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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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Toshimori A, Inoue H, Fujiyoshi MRA, Fujiyoshi Y, Nishikawa Y, Tanabe M, Shimamura Y, Ohwada K, Ono M, Ikeda H, Onimaru M. Novel modified side-by-side balloon dilatation method for esophagogastric junction strictures: Single-/double-barrel techniques. Dig Endosc 2022; 34:641-647. [PMID: 34837409 DOI: 10.1111/den.14205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/08/2023]
Abstract
Endoscopic balloon dilatation is an established treatment for benign gastrointestinal strictures. In order to dilatate safely, it is necessary to dilatate gradually and preferably under direct endoscopic visualization. However, it is currently difficult to achieve dilatation widths of 20-30 mm with commercial products and of over 30-mm with endoscopic visualization. Therefore, a safe and innovative application technique is needed for patients who need these 20-mm or greater dilatation widths. We have developed two methods that enable more than 20-mm dilatation under direct visualization. (i) Single-barrel method: an endoscopic balloon dilatation catheter was fixed with grasping forceps at the tip of the endoscope and carried into the stomach. The balloon catheter was released from the endoscope to create a retroflexed view. The endoscope and balloon were positioned adjacent to each other at the gastric cardia. The balloon was inflated gradually and the esophagogastric junction was dilatated under direct visualization. (ii) Double-barrel method: the same procedure was repeated with two balloons. Theoretically, we achieved a dilatation of >30-mm in diameter. These modified methods may be helpful for esophagogastric junction strictures, such as esophageal achalasia (serving as an initial endoscopic balloon dilatation prior to using a 30-mm achalasia balloon), or for functional strictures after Nissen fundoplication. In conclusion, our simple, modified method enables safe and gradual dilatation under direct endoscopic visualization. Additionally, combination of the sizes of one or two balloons can achieve various widths of dilatation.
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Affiliation(s)
- Akiko Toshimori
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruhiro Inoue
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Yusuke Fujiyoshi
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yohei Nishikawa
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kaori Ohwada
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Masashi Ono
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Haruo Ikeda
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Jeong SJ, Lee J. Management of gastric outlet obstruction: Focusing on endoscopic approach. World J Gastrointest Pharmacol Ther 2020; 11:8-16. [PMID: 32550041 PMCID: PMC7288729 DOI: 10.4292/wjgpt.v11.i2.8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/14/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
Gastric outlet obstruction (GOO) is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction. The obstructions typically involved in GOO can be benign or malignant. Peptic ulcer disease is the most common cause of benign GOO, and malignant causes include gastric cancer, lymphoma, and gastrointestinal stromal tumor. With the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors, the predominant causes have changed from benign to malignant diseases. Treatment of GOO depends on the underlying cause: Proton pump inhibitors, H. pylori eradication, endoscopic treatments including balloon dilatation or the placement of self-expandable stents, or surgery.
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Affiliation(s)
- Su Jin Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan 48108, South Korea
| | - Jin Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan 48108, South Korea
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Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction. Gastrointest Endosc 2018; 88:899-908. [PMID: 30017869 DOI: 10.1016/j.gie.2018.06.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/29/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIMS Peptic ulcer disease (PUD)-related gastric outlet obstruction (GOO) is known to respond favorably to endoscopic balloon dilation (EBD). However, data on efficacy of EBD for other etiologies of benign GOO are sparse. We aimed to compare the response of EBD among different etiologies of GOO. METHODS Records of all patients with benign GOO who underwent EBD at our tertiary-care center between January 1998 and December 2017 were analyzed. Dilation was done by using through-the-scope balloons. Procedural and clinical success of EBD was compared among different etiologies. RESULTS A total of 306 patients were evaluated, of whom 264 (mean [± standard deviation] [SD] age 37.89 ± 17.49 years; men 183, women 81) underwent dilation. Etiologically, caustic ingestion was the commonest cause of GOO (53.8%) followed by PUD (26.1%) and medication-induced (8.3%). Overall procedural and clinical success was achieved in 200 (75.7%) and 243 (92.04%) patients, respectively, requiring a mean (± SD) of 2.55 (2.8) and 5.37 (3.9) sessions, respectively. Caustic-induced GOO responded less favorably, requiring a higher number of dilation sessions and having more refractory strictures than other etiologies. Medication-induced GOO performed worse than PUD-related GOO. Of the 264 patients, 9 (3.4%) had perforations during EBD, 3 had contained leaks and were managed conservatively, and 6 underwent successful surgery. CONCLUSION EBD is successful in a majority of patients with benign GOO, with caustic-induced GOO and medication-induced GOO being more difficult than PUD-related GOO.
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Banerjee AK, Walters TK, Wilkins R, Burke M. Wire-Guided Balloon Coloplasty – a New Treatment for Colorectal Strictures? J R Soc Med 2018; 84:136-9. [PMID: 2013892 PMCID: PMC1293131 DOI: 10.1177/014107689108400307] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A new technique for dilatation of colorectal anastomotic strictures – wire-guided balloon coloplasty – is described. It is suitable for high strictures, may be performed without general anaesthetic and is repeatable. It does not require endoscopy and may be used to relieve obstructive symptoms in both benign and malignant strictures so avoiding the need for a defunctioning colostomy.
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Affiliation(s)
- A K Banerjee
- Department of Surgery, Northwick Park Hospital, Harrow, Middlesex
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Chao HC. Update on endoscopic management of gastric outlet obstruction in children. World J Gastrointest Endosc 2016; 8:635-645. [PMID: 27803770 PMCID: PMC5067470 DOI: 10.4253/wjge.v8.i18.635] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/18/2016] [Accepted: 08/08/2016] [Indexed: 02/06/2023] Open
Abstract
Endoscopic balloon dilatation (EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.
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Yu J, Hao J, Wu D, Lang H. Retrospective evaluation of endoscopic stenting of combined malignant common bile duct and gastric outlet-duodenum obstructions. Exp Ther Med 2014; 8:1173-1177. [PMID: 25187819 PMCID: PMC4151663 DOI: 10.3892/etm.2014.1899] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 07/21/2014] [Indexed: 01/14/2023] Open
Abstract
Malignant dual obstruction in the common bile duct and gastric outlet-duodenum can cause difficulties in palliative treatment. The purpose of this study was to summarize our successful experience with the endoscopic stenting procedure for the palliative treatment of malignant biliary and gastric outlet-duodenum obstruction. Seventeen patients who underwent dual stenting procedures for the common bile duct and duodenum were retrospectively reviewed. The success rate of placement, palliative effect for biliary and duodenal obstruction, incidence of complication and restricture and stent patency were analyzed. Stent placement achieved a 100% success rate. Total bilirubin decreased from 263.4±62.5 to 157.6±25.1 μmol/l, direct bilirubin decreased from 233.2±66.5 to 130.9±27.7 μmol/l and alkaline phosphatase from 534.2±78.7 to 216.3±23.3 IU/l. The differences between the preoperative and postoperative results were statistically significant (P<0.01). The gastric outlet obstruction score increased significantly from 0.9±1.1 to 2.1±0.7 points (P<0.01). The general nutritional status of the patients was improved. No serious complications occurred in any of the patients, and the survival time of patients following stenting ranged between 70 and 332 days with a mean survival time of 192 days. In conclusion, our methodology for combined biliary and enteral stenting is highly effective for the palliation of malignant biliary and gastric outlet-duodenal obstruction.
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Affiliation(s)
- Jianfeng Yu
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, P.R. China
| | - Jianyu Hao
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, P.R. China
| | - Dongfang Wu
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, P.R. China
| | - Haibo Lang
- Department of Gastroenterology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, P.R. China
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Ansari MM, Haleem S, Harris SH, Khan R, Zia I, Beg MH. Isolated corrosive pyloric stenosis without oesophageal involvement: an experience of 21 years. Arab J Gastroenterol 2011; 12:94-8. [PMID: 21684482 DOI: 10.1016/j.ajg.2011.04.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2010] [Revised: 03/11/2011] [Accepted: 04/06/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND STUDY AIMS Corrosive ingestion is common in Asia and it is a frequent cause of morbidity secondary to intense fibrotic reaction and stricture formation of the oesophagus. Isolated corrosive pyloric stenosis without oesophageal involvement is an uncommon phenomenon. PATIENTS AND METHODS All consecutive patients, with corrosive ingestion in the last two decades, were reviewed and analysed. Eleven out of 201 patients with corrosive ingestion had isolated gastric outlet obstruction. RESULTS Patients' age ranged from 11 to 29 years with a male:female ratio of 1.75:1. All patients developed pyloric stenosis following ingestion of solution of acids. Barium study revealed complete/near-complete gastric outlet obstruction in all patients. On laparotomy, there was gastric dilatation in 10 patients, who underwent posterior gastrojejunostomy, whereas the stomach was contracted in one patient, and hence anterior gastrojejunostomy was performed. Seven patients were completely relieved of their symptoms; persistent postprandial epigastric fullness and/or dyspepsia was observed in four patients whose gastrojejunostomy stoma was found adequate on barium study, suggestive of gastric motility disorder. We did not encounter gastrojejunostomy-related complication of stomal ulcer/stenosis in our patients. CONCLUSION Isolated corrosive pyloric stenosis is not as rare as is commonly thought. Gastrojejunostomy is effective, although a fair percentage of patients appear to develop gastric motility disorder secondary to corrosive injury.
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Kochhar R, Kochhar S. Endoscopic balloon dilation for benign gastric outlet obstruction in adults. World J Gastrointest Endosc 2010; 2:29-35. [PMID: 21160676 PMCID: PMC2998862 DOI: 10.4253/wjge.v2.i1.29] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Revised: 09/01/2009] [Accepted: 09/08/2009] [Indexed: 02/05/2023] Open
Abstract
Gastric outlet obstruction (GOO) includes obstruction in the antropyloric area or in the bulbar or post bulbar duodenal segments. Though malignancy remains the most common cause of GOO in adults, a significant number of patients have benign disease. The latter include peptic ulcer disease, caustic ingestion, post-operative anastomotic state and inflammatory causes like Crohn’s disease and tuberculosis. Peptic ulcer remains the most common benign cause of GOO. Management of benign GOO revolves around confirmation of the etiology, removing the offending agent Helicobacter pylori (H. pylori), non-steroidal anti-inflammatory drugs, etc. and definitive therapy. Traditionally, surgery has been the standard mode of treatment for benign GOO. However, after the advent of through-the-scope balloon dilators, endoscopic balloon dilation (EBD) has emerged as an effective alternative to surgery in selected groups of patients. So far, this form of therapy has been shown to be effective in caustic-induced GOO with short segment cicatrization and ulcer related GOO. In the latter, EBD must be combined with eradication of H. pylori. Dilation is preferably done with wire-guided balloon catheters of incremental diameter with the aim to reach the end-point of 15 mm. While it is recommended that fluoroscopic control be used for EBD, this is not used by most endoscopists. Frequency of dilation has varied from once a week to once in three weeks. Complications are uncommon with perforation occurring more often with balloons larger than 15 mm. Attempts to augment efficacy of EBD include intralesional steroids and endoscopic incision.
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Affiliation(s)
- Rakesh Kochhar
- Rakesh Kochhar, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
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10
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Abstract
PURPOSE OF REVIEW To examine the short and long-term success rates of balloon dilation of pyloric stenosis. RECENT FINDINGS Several large studies have demonstrated high rates of success for the relief of symptoms from pyloric stenosis using through-the-scope balloons. These dilating balloons readily increase the diameter of the stenotic pylorus on average from 6 to 16 mm. Patients who require more than two dilations are at high risk of endoscopic failure and the need for surgical intervention. Rapid re-stenosis rates are observed in patients with malignant pyloric obstruction. Since many patients with benign pyloric stenosis have underlying ulcer disease, helicobacter infection is a relatively common finding. Eradication of this infection at the time of balloon dilation will ensure higher long-term success rates. SUMMARY In summary, benign pyloric stenosis can be readily treated with endoscopic balloon dilation and should be the first-line therapy.
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Affiliation(s)
- Tony E Yusuf
- GI Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
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Artifon ELA, Sakai P, Hondo FY, Lopasso FP, Ishioka S, Gama-Rodrigues JJ. An evaluation of gastric scintigraphy pre- and postpyloroduodenal peptic stenosis dilation. Surg Endosc 2006; 20:243-8. [PMID: 16391961 DOI: 10.1007/s00464-005-0129-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2005] [Accepted: 07/19/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The usual treatment of pyloroduodenal peptic stenosis has been mainly surgical, through pyloroplasty or gastric resection, with or without vagotomy. Since the first description of treatment for this peptic complication by endoscopic balloon dilation perfomed by Benjamin in 1982 [2], this procedure has become a therapeutic option in association with the medical treatment of peptic disease. The aim of this study is to evaluate the results involving clinical, endoscopic, and gastric emptying scintigraphy parameters. METHODS Between August 1998 and February 2000, 20 patients with pyloroduodenal stenosis refractory to conservative treatment were treated at the Gastrointestinal Endoscopy Unit of the University of São Paulo Medical School. All patients who presented clinical manifestations of pyloroduodenal stenosis underwent upper gastrointestinal endoscopy to confirm peptic stenosis. Biopsy of the narrowing for the confirmation of a benign disease and gastric biopsy for Helicobacter pylori detection were performed. The treatment consisted of dilation of the stenosis with type TTS (Through The Scope) hydrostatic balloon under endoscopic control, treatment of Helicobacter pylori infection, and gastric acid suppression with oral administration of proton pump inhibitor. All patients, except one who was excluded from this study, were submitted to a clinical endoscopic assessment and gastric emptying evaluation by ingestion of (99m)Tc before and after the treatment. Endoscopic evaluation considered the diameter of the stenotic area before and after treatment. A scintigraphic study compared the time of gastric emptying before and after balloon dilation. RESULTS Nineteen patients completed treatment by hydrostatic balloon dilation. Clinical symptoms such as bloating (p < 0.0001), epigastric pain (p = 0.0159), gastric stasis (p < 0.0001), and weight gain (p = 0.036) showed significant improvement. The diameter of the stenotic area increased significantly (p < 0.01) after the dilation treatment as well as a better gastric emptying of (99m)Tc (p < 0.0001). CONCLUSION The dilation of the peptic pyloroduodenal stenosis using a hydrostatic balloon is a safe and effective procedure. The evaluation with gastric scintigraphy by ingestion of (99m)Tc is an effective method of assessment for the improvement of gastric function, because its results corresponded to the clinical improvement after endoscopic treatment.
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Affiliation(s)
- E L A Artifon
- Gastrointestinal Endoscopy Unit, University of São Paulo Medical School, São Paulo, Brazil.
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12
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Abstract
BACKGROUND AND AIM Endoscopic balloon dilatation (EBD) has been used for the treatment of gastric outlet obstruction (GOO). There are several reports on the utility and success of this non-surgical treatment option in peptic GOO, with variable results. However, there are only a few reports documenting the efficacy of this method for non-peptic GOO. The authors here report on experience with balloon dilatation in peptic and non-peptic GOO over a 3-year period. METHODS Twenty-three patients with benign GOO underwent EBD. Dilatation was carried out with through-the-scope balloon dilators after premedication. Dilatation was repeated every week and the response was documented on the basis of symptoms and endoscopic findings and barium studies. Helicobacter pylori was eradicated in patients with peptic GOO, when present. RESULTS The 23 patients with GOO included 11 with peptic ulcer as the etiology, eight with corrosive-induced and four with chronic pancreatitis (alcohol three, idiopathic one). Patients with peptic GOO required 1-3 sessions (mean 2.0 +/- 0.63) to achieve a diameter of 15 mm dilatation, with uniformly good response over a mean follow-up period of 14.04 +/- 9.79 months. Corrosive-induced GOO required a larger number of dilatation sessions (2-9, mean 5.63 +/- 2.88), but the response was equally good, with follow up of 12-30 months. Patients with pancreatitis-related GOO, however, failed to respond despite a mean of 5.50 (+/-0.58) dilatations, and continued to have symptoms. All these patients were subjected to surgical bypass. There were no major complications such as perforation. CONCLUSIONS A good response can be expected in the majority of patients with peptic and corrosive-related GOO after balloon dilatation; however, poor results are noted for chronic pancreatitis-related GOO.
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Affiliation(s)
- Rakesh Kochhar
- Clinical section, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Hewitt PM, Krige JE, Funnell IC, Wilson C, Bornman PC. Endoscopic balloon dilatation of peptic pyloroduodenal strictures. J Clin Gastroenterol 1999; 28:33-5. [PMID: 9916662 DOI: 10.1097/00004836-199901000-00007] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
A through-the-scope endoscopic balloon dilatation technique and acid-reducing medication was used in 46 consecutive patients (median age, 55; range, 21-88 years) with benign gastric outlet obstruction. In five patients, dilatation was not technically possible. In 41 patients, 122 dilatations (median, 2; range, 1-9 per patient) were performed without morbidity. Ninety-four procedures were successful (77%) at the initial attempt (able to pass a 12-mm endoscope into the duodenum at the end of the procedure). Median follow-up in the 41 patients was 19 (range, 1-78) months. Thirteen patients (32%) required subsequent surgery; 8 had delayed operation for persistent symptoms (1-28 months after the first dilatation), 1 had surgery during the initial hospital admission, and 4 required emergency surgery for other ulcer complications (3 perforation, 1 bleeding). Of the 28 patients who had only balloon dilatation and medical therapy, 11 are asymptomatic (4 with active ulceration), 9 have mild symptoms (Visick 2), and 3 have persistent symptoms (Visick 3). One patient was lost to follow-up and four patients have died (one from an ulcer-related complication). Balloon dilatation and sustained acid-reducing therapy with regular endoscopic surveillance should be first-line treatment of peptic pyloroduodenal strictures, because the procedure is safe and is likely to be successful in half of the patients in whom dilatation is technically possible.
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Affiliation(s)
- P M Hewitt
- Department of Surgical Gastroenterology, University of Cape Town and Groote Schuur Hospital, South Africa
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14
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Abstract
Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.
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Affiliation(s)
- S K Khullar
- Division of Gastroenterology, University of Utah School of Medicine and Health Sciences Center, Salt Lake City, USA
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15
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Abstract
Although the immediate success of endoscopic balloon dilation of nonmalignant and noncongenital pyloric stenosis is known, little information is available on the long-term results of such therapy. Of 19 patients who underwent this treatment at our institution for gastric outlet obstruction, 3 (16%) experienced sustained relief and 16 (84%) had a recurrence of symptoms during a median follow-up period of 45 months. Twelve of the patients who had a recurrence of gastric outlet obstructive symptoms required further therapy. Our results suggest that if followed for a prolonged period of time, patients who have undergone endoscopic balloon dilation of nonmalignant pyloric stenosis have a high recurrence rate of symptomatic gastric outlet obstruction.
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Affiliation(s)
- S K Kuwada
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota 55905, USA
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16
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Denys A, De Baere T, Lasser P, Elias D, Roche A. Single-step balloon dilation of postoperative pyloric stenosis: benefit of large-balloon technique. J Vasc Interv Radiol 1994; 5:781-2. [PMID: 8000130 DOI: 10.1016/s1051-0443(94)71602-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Affiliation(s)
- A Denys
- Department of Interventional Radiology, Institut Gustave Roussy, Villejuif, France
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Johnson DL, Lang E. Technical aspects of nonoperative dilation of a complex colon anastomotic stricture. Dig Dis Sci 1993; 38:1929-32. [PMID: 8404417 DOI: 10.1007/bf01296121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- D L Johnson
- Surgical Service, Department of Veterans Affairs, Stanford University Medical Center, Palo Alto, California 94304
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Affiliation(s)
- U K Murthy
- Department of Medicine, Veterans Administration Medical Center and Health Science Center, Syracuse, New York
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Dakkak M, Bennett JR. Balloon technology and its applications in gastrointestinal endoscopy. BAILLIERE'S CLINICAL GASTROENTEROLOGY 1991; 5:195-208. [PMID: 1854987 DOI: 10.1016/0950-3528(91)90012-p] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Abstract
Balloon dilating catheters (BDC) have provided a non-operative means of managing obstructive lesions within the gastrointestinal tract. Its potential utility in infants with hypertrophic pyloric stenosis (HPS) was studied. Six patients with HPS underwent balloon catheter dilatation of the pylorus under the direct observation of the surgeon. The pylorus was exposed using a standard right upper quadrant incision. The BDC was passed transorally into the stomach and manipulated into the pyloric canal by the surgeon. The balloon was inflated with saline to a maximum pressure of 50 psi for 2 minutes. Four patients were dilated with a 10-mm diameter balloon catheter, and in two patients, a 15-mm balloon was used. Success was defined as the complete and longitudinal disruption of the seromuscular ring without violation of mucosal integrity. Using this criterion, none had successful pyloric dilatation. No disruption occurred in three patients, partial disruption in two. These patients subsequently underwent a Ramstedt pyloromyotomy. Complete disruption was observed in one; however, a breach of the mucosa was evident. This was repaired without incident. All seromuscular breaks occurred at the point of vascular entry along the lesser curve, presumably the weakest point of the ring. Pyloric dilatation using BDC does not reliably disrupt the muscular ring. This preliminary report recognizes that major refinements must occur before this method will supplant the time-honored surgical pyloromyotomy for HPS.
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Affiliation(s)
- A H Hayashi
- Department of Surgery, IWK Children's Hospital, Halifax, Nova Scotia, Canada
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Griffin SM, Chung SC, Leung JW, Li AK. Peptic pyloric stenosis treated by endoscopic balloon dilatation. Br J Surg 1989; 76:1147-8. [PMID: 2597970 DOI: 10.1002/bjs.1800761112] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Twenty-five patients with proven gastric outlet obstruction secondary to peptic ulcer disease were treated by endoscopic balloon dilatation using 'through the scope' balloons. The stricture could not be negotiated in one patient. Two patients continued to have gastric outlet obstruction despite the dilatation and required surgery. Two patients have returned up to 11 weeks after treatment with signs of recurrent gastric outlet obstruction. Twenty patients (80 per cent) remained asymptomatic (follow-up: median 9 months, range 2-24 months).
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Affiliation(s)
- S M Griffin
- Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, New Territories
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22
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Lambert M, Faintuch JS. Laser recanalization of pyloric stenosis: a guidewire-directed contact probe technique. Lasers Surg Med 1989; 9:282-5. [PMID: 2733537 DOI: 10.1002/lsm.1900090312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A variety of techniques has been used to relieve the obstructive symptoms of pyloric stenosis. Endoscopic dilatation using hydrostatic balloon dilators, multiple-diameter bougies, and electrocautery with a sphincterotome have been described. The neodymium yttrium aluminum garnet laser also has been used, with both noncontact and contact probes. We describe a new technique using a guidewire-directed contact probe for laser recanalization of pyloric stenosis in a patient with radiation-induced gastric outlet obstruction.
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Affiliation(s)
- M Lambert
- Department of Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030
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23
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Heymans HS, Bartelsman JW, Herweijer TJ. Endoscopic balloon dilatation as treatment of gastric outlet obstruction in infancy and childhood. J Pediatr Surg 1988; 23:139-40. [PMID: 3343648 DOI: 10.1016/s0022-3468(88)80142-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The application of balloon dilatation as treatment of gastric outlet obstruction is described. In two infants after inadequate pyloromyotomy and in an 11-year-old boy with surgical damage to the vagus, balloon dilatation was successful and considered a good alternative to surgery in these conditions.
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Affiliation(s)
- H S Heymans
- Department of Pediatrics, University of Amsterdam, The Netherlands
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24
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Meeroff JC. A quick and safe maneuver for intubating the difficult pylorus. Gastrointest Endosc 1987; 33:465-6. [PMID: 3443275 DOI: 10.1016/s0016-5107(87)71701-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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25
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Graham DY, Tabibian N, Schwartz JT, Smith JL. Evaluation of the effectiveness of through-the-scope balloons as dilators of benign and malignant gastrointestinal strictures. Gastrointest Endosc 1987; 33:432-5. [PMID: 3443261 DOI: 10.1016/s0016-5107(87)71681-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- D Y Graham
- Digestive Disease Section, Veterans Administration Medical Center, Houston, Texas 77211
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26
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Neufeld DM, Shemesh EI, Kodner IJ, Shatz BA. Endoscopic management of anastomotic colon strictures with electrocautery and balloon dilation. Gastrointest Endosc 1987; 33:24-6. [PMID: 3557029 DOI: 10.1016/s0016-5107(87)71480-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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27
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Hegedüs V, Poulsen PE. Balloon dilatation of alimentary tract strictures. ACTA RADIOLOGICA: DIAGNOSIS 1986; 27:681-6. [PMID: 3812017 DOI: 10.1177/028418518602700610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
From a series of balloon dilatations of alimentary tract strictures 11 patients with different types of gastric and oesophagogastric anastomotic stenoses are reported. The dilatation of gastric outflow tract obstructions was highly effective in the treatment of retention. In 7 out of 8 cases with gastric outflow stenosis surgery could be entirely avoided and replaced by balloon dilatation. The importance of eliminating retention in the healing of gastric ulcer is discussed. Fistulation in oesophagogastric anastomoses due to stenosis of the outflow portion was successfully treated. The importance of achieving a free outflow tract in order to prevent insufficiency of the anastomosis and formation of a fistula is stressed.
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28
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Hogan RB, Hamilton JK, Polter DE. Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction. Gastrointest Endosc 1986; 32:71-4. [PMID: 3710101 DOI: 10.1016/s0016-5107(86)71758-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.
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29
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30
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Benjamin SB, Collins KS. The toposcopic through-lumen everting catheter to facilitate dilation of severe strictures of the gastrointestinal tract. Gastrointest Endosc 1986; 32:33-5. [PMID: 3949131 DOI: 10.1016/s0016-5107(86)71726-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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31
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