Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction

Exploring the safety and efficacy of stomach-partitioning gastrojejunostomy with distal selective vagotomy versus conventional gastrojejunostomy with highly selective vagotomy for treating benign gastric outlet obstruction: study protocol for a randomised controlled trial

INTRODUCTION

Benign gastric outlet obstruction (BGOO) severely impacts the quality of life of patients. The main treatment methods for BGOO include surgery and endoscopy, but both have significant drawbacks. Therefore, this study aims to explore the safety and efficacy of a new technique, to develop a new option for treating BGOO.

METHODS AND ANALYSIS

This is an ongoing prospective, single-centre, single-blind randomised controlled trial. The study will be conducted from January 2022 to December 2025, and 50 patients will be enrolled. The participants will be randomly assigned in a 1:1 ratio to either the experimental (stomach-partitioning gastrojejunostomy with distal selective vagotomy) or control groups (conventional gastrojejunostomy with highly selective vagotomy). We will collect baseline characteristics, laboratory tests, auxiliary examinations, operation, postoperative conditions and follow-up data. Follow-up will last for 3 years. The main outcome is the incidence of delayed gastric emptying within 30 days after surgery. Secondary outcomes include the efficacy indicator (consisting of serum gastrin level, pepsinogen level, 13C breath test, gastrointestinal quality of life index, operation time, blood loss and postoperative recovery), a safety evaluation index (consisting of complications and mortality within 30 days after surgery) and follow-up data (consisting of the incidence of primary ulcer progression in 3 years after surgery, and the gastroscopy results in 1 and 3 years after surgery).

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Beijing Friendship Hospital, Capital Medical University (no. 2021-P2-274-02). The study conformed to the provisions of the Declaration of Helsinki (as revised in 2013). Written informed consent will be obtained prior to study enrolment. The results of this study will be published in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR2100052197.

Endoscopic balloon dilation management for benign duodenal stenosis

BACKGROUND AND AIMS

Benign duodenal stenosis (BDS) is most commonly caused by peptic ulcer disease (PUD). Endoscopic balloon dilation (EBD) is the recommended initial management despite limited supporting literature. Our study investigated the etiologic spectrum of BDS and its response to endoscopic dilation.

METHODS

We performed a cohort study of a prospectively maintained database of BDS at our large tertiary academic center between 2002 and 2018. All patients who underwent EBD were analyzed. Dilation was performed using through-the-scope balloons. Technical and clinical successes of initial and repeat EBD were compared. Descriptive statistics, univariate, and multivariate analysis were performed.

RESULTS

The study included 86 patients with 54.7% female gender. Etiologies included 39 patients with PUD (45.3%), 19 patients with Crohn's disease (22.1%), 23 patients had idiopathic etiologies (26.7%), and 5 patients were listed as other etiologies (5.8%). Proximal stricture location (1st part of duodenum) occurred in 66% of females, whereas distal duodenal involvement was seen in 63.6% of males (p value 0.007). Usage of PPI was associated with 3.6 times higher clinical success rate (p value 0.04). Technical (97.4%) and clinical (77.8%) successes for index dilations in PUD were not significantly better than those of non-PUD patients (p values 0.99, 0.52).

CONCLUSION

EBD has both a high technical and clinical success for BDS regardless of etiology and should be considered over initial surgical intervention due to low risk profile. Males tend to have more distal duodenal involvement, and PPI usage is an independent predictor for clinical success.

Network Pharmacology and Molecular Docking Analysis on Pharmacological Mechanisms of Astragalus membranaceus in the Treatment of Gastric Ulcer

BACKGROUND

Astragalus membranaceus (AM, family: Leguminosae) exerts significant therapeutic effect on gastric ulcer (GU); however, there are scarce studies on its molecular mechanism against GU. This study aims to explore the key ingredients, key targets, and potential mechanisms of AM in the treatment of GU by utilizing network pharmacology and molecular docking.

METHODS

Several public databases were used to predict the targets of AM and GU, respectively, and the drug and disease targets were intersected to obtain the common targets. Next, the key ingredients and key targets were identified by constructing ingredient-target network and protein-protein-interaction (PPI) network. Gene Ontology biological processes (GOBP) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis were carried out on the common targets in order to ascertain the biological processes and signaling pathways involved. Finally, molecular docking was conducted to verify the binding affinity between the key ingredients and key targets.

RESULTS

A total of 552 predicted targets were obtained from 23 screened active ingredients, of which 203 targets were the common targets with GU. Quercetin, kaempferol, and isorhamnetin were identified as the key ingredients by constructing ingredient-target network, and TP53, AKT1, VEGFA, IL6, TNF, CASP3, and EGFR were selected as the key targets by constructing PPI network. GOBP and KEGG pathway enrichment analysis suggested that the therapeutic effect of AM on GU involved multiple biological processes and signaling pathways related to inflammation, oxidative stress, apoptosis, cell proliferation, and angiogenesis. Molecular docking validation demonstrated that all key ingredients had good binding affinity with the key targets.

CONCLUSION

This study revealed the key ingredients, key targets, and potential mechanisms of AM against GU, and these data may provide some crucial references for subsequent research and development of drugs for treating GU.

Predictors of outcomes of endoscopic balloon dilatation in strictures after esophageal atresia repair: A retrospective study

BACKGROUND

Endoscopic balloon dilatation (EBD) has become the first line of therapy for benign esophageal strictures (ESs); however, there are few publications about the predictive factors for the outcomes of this treatment.

AIM

To assess the predictive factors for the outcomes of EBD treatment for strictures after esophageal atresia (EA) repair.

METHODS

Children with anastomotic ES after thoracoscopic esophageal atresia repair treated by EBD from January 2012 to December 2016 were included. All procedures were performed under tracheal intubation and intravenous anesthesia using a three-grade controlled radial expansion balloon with gastroscopy. Outcomes were recorded and predictors of the outcomes were analyzed.

RESULTS

A total of 64 patients were included in this analysis. The rates of response, complications, and recurrence were 96.77%, 8.06%, and 2.33%, respectively. The number of dilatation sessions and complications were significantly higher in patients with a smaller stricture diameter (P = 0.013 and 0.023, respectively) and with more than one stricture (P = 0.014 and 0.004, respectively). The length of the stricture was significantly associated with complications of EBD (P = 0.001). A longer interval between surgery and the first dilatation was related to more sessions and a poorer response (P = 0.017 and 0.024, respectively).

CONCLUSION

The diameter, length, and number of strictures are the most important predictive factors for the clinical outcomes of endoscopic balloon dilatation in pediatric ES. The interval between surgery and the first EBD is another factor affecting response and the number of sessions of dilatation.

Update on endoscopic management of gastric outlet obstruction in children

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.

Retrospective evaluation of endoscopic stenting of combined malignant common bile duct and gastric outlet-duodenum obstructions

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.

Video capsule endoscopy and CT enterography in diagnosing adult hypertrophic pyloric stenosis

Primary adult hypertrophic pyloric stenosis is a rare but important cause of gastric outlet obstruction that may be misdiagnosed as idiopathic gastroparesis. Clinically, patients present with early satiety, abdominal fullness, nausea, epigastric discomfort and eructation. Permanent gastric retention of a video capsule endoscope is diagnostic in differentiating between the two diseases, in the absence of an organic gastric outlet obstruction. This case presents the longest video capsule retention in the medical literature to date. It is also the first case report of adult hypertrophic pyloric stenosis diagnosed with video capsule endoscopy or a computed tomography scan. Finally, an unusual “plugging” of the gastric outlet with free floating capsule has an augmented effect on disease physiology and on patient’s symptoms.

Peptic ulcer disease

Peptic ulcer disease (PUD) is due mostly to the widespread use of low-dose aspirin and nonsteroidal anti-inflammator drugs. It occurs mostly in older patients and those with comorbidities. Pain awakening the patient from sleep between 12 and 3 a.m. affects two-thirds of duodenal ulcer patients and one-third of gastric ulcer patients. Older adults (>80 years old) with PUD often do not present with abdominal pain; instead, epigastric pain, nausea and vomiting are among their most common presenting symptoms.

Two Cases of Helicobacter pylori-Negative Gastric Outlet Obstruction in Children

Gastric outlet obstruction (GOO) in children is most commonly caused by idiopathic hypertrophic pyloric stenosis. Prior to proton pump inhibitors and H2 blockers, peptic ulcer disease (PUD) secondary to H. pylori was a cause of GOO. Both patients presented with a history of weight loss, vomiting, and abdominal pain. Their diagnosis of PUD and GOO was made by EGD and UGI. H. pylori testing was negative for both on multiple occasions but still received H. pylori eradication therapy. Patient 1 after failing pharmaceutical management underwent surgery for definitive treatment. Patient 2 underwent six therapeutic pyloric dilations before undergoing surgery as definitive treatment. These cases suggest that GOO secondary to PUD occurs in the absence of H. pylori infection and surgical management can provide definitive therapy.

NSAIDs-Related Pyloroduodenal Obstruction and Its Endoscopic Management

Endoscopic balloon dilatation (EBD) has important role in the management of benign gastric outlet obstruction. Although there are many reports on the role of EBD in the management of corrosive-induced and peptic benign GOO, there is scanty data on its role in the management of NSAID-induced GOO. We report 10 cases of NSAID-induced pyloroduodenal obstruction and their endoscopic management. The most common site of involvement was duodenum (5/10) followed by both pylorus and duodenum (4/10) and pylorus (1/10). Most of the strictures were short web-like, and the mean (SD) number of stricture was 2.0 (0.94). Endoscopic balloon dilatation was successful in 90% (9/10) cases requiring mean (SD) of 2.0 (1.6) sessions of dilatation to achieve target diameter of 15 mm and mean (SD) of 5.3 (2.7) sessions to maintain it over a treatment period of 4.5 months (IQR 2–15 months). There was no procedure-related complication or mortality.

Isolated corrosive pyloric stenosis without oesophageal involvement: an experience of 21 years

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.

Endoscopic balloon dilatation without fluoroscopy for treating gastric outlet obstruction because of benign etiologies

BACKGROUND

Benign gastric outlet obstruction (GOO) causes considerable morbidity and conventional treatment has been surgery. Endoscopic balloon dilatation is a minimally invasive treatment modality for GOO but experience with its use is mainly in patients with GOO due to peptic ulcer disease. We report our experience of endoscopic balloon dilatation in benign GOO of various etiologies.

METHODS

Over 4 years, 25 patients with benign GOO were treated by endoscopic balloon dilatation done with through-the-scope controlled radial expansion (CRE) balloon dilators. Dilatation was repeated every 2 weeks with the end point being dilation of 15 mm or the need for surgery. Helicobacter pylori, when present, was eradicated.

RESULTS

Etiology of benign GOO was peptic ulcer (11), corrosive ingestion (7), chronic pancreatitis (4, groove pancreatitis in 1), tuberculosis (2), and Crohn's disease (1). Endoscopic balloon dilatation was successful in 21/25 (84%) patients. Patients required one to six sessions of endoscopic dilatation (mean=2.2±1.2). Corrosive-induced GOO required more dilatation sessions (3.83±0.75) compared to peptic GOO (2.1±0.56; p<0.05). Balloon dilatation was also effective in patients with GOO due to gastroduodenal tuberculosis and Crohn's disease. Patients with chronic pancreatitis-related GOO had poor response to dilatation, with two patients (50%) requiring surgery and the remaining two with recurrence of symptoms requiring repeat dilatation. None of the other patients with successful treatment had recurrence of symptoms. Complication in the form of perforation was noted in two patients (8%).

CONCLUSIONS

Endoscopic balloon dilatation is an effective, safe, and minimally invasive treatment modality for benign gastric outlet obstruction.

Late-onset hypertrophic pyloric stenosis: definition of diagnostic criteria and algorithm for the management

BACKGROUND AND PURPOSE

Gastric outlet obstruction (GOO) may be caused by various congenital and acquired conditions in children. The authors report 11 cases of GOO caused by muscular hypertrophy of the pylorus, which was proven histologically in 7. They describe this entity as "late-onset hypertrophic pyloric stenosis (HPS)," define the diagnostic criteria of the disease, and produce an algorithm for its management.

MATERIALS AND METHODS

The medical records of patients with GOO treated from 1999 and 2009 were retrospectively reviewed. Patients with infantile HPS and GOO secondary to corrosive ingestion or neoplasm were not included. Age, sex, family history, presenting symptoms and signs, radiologic methods and findings, type of management, histopathologic features, and outcome were noted for each patient.

RESULTS

Eleven patients (4 male, 7 female) ranging in age from 2 to 8 years (mean, 3.6 years) were included in the study. The symptoms were nonbilious vomiting (n = 11), abdominal pain (n = 4), and weight loss (n = 2). Abdominal ultrasound (n = 6) and upper gastrointestinal contrast studies were obtained (n = 11). Gastroscopy revealed complete (n = 6) or partial (n = 5) obstruction of the pylorus. Balloon dilatation of the pylorus was performed in 5 cases and repeated in 3 cases. Conservative treatment was initially attempted in 11 patients. Two patients with chronic gastritis and Helicobacter pylori (n = 2) were treated with amoxicillin-clavulanic acid, clarithromycin, and lansoprazole. A Billroth I procedure was performed in 7 cases. Hypertrophied pyloric muscle was noted in 7 patients and chronic gastritis in 2. The postoperative course was uneventful.

CONCLUSION

Hypertrophic pyloric stenosis is rarely seen after infancy. Analysis of our results and review of the literature prompted us to redescribe this entity as "late-onset HPS" and define the diagnostic criteria. Late-onset HPS is probably an acquired disease of unknown etiology. The management of late-onset HPS has been summarized in an algorithm, which will also be useful in the treatment of GOO in children caused by etiologies other than classical infantile HPS.

Early endoscopic balloon dilation in caustic-induced gastric injury

BACKGROUND

There are no reports on endoscopic balloon dilation (EBD) for caustic-induced gastric outlet obstruction (GOO) in the acute or subacute phase.

OBJECTIVE

To study the efficacy of early EBD in patients with caustic-induced gastric injury.

SETTING

Tertiary care center in India.

DESIGN

Retrospective analysis of data.

PATIENTS

Out of 41 patients with caustic-induced GOO who reported to us in the subacute phase between January 2001 and December 2008, 31 were treated by EBD. All 31 had ingested an acid 14.39 +/- 4.65 days earlier. EBD was achieved by using wire-guided balloons under endoscopic guidance.

INTERVENTION

The balloon was negotiated across the narrowed segment and inflated for 60 seconds using a pressure gun. Balloons of incremental diameter, up to a maximum of 3 sizes, were used in each sitting. Procedural success was defined as reaching the end point of dilation (15 mm) and absence of symptoms.

RESULTS

All 31 patients (18 male, mean age 32.06 +/- 11.04 years) could be successfully dilated. All but 1 underwent successful dilations to achieve the end point of 15 mm, requiring a median of 9 (range 3-18) dilations over a period of 7 (range 1.5-16) weeks. Complications included self-limiting pain (n = 10), bleeding at the time of the procedure (n = 9), and perforation in 1 patient (3.2%) who required surgery. Thirty patients were followed up for a median of 21 (range 3-72) months with no recurrence.

CONCLUSION

Early EBD by an expert endoscopist is a safe and effective treatment modality in the management of caustic-induced GOO.

Endoscopic balloon dilation for benign gastric outlet obstruction in adults

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.

Refractory peptic ulcer disease

Refractory PUD is a diagnostic and therapeutic challenge. Optimal management of severe or refractory PUD requires a multidisciplinary team approach, using primary care providers, gastroenterologists, and general surgeons. Medical management has become the cornerstone of therapy. Identification and eradication of H pylori infection combined with acid reduction regimens can heal ulceration and also prevent recurrence. Severe, intractable or recurrent PUD and associated complications mandates a careful and methodical evaluation and management strategy to determine the potential etiologies and necessary treatment (medical or surgical) required.

Endoscopic balloon dilation in caustic-induced chronic gastric outlet obstruction

BACKGROUND

The standard treatment of caustic-induced gastric outlet obstruction (GOO) is surgery. There are only a few reports in the medical literature on endoscopic balloon dilation (EBD) for caustic-induced GOO.

OBJECTIVE

To study the short-term and long-term response of EBD in patients with caustic-induced GOO.

SETTING

Tertiary-care center in India.

DESIGN

Retrospective analysis of data.

PATIENTS

Of the 49 patients with caustic-induced GOO seen by us between January 1998 and December 2003, 41 were treated by EBD. Thirty-seven patients had consumed an acid and 4 had consumed an alkali a mean (SD) of 19.5 +/- 14.5 weeks earlier. EBD was performed every 3 weeks by using through-the-scope balloons under endoscopic guidance.

INTERVENTION

The balloon was negotiated across the narrowed segment and inflated for 60 seconds by using a pressure gun. Balloons of incremental diameters, up to a maximum of 3 sizes, were used in each sitting. The end point of dilation was 15 mm, after which patients were assessed for recurrence. The patients were observed until August 2007.

RESULTS

All 41 patients (23 men; mean [SD] age 29.6 +/- 8.5 years) could be successfully taken for EBD. Thirty-nine patients underwent successful repeated dilations, which required a mean (SD) of 5.8 +/- 2.6 dilations (range 2-13) to achieve the end point of 15 mm. All 39 patients were followed up for an average (SD) of 35.4 +/- 11.1 months (range 18-58 months). The mean (SD) size of the first dilator was 8.2 +/- 0.6 mm (range 8-10 mm). One patient had a perforation and was subjected to antrectomy; another patient had pain every time he received EBD; he also had surgery. Other complications were minor: self-limiting pain (n = 8) or bleeding (n = 7).

CONCLUSIONS

EBD is a safe, effective, and long-lasting alternative to surgery for caustic-induced GOO.

Post-surgical and obstructive gastroparesis

Post-surgical gastroparesis (PSG) is recognized as a consequence of vagal nerve injury following upper abdominal surgery. It has been well documented following vagotomy for peptic ulcer surgery. With the increasing role of surgical treatment in the management of GERD and morbid obesity, PSG is now being diagnosed after fundoplication and bariatric surgery. PSG has also been reported after heart and lung transplantation, possibly due to opportunistic viral infection or motor-inhibitory effects of the immunosuppressive drugs, in addition to vagal nerve injury. Initial postoperative management of PSG should be conservative as many symptoms following abdominal surgery resolve with time. This occurs possibly because the enteric nervous system is able to adapt to the loss of vagal input or vagal reinnervation occurs. Persistent symptoms are difficult to manage and require a multidisciplinary team approach. Gastric electrical stimulation has shown promise in small series.