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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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2
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Mangiavillano B, Repici A. EUS-guided gastro-enteral anastomosis for the treatment of gastric outlet obstruction: is the end of the enteral stent? Expert Rev Gastroenterol Hepatol 2022; 16:587-589. [PMID: 35772181 DOI: 10.1080/17474124.2022.2097071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center IRCCS, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (MI), Italy
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Chamely EA, Hoang B, Jafri NS, Felinski MM, Bajwa KS, Walker PA, Barge J, Wilson EB, Cen P, Shah SK. Palliative Endoscopic Salvage of a Functionally Obstructed Gastrojejunostomy - Report of Technique. CRSLS : MIS CASE REPORTS FROM SLS 2022; 9:e2021.00094. [PMID: 36016812 PMCID: PMC9387390 DOI: 10.4293/crsls.2021.00094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Gastric outlet obstruction secondary to foregut gastrointestinal malignancies can be managed with a variety of medical, endoscopic, and surgical options. Laparoscopic gastrojejunostomy is an option for those patients who are able to tolerate an operation as a long-term palliative option. This operation may be associated with some significant postoperative technical and nontechnical complications, including delayed gastric emptying. This paper describes an incision-less, endoscopic option that we propose can be used to salvage a functionally obstructed gastrojejunostomy. CASE DESCRIPTION A 57-year old male patient had a history of pancreatic adenocarcinoma causing gastric outlet obstruction and underwent a previously created surgical gastrojejunostomy at an outside hospital. His procedure was complicated by anastomotic leak and essentially persistent obstructive symptoms secondary to delayed gastric emptying. Though his anastomosis was demonstrably patent, these symptoms were thought to be secondary to a functional obstruction at the gastrojejunostomy. After repeated workups and many failed attempts to treat these symptoms, he ultimately underwent endoscopic placement of an uncovered colonic stent into the efferent limb of his gastrojejunostomy. This allowed for preferential drainage of gastric contents down the efferent limb, and improvement of his delayed gastric emptying. CONCLUSIONS In a select group of patients with advanced foregut malignancy, and with high re-operative risks, salvage endoscopic stenting may be useful in the palliation of symptoms from a functionally obstructed gastrojejunostomy.
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Affiliation(s)
- Elias A Chamely
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Bryan Hoang
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Nadim S Jafri
- Michael E DeBakey Institute of Comparative Cardiovascular Science and Biomedical Devices, Texas A&M University, College Station, TX
| | - Melissa M Felinski
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Kulvinder S Bajwa
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Peter A Walker
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | | | - Erik B Wilson
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
| | - Putao Cen
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX
| | - Shinil K Shah
- Department of Surgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX
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Tey J, Zheng H, Soon YY, Leong CN, Koh WY, Lim K, So JBY, Shabbir A, Tham IWK, Lu J. Palliative radiotherapy in symptomatic locally advanced gastric cancer: A phase II trial. Cancer Med 2019; 8:1447-1458. [PMID: 30790469 PMCID: PMC6488108 DOI: 10.1002/cam4.2021] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/03/2018] [Accepted: 12/04/2018] [Indexed: 01/28/2023] Open
Abstract
To evaluate the response and quality of life of palliative gastric radiotherapy in patients with symptomatic locally advanced gastric cancer. Patients with bleeding, pain or obstruction and were treated with palliative gastric radiotherapy to a dose of 36 Gy in 12 daily fractions. The primary outcomes were symptom response rates. Secondary outcomes included overall survival, adverse events and proportion of patients with ≥10‐point absolute improvement in the fatigue, nausea/vomiting and pain subscales in the EORTC Qualify of Life Questionnaire C30 (EORTC QLQ‐C30) and dysphagia/pain subscales in the gastric specific module (STO22) at the end of RT and 1 month after the completion of radiotherapy. Fifty patients were accrued. Median survival duration was 85 days. 40/50 patients (80%) with bleeding, 2/2 (100%) patients with obstruction and 1/1 (100%) patient with pain responded to radiotherapy. Improvements fatigue, nausea/vomiting and pain subscales of the EORTC QLQ‐C30 was seen in 50%, 28% and 44% of patients at the end of RT and in 63%, 31% and 50% of patients 1 month after RT. Improvements in dysphagia/pain subscales of the STO22 was seen in 42% and 28% of patients at then end of RT and 44% and 19% of patients 1 month after RT. Two patients (5%) had grade 3 anorexia and gastritis. Palliative gastric radiotherapy was effective, well tolerated and resulted in improvement in fatigue, dysphagia and pain at the end of radiotherapy and 1 month after the completion of radiotherapy in a significant proportion of patients.
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Affiliation(s)
- Jeremy Tey
- Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore, Singapore
| | - Huili Zheng
- National Registry of Diseases, Singapore, Singapore
| | - Yu Y Soon
- Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore, Singapore
| | - Cheng N Leong
- Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore, Singapore
| | - Wee Y Koh
- Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore, Singapore
| | - Keith Lim
- Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore, Singapore
| | - Jimmy B Y So
- Department of Surgery, National University Hospital, Singapore, Singapore
| | - Asim Shabbir
- Department of Surgery, National University Hospital, Singapore, Singapore
| | - Ivan W K Tham
- Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore, Singapore
| | - Jiade Lu
- Shanghai Heavy ion and Proton Centre, Shanghai, China
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Leiyuan S, Jianli X, Zhengzhong Z, Guangyan J, Dailiang Z. Comparison of Treatment Outcomes of Endoscopic Stenting and Laparoscopic Gastrojejunostomy for Malignant Gastric Outlet Obstruction. Am Surg 2018. [DOI: 10.1177/000313481808400654] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To compare the clinic outcomes of endoscopic stenting and laparoscopic gastrojejunostomy (LGJ) for patients with malignant gastric outlet obstruction (GOO). We retrospectively reviewed 63 patients with malignant GOO that underwent endoscopic stenting [Stent Group (SG), n = 29] or LGJ [Laparoscopic Group (LG), n = 34]. Then, we evaluated the medical effects, postoperative hospital stay, and hospitalization expenses in both groups. Compared to LG, SG has a shorter operation time [SG: (41.1 ± 9.3) minutes vs LG: (137.4 ± 21.7) minutes, P = 0.000], less intra-operative blood loss [(23.7 ± 9.0) mL vs (121.1 ± 24.3) mL, P = 0.000], relatively lower hospitalization expenses [(2272.7 ± 413.9) $ vs (5182.4 ± 517.3) $, P = 0.000]. Besides, the median intake time was significantly shorter in the SG than that in the LG [(0.9 ± 0.3) days vs (4.1 ± 0.6) days, P = 0.000]. However, there were no significant differences between SG with LG in surgical success rate (100 vs 100%, P = 1.000), length of hospital stay [(6.1 ± 3.3) days vs (10.9 ± 4.7) days, P = 0.422], recurrent obstructive rate (37.9 vs 26.5%, P = 0.949) and median survivals [(141.4 ± 81.4) days vs (122.7 ± 88.8) days, P = 0.879]. Endoscopic stenting and LGJ are both relatively safe and effective treatments for patients with malignant GOO. But we suggest that endoscopic stenting should be considered first in patients with malignant GOO because it has many advantages over LGJ.
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Affiliation(s)
- Shuai Leiyuan
- Department of General Surgery, Jiangjin Central Hospital of Chongqing, Chongqing, China
| | - Xu Jianli
- Department of General Surgery, Jiangjin Central Hospital of Chongqing, Chongqing, China
| | - Zhao Zhengzhong
- Department of Endoscopic Treatment Center, Jiangjin Central Hospital of Chongqing, Chongqing, China
| | - Ji Guangyan
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhu Dailiang
- Department of General Surgery, Jiangjin Central Hospital of Chongqing, Chongqing, China
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Bian SB, Shen WS, Xi HQ, Wei B, Chen L. Palliative Therapy for Gastric Outlet Obstruction Caused by Unresectable Gastric Cancer: A Meta-analysis Comparison of Gastrojejunostomy with Endoscopic Stenting. Chin Med J (Engl) 2017; 129:1113-21. [PMID: 27098799 PMCID: PMC4852681 DOI: 10.4103/0366-6999.180530] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Background: Gastrojejunostomy (GJJ) and endoscopic stenting (ES) are palliative treatments for gastric outlet obstruction (GOO) caused by gastric cancer. We compared the outcomes of GJJ with ES by performing a meta-analysis. Methods: Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis. Procedure time, time to resumption of oral intake, duration of hospital stay, patency duration, and overall survival days were compared using weighted mean differences (WMDs). Technical success, clinical success, procedure-related mortality, complications, the rate of re-obstruction, postoperative chemotherapy, and reintervention were compared using odds ratios (ORs). Results: Nine studies were included in the analysis. Technical success and clinical success were not significantly different between the ES and GJJ groups. The ES group had a shorter procedure time (WMD = −80.89 min, 95% confidence interval [CI] = −93.99 to −67.78, P < 0.001), faster resumption of oral intake (WMD = −3.45 days, 95% CI = –5.25 to −1.65, P < 0.001), and shorter duration of hospital stay (WMD = −7.67 days, 95% CI = −11.02 to −4.33, P < 0.001). The rate of minor complications was significantly higher in the GJJ group (OR = 0.13, 95% CI = 0.04–0.40, P < 0.001). However, the rates of major complications (OR = 6.91, 95% CI = 3.90–12.25, P < 0.001), re-obstruction (OR= 7.75, 95% CI = 4.06–14.78, P < 0.001), and reintervention (OR= 6.27, 95% CI = 3.36–11.68, P < 0.001) were significantly lower in the GJJ group than that in the ES group. Moreover, GJJ was significantly associated with a longer patency duration (WMD = −167.16 days, 95% CI = −254.01 to −89.31, P < 0.001) and overall survival (WMD = −103.20 days, 95% CI = −161.49 to −44.91, P = 0.001). Conclusions: Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer. ES is associated with better short-term outcomes. GJJ is preferable to ES in terms of its lower rate of stent-related complications, re-obstruction, and reintervention. GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.
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Affiliation(s)
| | | | | | | | - Lin Chen
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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Polese L, Porzionato A, Luisetto R, Mastrogiacomo D, Macchi V, De Caro R, Norberto L, Merigliano S. Roux-en-Y gastrojejunal bypass using a hybrid NOTES-12 mm trocar technique in a porcine model. MINIM INVASIV THER 2016; 25:86-90. [PMID: 26751102 DOI: 10.3109/13645706.2015.1125929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
AIMS To evaluate the feasibility and safety of Roux-en-Y gastrojejunal bypass procedure using a hybrid NOTES-12 mm trocar technique in a survival porcine model. MATERIAL AND METHODS The procedure was carried out on ten pigs. Two gastroscopes were introduced through the mouth and through a 12 mm trocar, respectively. A mechanical circular gastro-jejunal anastomosis was created by introducing a stapler after the trocar incision was enlarged. A 21 mm EEA OrVil circular stapler was utilized in the first six pigs and a 25 mm one was used in the other four. All pigs were fed beginning 24 hours after the procedure and were euthanized three weeks later. RESULTS The procedure was successfully completed in all ten animals. The mean length of the skin incision was 2.5 cm. All pigs survived without complications. Endoscopic inspection detected anastomotic strictures in 5/6 of the 21 mm-stapler and in 0/4 of the 25 mm-stapler anastomoses (p < 0.05). CONCLUSION Roux-en-Y gastrojejunal bypass using a hybrid NOTES-single 12 mm trocar access technique is a simple and safe procedure in a survival porcine model. Functional results need to be evaluated by further studies.
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Affiliation(s)
- Lino Polese
- a Department of Surgery, Oncology and Gastroenterology , University of Padova , Padova , Italy
| | - Andrea Porzionato
- b Section of Anatomy, Department of Molecular Medicine , University of Padova , Padova , Italy
| | - Roberto Luisetto
- c Department of Experimental Surgery , University of Padova , Padova , Italy
| | - Doralba Mastrogiacomo
- a Department of Surgery, Oncology and Gastroenterology , University of Padova , Padova , Italy
| | - Veronica Macchi
- b Section of Anatomy, Department of Molecular Medicine , University of Padova , Padova , Italy
| | - Raffaele De Caro
- b Section of Anatomy, Department of Molecular Medicine , University of Padova , Padova , Italy
| | - Lorenzo Norberto
- a Department of Surgery, Oncology and Gastroenterology , University of Padova , Padova , Italy
| | - Stefano Merigliano
- a Department of Surgery, Oncology and Gastroenterology , University of Padova , Padova , Italy
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Berti S, Ferrarese A, Feleppa C, Francone E, Martino V, Bianchi C, Falco E. Laparoscopic perspectives for distal biliary obstruction. Int J Surg 2015; 21 Suppl 1:S64-7. [PMID: 26118614 DOI: 10.1016/j.ijsu.2015.04.092] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 03/24/2015] [Accepted: 04/10/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND In patients affected by distal biliary obstruction deemed unsuitable for pancreatoduodenectomy, biliary diversion is the only proposable option. Defined goals of this treatment are: relief from jaundice preventing its related complications, reduction of in-hospital stay and adequate control of pain. Palliation can be obtained either by surgical or conservative procedures (endoscopic stenting or percutaneous treatment). Considering early complications' incidence, surgical approach has always been reserved for low surgical risk patients with longer survival perspectives, while recently developed long-lasting patency stents enlarged mini-invasive application resort. Comparative studies on these therapeutic options favour the conservative one in respect of conventional open surgery, but data on minimally invasive surgery to pursue palliative aims are lacking. We present our six-years casuistic and results referring to laparoscopic biliary diversions. METHODS We analyzed results obtained in distal biliary neoplastic obstruction management between December 2008 and November 2014. During this period, selected patients considered unsuitable for pancreatoduodenectomy were scheduled to receive a laparoscopic biliary decompression. Perioperative variables and 30-days postoperative outcomes have been prospectively collected. RESULTS In the six-years period, 12 patients affected by distal biliary neoplastic obstruction were submitted to laparoscopic palliative bypass. Four procedures were proposed for distal biliary cancer, one for advanced periampullary cancer and seven for pancreatic head cancer. Ten hepatico-jejunal bypasses and two choledochoduodenostomies have been performed. No conversions to open surgery were encountered in this series. Main operative time was 85 min, main blood loss was 75 ml and main hospitalization was 4.5 days. According to Clavien Dindo Classification one class II and one class IIIb complications occurred. CONCLUSIONS Although the restricted number of patients, our results suggest that laparoscopic biliary bypass could be a valid option in managing distal biliary obstructions, resulting in low perioperative morbidity, effective long term palliation of symptoms and improved quality of life.
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Affiliation(s)
| | - Alessia Ferrarese
- University of Turin, Department of Oncology, School of Medicine, "San Luigi Gonzaga" Teaching Hospital, Section of General Surgery, Orbassano, Turin, Italy.
| | | | | | - Valter Martino
- University of Turin, Department of Oncology, School of Medicine, "San Luigi Gonzaga" Teaching Hospital, Section of General Surgery, Orbassano, Turin, Italy
| | | | - Emilio Falco
- Department of Surgery, POLL-ASL 5, La Spezia, Italy
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Abstract
The rapid growth of minimally invasive technology and experience in recent decades has revolutionized many aspects of oncologic surgery. Adoption of laparoscopic pancreatectomy has been slow due to the inherent anatomic complexity of pancreatic surgery, as well as concerns of perioperative complications and compromised oncologic results. With increasing surgeon experience and growing data, laparoscopic pancreatic resection is generating considerable attention and enthusiasm. This article provides an overview of laparoscopic pancreatic tumor surgery with respect to tumor biology and technical approaches. Current applications of laparoscopic approaches to left pancreatectomy, tumor enucleation, central pancreatectomy, and pancreaticoduodenectomy for treatment of pancreatic tumors are considered in light of available evidence demonstrating feasibility, safety, and oncologic efficacy. Future directions in minimally invasive pancreatic surgery are explored.
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Affiliation(s)
- Carrie K Chu
- Department of Surgery, Emory University School of Medicine, 1364 Clifton Road, NE, H120, Atlanta, GA 30322, USA
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