensive experience.
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Affiliation(s)
- Phillip S Ge
- Developmental Endoscopy Lab, Harvard Medical School, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Joyce Y Young
- Developmental Endoscopy Lab, Harvard Medical School, Boston, MA, USA
| | - William Dong
- Developmental Endoscopy Lab, Harvard Medical School, Boston, MA, USA
| | - Christopher C Thompson
- Developmental Endoscopy Lab, Harvard Medical School, Boston, MA, USA. .,Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Kerdsirichairat T, Irani S, Yang J, Brewer Gutierrez OI, Moran R, Sanaei O, Dbouk M, Kumbhari V, Singh VK, Kalloo AN, Khashab MA. Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction. Endosc Int Open 2019; 7:E144-E150. [PMID: 30705945 PMCID: PMC6353651 DOI: 10.1055/a-0799-9939] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/09/2018] [Indexed: 12/14/2022] Open
Abstract
Background and study aims EUS-guided gastroenterostomy (GE) is a novel, minimally invasive endoscopic procedure for the treatment of gastric outlet obstruction (GOO). The direct-EUS-GE (D-GE) approach has recently gained traction. We aimed to report on a large cohort of patients who underwent DGE with focus on long-term outcomes. Patients and methods This two-center, retrospective study involved consecutive patients who underwent D-GE between October 2014 and May 2018. The primary outcomes were technical and clinical success. Secondary outcomes were adverse events (AEs), rate of reintervention, procedure time, time to resume oral diet, and post-procedure length of stay (LOS). Results A total of 57 patients (50.9 % female; median age 65 years) underwent D-GE for GOO. The etiology was malignant in 84.2 % and benign in 15.8 %. Technical success and clinical success were achieved in 93 % and 89.5 % of patients, respectively, with a median follow-up of 196 days in malignant GOO and 319.5 days in benign GOO. There were 2 (3.5 %) AEs, one severe and one moderate. Median procedure time was 39 minutes (IQR, 26 - 51.5 minutes). Median time to resume oral diet after D-GE was 1 day (IQR 1 - 2 days). Median post D-GE LOS was 3 days (IQR 2 - 7 days). Rate of reintervention was 15.1 %. Conclusions D-GE is safe and effective in management of both malignant and benign causes of GOO. Clinical success with D-GE is durable with a low rate of reintervention based on a long-term cohort.
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Affiliation(s)
- Tossapol Kerdsirichairat
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Juliana Yang
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Olaya I. Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mohamad Dbouk
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Vikesh K. Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Anthony N. Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States,Corresponding author Mouen A. Khashab, M.D. Associate Professor of MedicineDirector of Therapeutic EndoscopyJohns Hopkins HospitalShiekh Zayed BuildingDivision of Gastroenterology and Hepatology1800 Orleans Street, Suite 7125GBaltimore, MD 21287+1- 410-502-7010
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Nabi Z, Reddy DN. Endoscopic Palliation for Biliary and Pancreatic Malignancies: Recent Advances. Clin Endosc 2019; 52:226-234. [PMID: 30665289 PMCID: PMC6547342 DOI: 10.5946/ce.2019.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023] Open
Abstract
Malignancies of the pancreatobiliary system are usually unresectable at the time of diagnosis. As a consequence, a majority of these cases are candidates for palliative care. With advances in chemotherapeutic agents and multidisciplinary care, the survival rate in pancreatobiliary malignancies has improved. Therefore, there is a need to provide an effective and long-lasting palliative care for these patients. Endoscopic palliation is preferred to surgery as the former is associated with equal efficacy and reduced morbidity. The main role of endoscopic palliation in the vast majority of pancreatobiliary malignancies includes biliary and enteral stenting for malignant obstructive jaundice and gastric outlet obstruction, respectively. Recent advances in endoscopic palliation appear promising in imparting long-lasting relief of symptoms. Use of radiofrequency ablation and photodynamic therapy in malignant biliary obstruction has been shown to improve the survival rates as well as the patency of biliary stents. The emergence of endoscopic ultrasound (EUS) as a therapeutic tool has enhanced the capability of minimally invasive palliation in pancreatobiliary cancers. EUS is a valuable alternative to endoscopic retrograde cholangiopancreatography for the palliation of obstructive jaundice. More recently, EUS is emerging as an effective primary modality for biliary and gastric bypass.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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Nakai Y, Isayama H, Kawakami H, Ishiwatari H, Kitano M, Ito Y, Yasuda I, Kato H, Matsubara S, Irisawa A, Itoi T. Prospective multicenter study of primary EUS-guided choledochoduodenostomy using a covered metal stent. Endosc Ultrasound 2019; 8:111-117. [PMID: 30168480 PMCID: PMC6482602 DOI: 10.4103/eus.eus_17_18] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background and Objectives: EUS-guided biliary drainage (EUS-BD) is increasingly reported as a salvage technique after failed endoscopic retrograde cholangiopancreatography, but it is still controversial whether EUS-BD can replace transpapillary biliary stenting. Therefore, we conducted this multicenter, prospective study of EUS-guided choledochoduodenostomy (EUS-CDS) using a covered metallic stent (CMS) as primary biliary drainage for unresectable distal malignant biliary obstruction (MBO). Methods: Patients with unresectable distal MBO without any prior drainage are enrolled. Primary endpoint is a technical success and secondary endpoints are adverse events, functional success, and recurrent biliary obstruction (RBO) of EUS-CDS. Clinical outcomes were compared between EUS-CDS and transpapillary stenting as a control. Results: A total of 34 patients were enrolled in 10 Japanese institutions. The cause of MBO was pancreatic cancer in 28 patients. Median tumor size and common bile duct diameter were 31 and 13 mm, respectively. Technical success rate was 97% with a median procedure time of 25 min and functional success rate was 100%. The rate of RBO was 29% and the causes of RBO were nontumor related: Migration in 18%, sludge/food impaction in 9%, and stent impaction to the duodenal wall in 3%. Other adverse events were abdominal pain in 6% and cholecystitis in 9%. A median cumulative time to RBO was 11.3 months. The rate of RBO and cumulative time to RBO of EUS-CDS were comparable to those of transpapillary stenting (36% and 9.1 months, respectively). Conclusion: EUS-CDS using a CMS as primary biliary drainage was technically feasible and its safety appeared comparable to transpapillary stenting.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo; Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Hiroshi Kawakami
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Hokkaido University, Sapporo; Department of Gastroenterology and Hepatology, University of Miyazaki; Center for Digestive Disease, University of Miyazaki Hospital, Miyazaki, Japan
| | - Hirotoshi Ishiwatari
- Department of Medical Oncology and Hematology, School of Medicine, Sapporo Medical University, Sapporo, Japan
| | - Masayuki Kitano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kinki University, Osaka-Sayama, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Ichiro Yasuda
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Hironari Kato
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine and Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Saburo Matsubara
- Department of Gastroenterology, Tokyo Metropolitan Police Hospital, Tokyo, Japan
| | - Atsushi Irisawa
- Department of Gastroenterology, Fukushima Medical University Aizu Medical Center, Aizuwakamatsu, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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Moran RA, Ngamruengphong S, Sanaei O, Fayad L, Singh VK, Kumbhari V, Khashab MA. EUS-directed transgastric access to the excluded stomach to facilitate pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. Endosc Ultrasound 2019; 8:139-145. [PMID: 30409927 PMCID: PMC6590006 DOI: 10.4103/eus.eus_41_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Robert A Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland; Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vikesk K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Shen Z, Tian L, Wang X. Treatment of pancreatic head cancer with obstructive jaundice by endoscopy ultrasonography-guided gastrojejunostomy: A case report and literature review. Medicine (Baltimore) 2018; 97:e11476. [PMID: 29995808 PMCID: PMC6076102 DOI: 10.1097/md.0000000000011476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Ultrasonography-guided gastrojejunostomy (EUS-GJ) might be a safe, innovative and minimally invasive interventional treatment for patients with gastric outlet obstruction (GOO) as an alternative to the surgical approach. To date, few cases have been reported in the literature. PATIENT CONCERNS A case of pancreatic head carcinoma with obstructive jaundice occurred in a 78-year-old man with a prior history of pancreatic head cancer. Biliary stent placement was conducted 1 year earlier. DIAGNOSES The patient was diagnosed with pancreatic cancer, pulmonary infection, pyloric obstruction, and biliary stent implantation. INTERVENTIONS EUS-GJ was performed. The wire and a double-balloon catheter reached the position of stenosis, then a double mushroom head bracket was released under EUS. The position was confirmed via X-ray. OUTCOMES The symptoms of obstruction were alleviated. No recurrence of obstruction, bleeding, perforation, and other complications occurred for the following 1.5 months while he died because of whole body spread of pancreatic cancer. LESSONS EUS-GJ may be reliable and effective for patients with GOO.
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Chen YI, Kunda R, Storm AC, Aridi HD, Thompson CC, Nieto J, James T, Irani S, Bukhari M, Gutierrez OB, Agarwal A, Fayad L, Moran R, Alammar N, Sanaei O, Canto MI, Singh VK, Baron TH, Khashab MA. EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc 2018; 87:1215-1221. [PMID: 28750837 DOI: 10.1016/j.gie.2017.07.030] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 07/17/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND EUS-guided gastroenterostomy (EUS-GE) is a developing modality in the management of gastric outlet obstruction (GOO) with several technical approaches, including the direct and balloon-assisted techniques. The aim of this study was to compare the direct with the balloon-assisted modality while further defining the role of EUS-GE in GOO. METHODS This multicenter, retrospective study involved consecutive patients who underwent EUS-GE with the direct or balloon-assisted technique for GOO (January 2014 to October 2016). The primary outcome was technical success. Secondary outcomes were success (ability to tolerate at least a full fluid diet), procedure time, and rate/severity of adverse events (AEs). RESULTS A total of 74 patients (44.6% women; mean age 63.0 ± 11.7 years) underwent EUS-GE for GOO (direct gastroenterostomy, n = 52; balloon-assisted gastroenterostomy, n = 22). GOO was of malignant and benign etiology in 66.2% and 33.8% of patients, respectively. Technical success was achieved in 94.2% of the direct and 90.9% of the balloon-assisted approach (P = .63). Mean procedure time was shorter with the direct technique (35.7 ± 32.1 minutes vs 89.9 ± 33.3 minutes, P < .001). The clinical success rate was 92.3% for the direct technique and 90.9% for the balloon-assisted modality (P = 1.00), with a mean time to oral intake of 1.32 ± 2.76 days. The AE rate was 6.8% with only 1 severe AE noted. Rate of AEs, postprocedure length of stay, need for reintervention, and survival were similar between the 2 groups. CONCLUSIONS EUS-GE is effective and safe in the management of GOO. The direct technique may be the preferred method given its shorter procedure time when compared with the balloon-assisted approach. Prospective trials are needed to confirm these findings.
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Affiliation(s)
- Yen-I Chen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA; Division of Gastroenterology and Hepatology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Rastislav Kunda
- Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew C Storm
- Division of Gastroenterology, Hepatology and endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hanaa Dakour Aridi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jose Nieto
- Division of Gastroenterology and Hepatology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Theodore James
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Shayan Irani
- Division of Gastroenterology and Hepatology, Virgina Mason Medical Center, Seattle, Washington, USA
| | - Majidah Bukhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Olaya Brewer Gutierrez
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Amol Agarwal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Robert Moran
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Nuha Alammar
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Omid Sanaei
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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Roos E, Hubers LM, Coelen RJS, Doorenspleet ME, de Vries N, Verheij J, Beuers U, van Gulik TM. IgG4-Associated Cholangitis in Patients Resected for Presumed Perihilar Cholangiocarcinoma: a 30-Year Tertiary Care Experience. Am J Gastroenterol 2018; 113:765-772. [PMID: 29549357 DOI: 10.1038/s41395-018-0036-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/18/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Distinguishing perihilar cholangiocarcinoma (PHC) from benign forms of sclerosing cholangitis affecting the hilar bile ducts is challenging, since histological confirmation of PHC is difficult to obtain and accurate non-invasive diagnostic tests are not available. IgG4-associated cholangitis (IAC), an imitator of PHC, may present with clinical and radiographical signs of PHC. IAC can be accurately diagnosed with a novel qPCR test. The aim of this study was to investigate the incidence and long-term activity of IAC in patients resected for PHC in a single tertiary center over a period of 30 years. METHODS All patients with benign disease who underwent surgery for presumed PHC in our institute between 1984 and 2015 were identified. Benign liver and bile duct specimens were re-evaluated by a pathologist and scored according to international consensus pathology criteria for IgG4-related disease (IgG4-RD). Patients with benign disease still alive were followed-up and a clinical diagnosis of IAC was made using a combination of the HISORt group C (response to steroids) criteria and elevated serum IgG4 levels and/or the novel IgG4/IgG RNA ratio. Also, recurrent symptomatic disease at any time after surgery requiring immunosuppression was assessed. RESULTS Out of 323 patients who underwent surgery for presumed PHC, 50 patients (15%) had benign disease. In 42% (n = 21/50) of these patients a histological (n = 17) or clinical (n = 4) diagnosis of IAC was established. The remaining patients were diagnosed with unclassified sclerosing inflammation, cystadenoma, or sclerosing hemangioma. Nine out of 12 IAC patients who were followed-up showed episodes of recurrent disease requiring immunosuppressive treatment. CONCLUSIONS Liver and bile duct resections for PHC during three decades disclosed in 15% benign biliary disorders mimicking PHC of which 42% were definitely diagnosed as IAC. IgG4-RD remains active in the majority of patients with IAC years after surgery. Novel diagnostic tests for IAC might reduce misdiagnosis, unnecessary surgery, and life-threatening complications.
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Affiliation(s)
- Eva Roos
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Lowiek M Hubers
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Robert J S Coelen
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Marieke E Doorenspleet
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Niek de Vries
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Joanne Verheij
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Ulrich Beuers
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
| | - Thomas M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands. Department of Gastroenterology & Hepatology and Tytgat institute for Liver and intestinal Research, Academic Medical Center, Amsterdam, The Netherlands. Department of Clinical immunology and Rheumatology, Amsterdam Rheumatology and immunology Center, & Laboratory of Experimental Medicine, Academic Medical Center, Amsterdam, The Netherlands. Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands. These authors contributed equally: Eva Roos, Lowiek M. Hubers
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Rassam F, Roos E, van Lienden KP, van Hooft JE, Klümpen HJ, van Tienhoven G, Bennink RJ, Engelbrecht MR, Schoorlemmer A, Beuers UHW, Verheij J, Besselink MG, Busch OR, van Gulik TM. Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience. Langenbecks Arch Surg 2018; 403:289-307. [PMID: 29350267 PMCID: PMC5986829 DOI: 10.1007/s00423-018-1649-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 09/15/2017] [Indexed: 12/12/2022]
Abstract
AIM Perihilar cholangiocarcinoma (PHC) is a challenging disease and requires aggressive surgical treatment in order to achieve curation. The assessment and work-up of patients with presumed PHC is multidisciplinary, complex and requires extensive experience. The aim of this paper is to review current aspects of diagnosis, preoperative work-up and extended resection in patients with PHC from the perspective of our own institutional experience with this complex tumor. METHODS We provided a review of applied modalities in the diagnosis and work-up of PHC according to current literature. All patients with presumed PHC in our center between 2000 and 2016 were identified and described. The types of resection, surgical techniques and outcomes were analyzed. RESULTS AND CONCLUSION Upcoming diagnostic modalities such as Spyglass and combinations of serum biomarkers and molecular markers have potential to decrease the rate of misdiagnosis of benign, inflammatory disease. Assessment of liver function with hepatobiliary scintigraphy provides better information on the future remnant liver (FRL) than volume alone. The selective use of staging laparoscopy is advisable to avoid futile laparotomies. In patients requiring extended resection, selective preoperative biliary drainage is mandatory in cholangitis and when FRL is small (< 50%). Preoperative portal vein embolization (PVE) is used when FRL volume is less than 40% and optionally includes the left portal vein branches to segment 4. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as alternative to PVE is not recommended in PHC. N2 positive lymph nodes preclude long-term survival. The benefit of unconditional en bloc resection of the portal vein bifurcation is uncertain. Along these lines, an aggressive surgical approach encompassing extended liver resection including segment 1, regional lymphadenectomy and conditional portal venous resection translates into favorable long-term survival.
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Affiliation(s)
- F Rassam
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
| | - E Roos
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - K P van Lienden
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - J E van Hooft
- Department of Gastroenterology & Hepatology and Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - H J Klümpen
- Department of Medical Oncology, Academic Medical Center, Amsterdam, The Netherlands
| | - G van Tienhoven
- Department of Radiotherapy, Academic Medical Center, Amsterdam, The Netherlands
| | - R J Bennink
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - M R Engelbrecht
- Department of Radiology and Nuclear Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - A Schoorlemmer
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - U H W Beuers
- Department of Gastroenterology & Hepatology and Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, Amsterdam, The Netherlands
| | - J Verheij
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - M G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - O R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Disorders of gastric outflow and outlet obstruction include a variety of benign and malignant disorders such as peptic strictures, foreign bodies, gastroparesis, and cancers of the stomach, duodenum, and pancreas. Historically, a majority of patients presenting with gastric outlet obstruction (GOO) were to the result of peptic ulcers and surgical management of peptic ulcer complications was a mainstay of general surgical training. Invasive surgery is being performed less frequently today due to realization of the role of Helicobacter pylori in peptic ulcer disease and the introduction of novel endoscopic techniques for management of GOO. RECENT FINDINGS For malignant GOO, the introduction of lumen-apposing metal stents have opened the door for the development and performance of endoscopic ultrasound-guided gastric bypass procedures. For benign GOO, including gastroparesis and pyloric stenosis, endoscopic myotomy shows promise. SUMMARY Endoscopic ultrasound-guided gastric bypass, per-oral endoscopic myotomy, and other novel techniques in the endoscopic management of GOO, are discussed in this review.
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