OBJECTIVE: Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an alternative to duodenal stenting and surgical GJ (SGGJ) in malignant gastric outlet obstruction (MGOO). European Society of Gastrointestinal Endoscopy guidelines restricted EUS-GJ for MGOO only, because of misdeployment. The aim was to evaluate its outcomes focusing on benign indications.
METHODS: This was a retrospective study conducted from 2016 to 2023 in a tertiary center. Patients included had malignant or benign GOO indicated for EUS-GJ. Techniques were the direct approach until August 2021, and the wire endoscopic simplified technique (WEST) afterwards. The main objective was to compare outcomes in benign vs. MGOO. Secondary end-points were technical success, adverse events rates, and describing the evolution of techniques and indications.
RESULTS: In all, 87 patients were included, 46 men, mean age 66 ± 16.2 years. Indications were malignant in 60.1% and benign in 39.1%. The EUS-GJ technique was direct in 33 patients (37.9%) and WEST in 54 (62.1%). No difference was found in terms of technical, clinical, or adverse events rates. The initial technical success rate was 88.5%. The final technical and clinical success rates were 96.6% and 94.25%, respectively. In the last year, benign exceeded malignant indications (70.4% vs. 29.6%, P < 0.05). Seven misdeployments occurred, six being addressed with the rescue technique. The misdeployment rate was significantly decreased using the WEST approach compared to the direct one: 3.7% vs. 18% (P < 0.05). The severe postoperative adverse events rate was 2.3%.
CONCLUSIONS: This study demonstrated similar outcomes of EUS-GJ between benign and MGOO, with a decreasing misdeployment rate (<4%) applying WEST. This represents an additional step towards recommending EUS-GJ in benign indications.

To provide optimal care in pancreatic ductal adenocarcinoma, involvement of palliative medicine and nutritional support is recommended. Advances in endoscopy have resulted in robust options for biliary and gastrointestinal stenting for relief of obstruction. Notwithstanding, surgical hepaticojejunostomy and gastrojejunostomy remain incontrovertible considerations for biliary obstruction and gastric outlet obstruction, respectively. For PDAC-associated pain, opioid therapy continues to be the mainstay. However, refractory pain may be treated with interventional procedures such as celiac or splanchnic nerve blocks or neurolysis. In patients with PDAC, enteral nutrition can be further complicated by exocrine pancreatic insufficiency, which should be treated with oral pancreatic enzyme supplementation.

Adhesive small bowel obstruction is thought to be a disorder limited to the jejunum and ileum. As a result, the list of aetiologies for duodenal obstruction does not include adhesions. We report the case of a patient who presented with gastric outlet obstruction (GOO), but with no lesions identified on cross-sectional imaging or endoscopy. Laparoscopy revealed duodenal adhesions as the cause of her GOO. Kockerization of the duodenum led to resolution of her symptoms. This previously undocumented finding leads us to suggest that laparoscopy should be considered in patients who have features highly suspicious for GOO, but have no cause identified on investigation.

A woman in her 20s presented with 6 weeks of fever, persistent vomiting and 28% loss of body weight. Symptoms were refractory to treatment with antiemetics and broad spectrum antibiotics.Further investigation via oesophageogastroduedenoscopy revealed a large gastric ulcer and pyloric stricture, causing gastric outlet obstruction (GOO). Biopsies of the stomach and duodenum showed plasma cell infiltration with a large proportion being IgG4 positive.Treatment with methylprednisolone, and later prednisolone, quickly improved inflammatory markers and symptoms. Balloon dilatation of the pyloric stricture also improved vomiting, allowing eventual re-establishment of oral nutrition. The patient made a full recovery with maintenance treatment on mycophenolate mofetil.IgG4-related disease (IgG4-RD) is a multisystem disorder with unpredictable presentation. The case highlights diagnostic challenges in IgG4-RD and identifies it as a rare differential in upper gastrointestinal symptoms. To our knowledge this is the first published case of IgG4-RD in the duodenum causing GOO.

BACKGROUND: Gastric adenomyoma is a rare benign tumor composed of glandular structures and smooth muscle fibers. While some classify gastric adenomyoma as a hamartoma, others view it as an abortive form of heterotopic pancreas. Despite its benign nature, there is a risk of malignant transformation. Predominantly found in the antrum, gastric adenomyoma affects all ages but is most common in adults aged 40-60 years. Symptoms are nonspecific, and its similarity to other lesions complicates diagnosis. This paper aims to provide a review of medical literature on gastric adenomyoma and its diagnosis and treatment methods, along with presenting an additional case report on the same topic.
METHODS: We present the case of a 55-year-old Syrian man who experienced vomiting, weight loss, and chronic partial constipation. An obstructing mass in the pylorus was detected, and then an open surgery was performed to excise the lesion. A biopsy of the resected mass was obtained for histopathological examination. The final diagnosis of the lesion was pyloric-region adenomyoma with severe pyloric stenosis. After the successful surgery, the patient recovered without any recurrence or complications.
CONCLUSIONS: Several diagnostic approaches are available, including radiological studies, endoscopic examination, and fine needle aspiration guided by endoscopic ultrasonography. Treatment options involve endoscopic submucosal dissection and complete laparotomy resection. Further studies and thorough reviews are recommended to better understand the best clinical practices. Practitioners should consider gastric adenomyoma when encountering a mural gastric lesion.

BACKGROUND: We aimed at evaluating the safety and efficacy of self-expandable metallic stent (SEMS) insertion for managing patients with benign gastric outlet obstruction (GOO).
METHODS: This prospective interventional study included 23 patients. All consecutive treatment-naïve symptomatic patients with benign GOO were recruited. Fully covered SEMS were deployed across the stricture under fluoroscopic and endoscopic guidance. Technical success, clinical success and sustained treatment response (STR) were assessed. Technical success was defined as the successful deployment of SEMS at the desired anatomic location. Clinical success was defined as the resolution of symptoms and an increase in Gastric Outlet Obstruction Scoring System (GOOSS) of at least 1 point from the baseline score on Day 7. STR was assessed at four and eight weeks post stent removal in patients who had a response at week four. Factors associated with stent migration and non-response at week four were also assessed.
RESULTS: The median age of the study population was 30 years (range 19-65 years). Males constituted 65.22%. Most patients presented with vomiting (100%) and abdominal pain (95.65%). Peptic stricture was most common etiology for GOO (60.9%) followed by tubercular (26.1%) and corrosive (13%). Most common site of obstruction was junction of first and second part of duodenum (69.57%) followed by pyloric (30.43%). Median length of stricture was 2 cm (range 1.5-4). Technical success was achieved in all 23 patients (100%). Clinical success was achieved in 21 patients (91.3%). Response at Day 28 was seen in 20 patients (86.95%). Eighteen of 20 (90%) patients who had a response at week four had STR at week four and week eight after stent removal. Stent migration occurred in five (21.7%) patients. On univariate analysis, stricture length, calibre and stent length were found to predict migration.
CONCLUSIONS: Fully covered SEMS was an effective and safe management modality in patients with benign GOO. Stent migration remains a troublesome disadvantage.

Bouveret syndrome is one of the complications of gallstone disease possibly fatal, which proposes the presence of a large stone obliterating the lumen of the duodenum or stomach because of the formation of a bilioenteric fistula. This review article, therefore, plans to review the causes, patient characteristics, diagnostic workup, associated conditions, and treatment of Bouveret syndrome. A literature search was also performed through scientific databases such as Scopus, Google Scholar, and PubMed concerning articles related to Bouveret syndrome written by different authors. The terms employed for the search were bilioduodenal fistula, Bouveret syndrome, gastric outlet obstruction, and gallstone ileus. Both case reports and systematic reviews that were written in the English language and published between the years 2000 and 2024 were considered. Finally, the review establishes the relevant concerns surrounding the diagnosis of Bouveret syndrome, focusing on the diagnosing issues. It emphasises the need for some specialities\' involvement and focuses on the importance of endoscopic intervention. For patients, endoscopy remains the first line of treatment, while surgery is necessary in cases where conservative methods cannot be used. The article also focuses on new approaches to treating the conditions, such as percutaneous gallbladder stone dissolution. Latterly, further developments in minimally invasive surgery pertain to refining methods, including endoscopic removal and lithotripsy, to improve the survival rate of patients. Further investigation is required, especially regarding the administration schedule in relation to this disorder and goals that can reduce mortality and morbidity, especially in elderly patients with comorbid diseases.

BACKGROUND: Pneumatosis Intestinalis (PI) is a rare disease, majority of which are self-limited processes, in which the intestinal sub mucosa and sub serosa are filled with gas-filled cysts. The exact cause and pathogenesis is not well known yet but there are different theories. The two well accepted fundamental pathogenesis is: mechanical and bacterial.
METHODS: Here we report a case of a 25 years old patient presented with history of persistent vomiting, intermittent abdominal cramp and significant weight loss over three months. The primary diagnosis was made as gastric outlet obstruction with concomitant small bowel extensive PI.
CONCLUSIONS: Primary PI has no known cause while secondary type has proposed underlying pathologies with different theorized pathogenesis. The current case report has an underlying pathology of long standing peptic ulcer disease with recent diagnosis of gastric outlet obstruction in favor of the mechanical theory. PI has a broad spectrum of clinical symptoms; ranges from asymptomatic patients to non-specific gastrointestinal symptoms like diarrhea, abdominal distention, weight loss, bloody or mucous stool. Patients with underlying pyloric stenosis, peptic ulcer disease presents with more of upper GI symptoms. Conservative management is usually the treatment of choice. However, surgery must be considered if peritoneal irritation or bowel obstruction appears overt.
CONCLUSIONS: Concomitant occurrence of gastric outlet obstruction with small bowel PI is not uncommon disease but severe and extensive inflammatory adhesion was rarely reported. Therefore surgical intervention is mandated for the former or both depending the severity of the PI.

BACKGROUND: Ingestion of foreign bodies may be seen unconsciously or intentionally in patients with mental health problems. Most cases pass through the esophagus slowly; however, in some cases, the tumor may be located in narrower areas of the digestive tract that require endoscopic or surgical intervention. This study describes a rare case of successful removal of more than 450 pieces of metal objects from the stomach of a 36-year-old man via ingestion of foreign bodies at Imam Khomeini Hospital in Ahvaz.
METHODS: A 36-year-old male patient (Aryan race) presented with complaints of chronic abdominal pain, frequent vomiting, and intolerance to liquids and food. The patient\'s companions mentioned a history of gradual ingestion of small metal objects 3 months prior. The patient was conscious and had stable vital signs. In the patient\'s X-ray and endoscopy, multiple metal objects inside the patient\'s stomach were observed, causing gastric outlet obstruction. The patient underwent gastrostomy surgery, and 452 screws, nuts, keys, stones, and other metal parts weighing 2900 g were removed from the stomach. Five days after the operation, the patient was transferred to the psychiatric service in good general condition and was diagnosed with psychosis, and her condition returned to normal at follow-up.
CONCLUSIONS: Successful removal of this foreign body is rare. In chronic abdominal pain, especially in the context of psychiatric disorders, attention should be given to the ingestion of foreign bodies. In swallowing large amounts of sharp and metallic foreign objects, surgical intervention is necessary, especially in cases of obstruction, and saves the patient\'s life.

Gastric outlet obstruction (GOO) is a mechanical obstruction of the distal stomach or proximal duodenum. Surgical gastro-jejunostomy and self-expanding metal duodenal stents were the conventional treatments for GOO. In recent years, a new treatment option emerged using echo-guided endoscopic gastroenterostomy (EUS-GE). It appears to be a safe and effective technique with a clinical success rate of 85-90 % and a side effect rate of less than 18 %. Compared to metal duodenal prostheses, the risk of recurrence of GOO and of re-intervention is lower with EUS-GE. The rate of side effects also appears to be lower than with the surgical technique, with a shorter length of hospital stay. Randomised studies comparing these different techniques are still needed to determine a new treatment algorithm for GOO. We report a case of successful EUS-GE performed at our institution.
La «gastric outlet obstruction» (GOO) est une obstruction mécanique de l’estomac distal ou du duodénum proximal. La gastro-jéjunostomie chirurgicale et les endoprothèses métalliques auto-expansibles duodénales étaient les traitements conventionnels de la GOO. Ces dernières années, une nouvelle option thérapeutique est apparue utilisant la gastro-entéro-anastomose par voie endoscopique écho-guidée (GE-EEG). Elle semble être une technique sûre et efficace avec un taux de succès clinique de 85 à 90 % et un taux d’effets secondaires de moins de 18 %. Comparé aux prothèses duodénales métalliques, le risque de récidive de la GOO et de réintervention est plus faible avec la GE-EEG. Le taux de manifestations indésirables semble également être plus faible qu’avec la technique chirurgicale, avec une durée de séjour hospitalier plus courte. Des études randomisées comparant ces différentes techniques sont encore nécessaires pour déterminer un nouvel algorithme de traitement pour la GOO. Nous rapportons un cas de GE-EEG réalisée avec succès dans notre institution.