Laparoscopic gastrojejunostomy for the treatment of gastric outlet obstruction

Background and Objectives:

Laparoscopic gastrojejunostomy (LGJ) has been proposed as the technique preferred over open gastrojejunostomy for relieving gastric outlet obstruction (GOO) due to malignant and benign disease. This study investigates the feasibility and safety of LGJ for GOO.

Methods:

A retrospective review was performed of patients who underwent LGJ at Mount Sinai Medical Center from 2004 to 2008. Patient''s operative course and long-term outcomes were collected.

Results:

Twenty-eight patients were reviewed (16 had malignancy, 7 had PUD, 3 had Crohn''s disease, and one had obstruction of unclear cause). Average operative time was 170 minutes, and estimated blood loss was 80cc. One case was converted to open; another had stapler misfiring. Patients regained bowel function at a median of 3 days and remained in the hospital for a median of 8 days. There were 4 major postoperative complications (14%): 1 anastomotic leak and 1 trocar-site hemorrhage requiring reoperation and 2 gastrointestinal bleeds requiring endoscopic intervention. There were 5 minor complications (18%), including a partial small bowel obstruction, 1 patient developed bacteremia, and 3 patients had delayed gastric emptying. One patient had persistent GOO requiring reoperation 3 months later.

Conclusion:

LGJ can be performed for GOO with improved outcome and an acceptable complication rate compared to the open GJ reported in the literature.     

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

Background/ PurposeIdiopathic hypertrophic pyloric stenosis is by far the most common cause of gastric outlet obstruction (GOO) in young infants, with more than 90% of cases presenting between 3 and 10 weeks after birth. While cases of late onset pyloric stenosis beyond infancy have been reported, the etiology is poorly understood. We report our experience of 5 cases, describing the similarities and differences in management of our patient population which happens to be the second largest reported in literature.MethodsFrom July 2014 to June 2018 (4 years) a total of five patients of primary acquired GOO were encountered at our center.ResultsThe age range was 3 to 6 years and only one of them was a female. All presented with characteristic nonbilious vomiting that was recurrent and episodic. Upper GI (gastrointestinal) contrast study series revealed a dilated stomach and delayed gastric emptying. Upper GI endoscopy also demonstrated a dilated stomach without any intraluminal polyp, ulcer or any other pathology. Intraoperatively the pylorus had no evidence of scarring, inflammation, external compression or any mass in and around the pylorus. A retrocolic gastrojejunostomy was curative in all patients.ConclusionThough rare, one must maintain a high index of suspicion for primary acquired GOO in the differential diagnosis of older children with nonbilious vomiting and failure to thrive. Following appropriate diagnostic workup, surgical interventions should be performed expeditiously because adequate nutrition is key to proper physical and mental development of the child. Further research will hopefully elucidate the underlying pathophysiology in order to guide clinical options for both prevention and treatment.Type of studyRetrospective single center study.Level of evidenceLevel 4.     

A prospective observational study examining quality of life in patients with malignant gastric outlet obstruction

Background

Gastric outlet obstruction (GOO) often complicates advanced malignancy. Palliative options include surgical bypass, endoscopic stent, percutaneous gastrostomy (PEG), or percutaneous jejunostomy (PEJ).

Methods

We enrolled 50 patients with GOO secondary to unresectable primary or metastatic cancer in a study examining palliative interventions. Validated instruments assessed quality of life (QOL) at baseline, 1 month, and 3 months following intervention.

Results

Median overall survival was 64 days. A shorter hospital stay and trend to lower mortality were observed after stent placement; solid food intake and rates of secondary intervention were comparable. Both stent and surgical bypass were associated with acceptable QOL outcomes. Fifteen patients refused participation at 1 month and 28 died of disease before 3 months, so 10 patients completed all surveys.

Conclusions

Although malignant GOO is associated with poor survival, there are reasonable alternatives for palliation. QOL studies are difficult to complete in this population due to severity of illness and short life expectancy.     

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction(GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum. GOO can be caused by either benign or malignant etiologies, often resulting in early satiety, nausea, vomiting and poor oral intake. GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies. Traditional treatment options for GOO can be broadly divided into surgical [surgical gastrojejunostomy(GJ)] and endoscopic interventions(dilation and/or placement of luminal self-expanding metal stents). While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting, it has also been associated with a higher rate of adverse events. Furthermore, many patients with advanced metastatic disease are not good surgical candidates. More recently, endoscopic ultrasound(EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches. This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.     

Surgical palliation of gastric outlet obstruction in advanced malignancy

Gastric outlet obstruction(GOO) is a common problem associated with advanced malignancies of the upper gastrointestinal tract.Palliative treatment of patients' symptoms who present with GOO is an important aspect of their care.Surgical palliation of malignancy is defined as a procedure performed with the intention of relieving symptoms caused by an advanced malignancy or improving quality of life.Palliative treatment for GOO includes operative(open and laparoscopic gastrojejunostomy) and non-operative(endoscopic stenting) options.The performance status and medical condition of the patient,the extent of the cancer,the patients prognosis,the availability of a curative procedure,the natural history of symptoms of the disease(primary and secondary),the durability of the procedure,and the quality of life and life expectancy of the patient should always be considered when choosing treatment for any patient with advanced malignancy.Gastrojejunostomy appears to be associated with better long term symptom relief while stenting appears to be associated with lower immediate procedure related morbidity.     

Palliative gastrojejunostomy

Palliative bypass for neoplastic gastric outlet obstruction should be minimally invasive. We designed a laparoscopically assisted approach that appears to meet the need. The proximal jejunum is exteriorized by laparoscopy via an epigastric trocar-site incision. An EEA anvil is installed in the exteriorized jejunum, which is returned to the abdomen. Through this mini-incision, the anterior wall of the stomach is opened for insertion of the EEA stapler, which penetrates the posterior gastric wall. When snapped to the anvil and fired, an antecolic gastrojejunostomy is created. No mortality or anastomotic leak occurred in two cases. The operation and recovery appeared to be faster than historic controls. This operation is minimally invasive and expeditious, ideal for patients requiring palliative bypass. Received: 28 June 1996/Accepted: 26 July 1996     

Non-centralised service for palliative stenting of malignant gastric outlet obstruction

IntroductionMalignant gastric outlet obstruction (GOO) is a common, debilitating and frequently pre-terminal symptom of intra-abdominal malignancies. Traditional ‘gold standard’ treatment has been palliative surgical gastro-enterostomy. Over the past two decades, use of self-expanding metallic stents (SEMSs) to relieve malignant GOO has become first-line treatment. We present the results from a single district general hospital in the UK in which malignant GOO was treated with SEMSs over a six-year period.MethodsAll patients who underwent palliative stenting for malignant gastro-duodenal tumours in our centre for six years up to January 2013 were assessed retrospectively. Outcomes were assessed with regard to: technical and clinical success; return to oral nutrition; prevalence of complications and re-intervention; and overall survival.ResultsThirty-two stents were implanted in 29 patients. Technical success was 100%. Clinical success and return to oral nutrition were both 91%. The prevalence of complications was 16%. The prevalence of re-intervention was 13%. Mean survival was 91 (range, 5–392) days. Median wait from decision to implant a stent to stent implantation was 1 (range, 0–14) day. Overall, 25 covered and nine uncovered stents were implanted.ConclusionStent implantation for GOO in this patient group is an established and preferable alternative to surgical intervention. Much of the treatment for malignancies of the upper gastrointestinal tract has now been centralised. Our data showed comparable results with published data for these procedures, with a high prevalence of success and low prevalence of major complications. It is of considerable benefit to these patients not to have to travel to a regional centre for stent implantation.     

Palliative antecolic isoperistaltic gastrojejunostomy: a randomized controlled trial comparing open and laparoscopic approaches

Gastric outlet obstruction is a common, often preterminal, event for patients with inoperable neoplasms of the distal stomach, duodenum, and biliopancreatic area. It can be surgically managed by open or laparoscopic gastrojejunostomy. This study aimed to compare the results of open and laparoscopic palliative gastrojejunostomy for patients with gastric outlet obstruction resulting from inoperable neoplasms. A total of 24 patients were randomized prospectively to undergo laparoscopic (12 patients) or open (12 patients) palliative laterolateral antecolic isoperistaltic gastrojejunostomy. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the two groups (p = 0.75). The mean intraoperative blood loss was significantly less after laparoscopic gastrojejunostomy (LGJ) (p = 0.0001). Time to oral solid food intake was longer after open gastrojejunostomy (OGJ) (p = 0.04). Two patients in the OGJ group experienced postoperative delayed gastric empting, whereas no patients in the LGJ group experienced such a complication (p = 0.04). The mean postoperative stay was shorter in the LGJ group, but the difference did not reach statistical significance (p = 0.65). No readmissions were registered after a minimum follow-up period of 2 months. The findings show that LGJ is a safe, feasible, and effective alternative to OGJ. However, because the current data involved only a small number of patients, large studies still are required for further evaluation of the this operation’s effectiveness.     

经内镜金属支架治疗胃出口梗阻的疗效评价

目的评价经内镜金属支架治疗胃出口梗阻的临床价值。方法总结1999年3月至2008年1月间复旦大学附属中山医院内镜中心采用内镜金属支架治疗胃出口梗阻56例患者的临床资料。结果56例患者中男33例、女23例，年龄（65±14）岁；晚期胃窦癌17例，胃癌术后复发15例（其中毕I式吻合8例），十二指肠癌4例，壶腹周围癌7例，转移性肿瘤13例。支架置入成功率98．2％（55／56）。49例患者（87．5％）在支架置入1～3（2±1）d后开始进流质饮食，进食半流质的时间为4-9（6±2）d；42例（76．4％）患者在支架置入10～16（13±3）d后开始进普通饮食。并发症发生率包括疼痛14．5％、支架移位1．8％和出血25．5％，无穿孔。截至2008年1月20日，53例（96．4％）接受了随访，生存期14～332（139±15）d，中位生存期135d。支架通畅率94．3％（50／53），有3例患者分别在术后143d、158d和190d出现了再狭窄，通过再次置入金属支架后好转。结论内镜下金属支架引流术是治疗胃出口梗阻的一种微创、安全、有效的方法。     

经内镜金属支架治疗胃出口梗阻的疗效评价

目的 评价经内镜金属支架治疗胃出口梗阻的临床价值.方法 总结1999年3月至2008年1月间复旦大学附属中山医院内镜中心采用内镜金属支架治疗胃出口梗阻56例患者的临床资料.结果 56例患者中男33例、女23例.年龄(65±14)岁;晚期胃窦癌17例,胃癌术后复发15例(其中毕Ⅰ式吻合8例),十二指肠癌4例,壶腹周围癌7例,转移性肿瘤13例.支架置入成功率98.2%(55/56).49例患者(87.5%)在支架置入1～3(2±1)d后开始进流质饮食,进食半流质的时间为4～9(6±2)d;42例(76.4%)患者在支架置入10～16(13±3)d后开始进普通饮食.并发症发生率包括疼痛14.5%、支架移位1.8%和出血25.5%,无穿孔.截至2008年1月20日,53例(96.4%)接受了随访,生存期14～332(139±15)d,中位生存期135 d.支架通畅率94.3%(50/53),有3例患者分别在术后143 d、158 d和190 d出现了再狭窄,通过再次置入金属支架后好转.结论 内镜下金属支架引流术是治疗胃出口梗阻的一种微创、安全、有效的方法.     

Antral hyperplastic polyp: A rare cause of gastric outlet obstruction

INTRODUCTION

Gastric polyps are usually found incidentally during upper gastrointestinal endoscopic examinations. These polyps are generally benign, with hyperplasia being the most common. While gastric polyps are often asymptomatic, they can cause gastric outlet obstruction.

PRESENTATION OF CASE

A 64 years-old female patient presented to our polyclinic with a history of approximately 2 months of weakness, occasional early nausea, vomiting after meals and epigastric pain. A polypoid lesion of approximately 25 mm in diameter was detected in the antral area of the stomach, which prolapsed through the pylorus into the duodenal bulbus, and subsequently caused gastric outlet obstruction, as revealed by upper gastrointestinal endoscopy of the patient. The polyp was retrieved from the pyloric canal into the stomach with the aid of a tripod, and snare polypectomy was performed.

DISCUSSION

Currently, widespread use of endoscopy has led to an increase in the frequency of detecting hyperplastic polyps. While most gastric polyps are asymptomatic, they can cause iron deficiency anemia, acute pancreatitis and more commonly, gastric outlet obstruction because of their antral location. Although there are no precise principles in the treatment of asymptomatic polyps, polyps >5 mm should be removed due to the possibility of malignant transformation.

CONCLUSION

According to the medical evidence, polypectomy is required for gastric hyperplastic polyps because of the risks of complication and malignancy. These cases can be successfully treated endoscopically.     

Laparoscopic gastrojejunostomy and endoscopic biliary stent placement for palliation of incurable gastric outlet obstruction with cholestasis

Background: For patients with incurable malignant gastric outlet obstruction and cholestasis, laparoscopic gastrojejunostomy combined with endoscopic biliary stent placement seems to offer a minimally invasive palliation. Methods: We retrospectively analyzed the data of 16 patients submitted to laparoscopic gastrojejunostomy. Laparoscopic gastroenterostomy was performed as an antecolic, side-to-side gastrojejunostomy with enteroenterostomy. In 12 patients cholestasis was relieved preoperatively by stent placement via endoscopy (n= 6, 37.5%), percutaneous access (n= 5, 31%) or bilioenteric anastomosis (n= 1, 6.25%). One patient needed a percutaneous Yamakawa prosthesis postoperatively. Results: Mean operative time was 126 min. There were no intraoperative complications. In one patient conversion to open surgery became necessary because of extensive adhesions. The only postoperative complication was bleeding from a trocar site requiring reintervention; there was no mortality. Median postoperative hospital stay was 7 days. Delayed gastric emptying was observed in 3 (18.7%) patients. Median survival was 87 days after the operation. All patients died from their primary disease but could maintain oral intake during the remaining survival time. Conclusions: We conclude that laparoscopic gastrojejunostomy and endoscopic or percutaneous biliary stenting provide a good functional result while impairing the quality of life only to a minimal extent. Received: 7 May 1996/Accepted: 12 December 1996     

Congenital thickening and shortening of the round ligament of the liver causing gastric outlet obstruction

This report describes a case of congenital thickening and shortening of the round ligament of the liver, a rare cause of gastric outlet obstruction. There are few published cases in the literature and these were generally diagnosed at a late stage and were mostly among adults. The patient underwent exploratory laparotomy, which showed gastric compression in the distal antrum, close to the pylorus, caused by the round ligament, which was shortened and thickened. The round ligament was suture ligated and divided, and the patient's symptoms resolved. Comments on this abnormality and its rarity are presented.     

三种方法治疗恶性胃出口梗阻患者生活质量的比较

目的 探讨恶性胃出口梗阻（GOO）患者的治疗选择.方法 对39例继发于不可切除的原发性或转移性消化系统肿瘤的GOO患者分别予以内镜下支架置入术（支架组,13例）、胃旁路手术（旁路组,21例）和经皮胃造口术（造口组,5例）,分别于术前、术后1、3个月采用QLQ-STO22表进行生活质量（QOL）评估.结果 本组39例患者术后中位生存时间是68 d,其中支架组（85 d）和旁路组（72 d）的中位生存时间明显长于造口组的48 d（P〈0.05）;但支架组与旁路组比较生存时间的差异无统计学意义（P〉0.05）.本组共有14例患者（支架组和旁路组各7例）在治疗前、治疗后1个月和3个月均完成了QOL调查,支架组患者吞咽困难、饮食限制、舌干及反流症状均得到明显改善（P〈0.05）;旁路组患者吞咽困难和饮食限制得到明显改善（P〈0.05）,但舌干、反流及疼痛症状则无明显改善（P〉0.05）.结论 尽管恶性GOO患者预后很差,旁路手术和内镜下支架置入术仍然能有效缓解恶性GOO患者的症状,可作为积极的治疗选择.     

Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group

Background

The authors report the final results of a prospective single-center randomized study whose aim was to compare the endoscopic placement of self-expandable stents with open surgical gastroenterostomy to relieve gastric outlet obstruction (GOO) in patients with advanced antropyloric adenocarcinoma. A systematic review of the medical literature from December 1999 to December 2011 was carried out to determine the results of endoscopic stenting in patients with GOO from unresectable primary cancer of the antropyloric region.

Methods

In the prospective study, 18 patients with advanced adenocarcinoma of the antropyloric region and symptoms of GOO were enrolled. In 9 patients, self-expandable stents were placed, and in 9 patients, open surgical gastroenterostomy was performed. Patients were followed until death. Six hundred seventy-two patients with primary unresectable cancer of the antropyloric region and GOO syndrome who underwent endoscopic stenting were identified from the literature.

Results

In the prospective study of 18 patients, there was no case of postprocedural mortality. Efficient gastric emptying resumed more quickly in patients who received stents, although 3 months after the procedures, there was no difference between the 2 groups. Mean crude survival was 258 days in patients who received stents and 283 days in those who underwent surgical gastroenterostomy (P = NS). In patients who underwent stent placement, there were 2 cases of stent migration and 2 cases of food impaction, which were resolved with endoscopy at a mean follow-up of 70 days. In the 672 patients from the literature, operative mortality and morbidity were very low. In prospective studies, complications related to stents were more common than previously thought.

Conclusions

Endoscopic placement of metallic stents offers an effective therapy in patients with advanced primary adenocarcinoma of the antropyloric region and poor general condition. In patients with longer life expectancies, the form of therapy should be chosen individually, considering that surgical gastroenterostomy has fewer complications in the medium term and that in patients with endoscopic stenting, very careful follow-up is required, with the possibility of new operative endoscopy in half of the patients.     

经内镜金属支架治疗胃出口梗阻的疗效评价

目的评价经内镜金属支架治疗胃出口梗阻的临床价值。方法1999年3月至2009年7月,我院内镜中心采用内镜金属支架治疗胃出口梗阻77例,评价手术成功率、并发症和远期疗效。结果共77例患者,男43例,女34例,年龄24—90（65±14）岁。其中晚期胃窦癌24例,胃癌术后复发19例（其中毕Ⅰ式吻合10例）,十二指肠癌7例,壶腹周围癌7例,转移性肿瘤20例。支架置入成功率为93．5％（72,77）,59例（81．9％）在支架置入1．3d后开始流质饮食,进食半流质的时间为4～9（5±3）d,其中52例（72．2％）患者在支架置入10～16（13±3）d后开始普通饮食。并发症包括疼痛（15.3％）、支架移位（2．8％）、出血（22．2％）。截至2009年8月30日,获随访率94．8％（73／77）,中位生存期135（13～336）d。7例患者出现了再狭窄,支架通畅率90．3％（65／72）,再次置入金属支架后好转。结论内镜下金属支架引流术是治疗胃出口梗阻的一种微创且安全有效的方法。     

Gastric outlet obstruction secondary to acid ingestion in children

Background/Purpose

Gastric outlet obstruction (GOO) is a well-known complication of acid ingestion. However, most reports deal with adults. In this report, the authors present their experience with the treatment of acid-induced GOO in children.

Methods

The records of patients admitted for unintentional ingestion of corrosive agents between 1980 and 2002 were reviewed retrospectively. Data concerning age at ingestion, type of ingested substance, time between ingestion and the first signs of GOO, weight loss, treatment, complications, duration of hospital stay, and long-term follow-up were reviewed.

Results

GOO was not observed in any of the children admitted for alkaline ingestion, whereas GOO developed in 8 of 98 children (8.2%) in a mean period of 26.7 ± 10 days after the ingestion of acid substances. Presenting symptoms were frequent nonbilious vomiting and marked weight loss. All had pyloric obstructions in the upper gastrointestinal series and required surgical intervention. Gastrojejunostomy was the operation of choice for all patients. Oral feedings were started on the third postoperative day. The complications were wound infection in 1 and upper gastrointestinal bleeding in another in the early postoperative period. Mean follow-up is 8.33 ± 4.45 (4.8-18.7) years. No late complications such as marginal ulcus or stricture at the anastomosis site were observed in the series.

Conclusions

Treatment of GOO with gastrojejunostomy gives good long-term results in children. This procedure is safe and causes minimal morbidity particularly in patients without extensive gastric damage.