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Gut and Liver May 2024Malignant duodenal obstruction has become more common with the development of palliative therapies.The outcomes of endoscopic ultrasound-guided gastrojejunostomy...
Clinical Outcomes of Secondary Duodenal Self-Expandable Metallic Stenting for Duodenal Stent Dysfunction in Patients with Malignant Duodenal Obstruction: A Retrospective Multicenter Study.
BACKGROUND/AIMS
Malignant duodenal obstruction has become more common with the development of palliative therapies.The outcomes of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) are comparable to those of surgical gastrojejunostomy or duodenal stenting. However, EUS-GJ is technically challenging. Duodenal self-expandable metallic stent (SEMS) placement is popular; however, obstructions are common. Duodenal SEMS obstruction can be managed with the insertion of a second SEMS in a stent-in-stent manner. Therefore, we aimed to analyze the clinical outcomes of secondary duodenal SEMS placement in patients with malignant duodenal obstruction.
METHODS
We retrospectively analyzed the data of patients who underwent secondary duodenal stent insertion for duodenal stent dysfunction between January 2016 and December 2021. The primary outcome was stent patency. The secondary outcomes were clinical success, factors associated with dysfunction, patient survival, and adverse events.
RESULTS
A total of 109 patients were included. The mean age was 64.4±11.2 years, and 63 patients (57.8%) were male. Ninety-two patients (84.4%) had pancreaticobiliary cancer. Clinical success was achieved in 94 cases (86.2%). Twenty-three patients experienced stent dysfunction with 231 days of median stent patency (95% confidence interval [CI], 169 to not available). After a multivariable Cox hazard analysis of stent patency, the Eastern Cooperative Oncology Group performance status (hazard ratio [HR], 2.13; 95% CI, 1.20 to 3.81; p=0.010) and the first stent patency ≥6 months (HR, 0.33; 95% CI, 0.11 to 0.95; p=0.050) remained significant associated factors. Adverse events occurred in five patients (4.6%).
CONCLUSIONS
Secondary duodenal stent insertion is a viable option for first duodenal stent obstruction. Further comparative studies involving surgery or EUS-GJ for obstructed duodenal stents are warranted.
PubMed: 38772730
DOI: 10.5009/gnl240014 -
JFMS Open Reports 2024A 5-year-old neutered Somali cat presented with a 2-week history of icterus. Diagnostic imaging revealed extrahepatic biliary obstruction (EHBO) due to a common bile...
CASE SUMMARY
A 5-year-old neutered Somali cat presented with a 2-week history of icterus. Diagnostic imaging revealed extrahepatic biliary obstruction (EHBO) due to a common bile duct (CBD) mass. During exploratory laparotomy, a duodenal perforation was discovered incidentally. Choledochoduodenostomy combined with the Billroth II procedure was performed after resection of the CBD mass and the proximal duodenum to treat the EHBO and duodenal perforation. Based on histological and immunohistochemical findings, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation. The cat recovered almost uneventfully and was discharged 11 days after surgery. The cat survived for nearly 100 days without recurrence of EHBO or duodenal perforation; however, intermittent vomiting and weight loss persisted despite supportive medications.
RELEVANCE AND NOVEL INFORMATION
To the best of our knowledge, there is no detailed report on the application of choledochoduodenostomy combined with the Billroth II procedure in cats, as we used to treat the EHBO and duodenal perforation in the present case. As serum gastrin concentrations were elevated on the first day of hospitalisation, the CBD mass was diagnosed as a neuroendocrine carcinoma with gastrin-producing cell differentiation, which seemed to have caused not only EHBO but also duodenal perforation (Zollinger-Ellison syndrome). The cat survived for almost 100 days without any perioperative complications. However, this combined procedure might be considered as only a salvage option and not as a definitive treatment option in cats requiring simultaneous biliary and gastrointestinal reconstruction because postoperative supportive care could not improve the cat's condition or maintain its quality of life.
PubMed: 38766407
DOI: 10.1177/20551169241246415 -
Journal of Surgical Case Reports May 2024A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of...
A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of malrotation, strangulation may occur both inside and outside the hernial sac. Strangulation outside the hernial sac makes the preoperative diagnosis more difficult. Herein, we report a patient with a right paraduodenal hernia, intestinal malrotation, and strangulation outside the hernia. An 86-year-old woman was admitted to our hospital with abdominal pain. Enhanced computed tomography showed a closed-loop obstruction of the hypo-enhancing small bowel and absence of a horizontal duodenal leg. The patient underwent an emergency laparotomy and was diagnosed with strangulated bowel obstruction due to a right paraduodenal hernia and malrotation. The patient underwent resection of the ischemic ileum, closure of the hernial orifice, and repositioning of the intestine. The postoperative course was uneventful. The patient reported no abdominal discomfort after 7 months of follow-up.
PubMed: 38764731
DOI: 10.1093/jscr/rjae311 -
International Journal of Surgery Case... Jun 2024Congenital obstruction of duodenojejunal junction is a rare unexplored pathologic entity. Most of the cases reported so far are regarding extrinsic band or narrower...
INTRODUCTION AND IMPORTANCE
Congenital obstruction of duodenojejunal junction is a rare unexplored pathologic entity. Most of the cases reported so far are regarding extrinsic band or narrower attachment of ligament of Treitz, which will be presenting with vomiting in neonates and children without malrotation.
CASE PRESENTATION
Author is reporting here two rare cases of congenital intrinsic duodenojejunal junctional obstruction and their management in toddlers.
CLINICAL DISCUSSION
Duodenojejunal junction, is an embryologically, pathologically and radiographically, yet unexplored region except anatomically and surgically. Only few pathologies have been described in this region so far CONCLUSION: An abnormal embryogenesis could be speculated and contemplated to be the reason for such rare congenital duodeno jejunal junctional obstruction which should be managed promptly as per required surgical techniques.
PubMed: 38762960
DOI: 10.1016/j.ijscr.2024.109766 -
Prague Medical Report 2024We present a case of obstruction in the third portion of the duodenum secondary to a phytobezoar in an adult patient with no surgical history and without a vegan diet....
We present a case of obstruction in the third portion of the duodenum secondary to a phytobezoar in an adult patient with no surgical history and without a vegan diet. High intestinal obstruction due to a phytobezoar is rarely described in the literature, posing a diagnostic challenge when evaluating potential differentials in the emergency setting. Subsequently, we conduct a review focusing on tomographic findings and the surgical specimen, highlighting key points to consider when addressing such pathologies.
Topics: Humans; Male; Middle Aged; Bezoars; Duodenal Obstruction; Duodenum; Tomography, X-Ray Computed
PubMed: 38761047
DOI: 10.14712/23362936.2024.13 -
Journal of Investigative Medicine High... 2024Diverticular disease is a major cause of hospitalizations, especially in the elderly. Although diverticulosis and its complications predominately affect the colon, the...
Diverticular disease is a major cause of hospitalizations, especially in the elderly. Although diverticulosis and its complications predominately affect the colon, the formation of diverticula in the small intestine, most commonly in the duodenum, is well characterized in the literature. Although small bowel diverticula are typically asymptomatic, and diagnosed incidentally, a complication of periampullary duodenal diverticulum is Lemmel syndrome. Lemmel syndrome is an extremely rare condition whereby periampullary duodenal diverticula, most commonly without diverticulitis, leads to obstruction of the common bile duct due to mass effect and associated complications including acute cholangitis and pancreatitis. Here, we present the first case, to our knowledge, of periampullary duodenal diverticulitis complicated by Lemmel syndrome with concomitant colonic diverticulitis with colovesical fistula. Our case and literature review emphasizes that Lemmel syndrome can present with or without suggestions of obstructive jaundice and can most often be managed conservatively if caught early, except in the setting of emergent complications.
Topics: Humans; Duodenal Diseases; Tomography, X-Ray Computed; Male; Aged; Intestinal Fistula; Diverticulitis, Colonic; Female; Sigmoid Diseases; Diverticulitis
PubMed: 38742534
DOI: 10.1177/23247096241253342 -
Case Reports in Medicine 2024Duodenal atresia or stenosis are different degrees of the same abnormality. They usually occur at the level of the ampulla of Vater and are thought to be an embryologic...
BACKGROUND
Duodenal atresia or stenosis are different degrees of the same abnormality. They usually occur at the level of the ampulla of Vater and are thought to be an embryologic defect during the development of the foregut, leading to abnormal recanalization. Complete duodenal atresia is usually symptomatic in the early neonatal period, while partial obstruction (web, stenosis) may have a late presentation and a more challenging diagnosis such as in our case. . The patient, a 16-year-old girl, presented with abdominal pain, recurrent vomiting, and growth failure. An upper GI study with barium showed an image compatible with gastroptosis. Further diagnostic procedures confirmed a rare finding such as congenital duodenal stenosis. She underwent surgical intervention, and the recovery period was uneventful.
CONCLUSION
Gastroptosis is not diagnostic for a particular disease. This rare radiological finding in children may obscure uncommon diagnosis, such as congenital duodenal stenosis, which can present a diagnostic challenge beyond early childhood.
PubMed: 38736458
DOI: 10.1155/2024/1070253 -
SAGE Open Medical Case Reports 2024Superior mesenteric artery syndrome is a rare condition that causes duodenal obstruction due to compression by the superior mesenteric artery and the aorta. It can be...
Superior mesenteric artery syndrome is a rare condition that causes duodenal obstruction due to compression by the superior mesenteric artery and the aorta. It can be related to congenital or acquired factors that reduce the aortomesenteric angle and distance. The clinical presentation is nonspecific and often mimics other causes of upper gastrointestinal obstruction. The diagnosis requires a high index of suspicion and a correlation of clinical symptoms with radiographic findings. We report a case of a 17-year-old female patient who presented with chronic abdominal pain, vomiting, and weight loss. She was diagnosed with superior mesenteric artery syndrome based on an abdominal computed tomography scan that showed a reduced aortomesenteric angle of 30° and a reduced aortomesenteric distance of 7 mm. She was treated conservatively with anticoagulation therapy, dietary modification, and physical activity. She reported symptom improvement and weight gain after 2 weeks of treatment. This case illustrates the challenges and pitfalls in diagnosing superior mesenteric artery syndrome.
PubMed: 38715898
DOI: 10.1177/2050313X241249614 -
International Journal of Surgery Case... Jun 2024Congenital causes of duodenal obstruction can be grouped into intrinsic and extrinsic causes. The degree of obstruction caused by such etiologies determines the severity...
INTRODUCTION
Congenital causes of duodenal obstruction can be grouped into intrinsic and extrinsic causes. The degree of obstruction caused by such etiologies determines the severity and timing of symptom presentation. Early neonatal diagnosis is common in patients with etiologies that present with high degrees of obstruction such as atresia whereas etiologies that cause lesser degrees of obstruction such as malrotation and duodenal stenosis can go undiagnosed into adulthood.
PRESENTATION OF CASE
We report a case of a 24-year-old female who presented with acute on chronic abdominal pain with bilious vomiting. She was diagnosed with intermittent small bowel volvulus which resolved spontaneously but was found to have adult intestinal malrotation diagnosed intraoperatively. She had a Ladd procedure done but had persistent obstructive small bowel symptoms after the Ladd procedure. She was found to have duodenal stenosis from fibrosis of the duodenum on relaparotomy which was treated surgically with Heineke-Mikulicz strictureplasty leading to total resolution of symptoms.
DISCUSSION
Congenital extrinsic and intrinsic causes of partial duodenal obstruction such as Ladd bands in malrotation and duodenal stenosis respectively, can co-exist and persist into adulthood due to their lesser symptomatology and degree of obstruction. Surgical treatment must identify and correct both conditions when they co-exist to ensure complete resolution of symptoms.
CONCLUSION
This case report highlights the association of duodenal stenosis with adult malrotation which may account for persistent symptoms after the Ladd procedure and suggests the use of Heineke-Mikulicz strictureplasty as a complementary procedure for complete symptom resolution.
PubMed: 38703614
DOI: 10.1016/j.ijscr.2024.109713 -
Frontiers in Pediatrics 2024Eosinophilic gastrointestinal diseases (EGIDs) are rare, chronic inflammatory disorders characterized by eosinophilic infiltration of the gastrointestinal tract....
Eosinophilic gastrointestinal diseases (EGIDs) are rare, chronic inflammatory disorders characterized by eosinophilic infiltration of the gastrointestinal tract. Symptoms and clinical presentations vary depending on the site and layer of the gastrointestinal wall infiltrated by eosinophils. Gastrointestinal obstruction is a serious, though uncommon, presentation. Management can be extremely challenging because of the rarity of the condition and the lack of robust scientific evidence. Current treatment approaches for EGIDs mainly focus on elimination diets, proton pump inhibitors and corticosteroids, which present high refractoriness rates. Novel targeted therapies are being investigated but not routinely used. Surgery should be avoided as far as possible; however, it may be the only option in gastrointestinal obstruction when long-term remission cannot be attained by any medical strategy. Herein we report the case of an adolescent boy affected by an eosinophilic gastrointestinal disease with progressive duodenal stenosis, refractory to medical therapy, who successfully benefitted from surgical management. He presented with a one-year history of gastrointestinal obstructive symptoms with feeding intolerance. After the diagnostic workup, he was diagnosed with an eosinophilic gastrointestinal disease (esophagitis and enteritis) with a duodenal involvement causing a progressive duodenal stenosis. Due to refractoriness to the conventional medical therapies and the consequent high impact on his quality of life, related both to the need for enteral nutrition and repeated hospitalizations, we decided to perform a gastro-jejunum anastomosis, which allowed us to obtain a clinical and endoscopic long-term remission. The early discussion of the case and the involvement of all experienced specialists, pediatricians and pediatric surgeons is essential.
PubMed: 38699150
DOI: 10.3389/fped.2024.1390946