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Objective: While sleeve gastrectomy (SG) results in sustained weight loss for the majority of patients, some will experience inadequate weight loss or weight regain requiring revision. The objective of this study was to evaluate differences in weight loss over time between patients undergoing Roux-en-Y gastric bypass (RYGB) or single anastomosis duodenoileostomy (SADI) after SG., Methods: We queried a single institution's bariatrics registry to identify patients who underwent RYGB or SADI after previous SG over a three-year period. Demographics, operative characteristics, and post-operative complications were evaluated. Interval total body weight loss (TBWL) and excess body weight loss (EBWL) were calculated from available follow-ups within 2 years., Results: We identified 124 patients who underwent conversion to RYGB (n = 61) or SADI (n = 63) following previous SG. There were no differences in sex, age, or medical comorbidities between groups. The median initial BMI was higher in the SADI group (44.9 vs. 41.9 for RYGB, p = 0.03) with greater excess body weight (56.7 vs. 64.3 kg, p = 0.04). The SADI group had a shorter median operative duration (157 vs. 182 min for RYGB, p < 0.01) and lower readmission rates (0 vs. 14.75%, p < 0.01). There was no difference in post-operative complications or need for rehydration therapy between the groups. Among 122 patients (98.4%) that had follow-up weights available, there were no differences in TBWL between groups. RYGB patients had a higher EBWL at 2, 3, and 6 months (p < 0.05 for all comparisons), but there were no differences between RYGB and SADI at 1 or 2 years., Conclusions: Both RYGB and SADI conversions proved effective for further weight loss following failed SG at our academic center. While neither demonstrated clear superiority in long-term (> 1 year) weight loss, RYGB's restrictive gastric pouch may explain its early weight loss advantage., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Superior mesenteric artery syndrome is a rare condition that has only around 400 reported cases so far. Typically, the superior mesenteric artery branches off the abdominal aorta at 45° to create an aortomesenteric distance of 10-28 mm, with the duodenum passing through. However, if this aortomesenteric angle reduces to less than 25°, the third portion of the duodenum becomes compressed between the SMA and aorta, causing mechanical obstruction., Case Presentation: This case report aims to demonstrate the diagnostic difficulties and the laparoscopic management of a 52-year-old Indian male presenting with abdominal pain and vomiting, with associated weight loss. Imaging was further suggestive of high intestinal obstruction, and he was later found to have superior mesenteric artery syndrome., Conclusion: Taking into account a significant reduction in morbidity, we propose laparoscopic duodenojejunostomy to be the new procedure of choice for superior mesenteric artery syndrome., (© 2024. The Author(s).)

Duodeno-duodenostomy (DD) has been proposed as a more physiological alternative to conventional duodeno-jejunostomy (DJ) for pancreas transplantation. Accessibility of percutaneous biopsies in these grafts has not yet been assessed. We conducted a retrospective study including all pancreatic percutaneous graft biopsies requested between November 2009 and July 2021. Whenever possible, biopsies were performed under ultrasound (US) guidance or computed tomography (CT) guidance when the US approach failed. Patients were classified into two groups according to surgical technique (DJ and DD). Accessibility, success for histological diagnosis and complications were compared. Biopsy was performed in 93/136 (68.4%) patients in the DJ group and 116/132 (87.9%) of the DD group ( p = 0.0001). The graft was not accessible for biopsy mainly due to intestinal loop interposition (n = 29 DJ, n = 10 DD). Adequate sample for histological diagnosis was obtained in 86/93 (92.5%) of the DJ group and 102/116 (87.9%) of the DD group ( p = 0.2777). One minor complication was noted in the DD group. The retrocolic position of the DD pancreatic graft does not limit access to percutaneous biopsy. This is a safe technique with a high histological diagnostic success rate., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Bassaganyas, Darnell, Soler-Perromat, Rafart, Ventura-Aguiar, Cuatrecasas, Ferrer-Fàbrega, Ayuso and García-Criado.)

Background: Superior mesenteric artery syndrome (SMAS) is a rare condition, for which laparoscopic surgery was successfully performed safely and with long-term efficacy., Methods: This single center retrospective clinical study comprised 66 patients with SMAS, surgically treated between January 2010 and January 2020, who were allocated to three different surgical groups according to their medical history and symptoms (Laparoscopic duodenojejunostomy, n  = 35; Gastrojejunostomy, n  = 16; Duodenojejunostomy plus gastrojejunostomy, n  = 15). Patient demographics, surgical data and postoperative outcomes were retrieved from the medical records., Results: All operations were successfully completed laparoscopically, and with a median follow-up of 65 months, the overall symptom score was significantly reduced from 32 to 8 ( p  < 0.0001) and the BMI was increased from 17.2 kg/m 2 to 21.8 kg/m 2 ( p  < 0.0001)., Conclusions: When conservative measures failed in the treatment of SMAS, laparoscopic surgery proved to be a safe and effective method. The specific surgical technique was selected according to the history and symptoms of each individual patient. To our knowledge, this study represents the largest number of laparoscopic procedures at a single center for the treatment of superior mesenteric artery syndrome.

Mirizzi syndrome is a rare complication of chronic gallstone disease characterised by the compression of the common bile duct due to an impacted lithiasis in the infundibulum of the gallbladder or cystic duct. In this case study, we discuss an 85-yearold patient who presented with Mirizzi syndrome associated with septic shock. She was not eligible for cholecystectomy due to her advanced age and frailty, requiring a less invasive alternative. Gallbladder drainage was initiated by endoscopic ultrasoundguided cholecystoduodenostomy with a lumen-apposing metal stent (LAMS). Utilising this bulbo-cholecystic stent, SpyGlassguided electrohydraulic lithotripsy (SGEHL) was then performed, resulting in successful extraction of multiple bile stones, including a 20 mm lithiasis that was lodged in the cystic infundibulum. Subsequently, serum bilirubin levels and inflammatory markers were significantly reduced, consistent with resolution of Mirizzi syndrome. The combination of SGEHL and LAMS, designated as SLAMS, represents a novel, minimally invasive intervention for this potentially life-threatening disease., Competing Interests: The authors declare that they have no conflict of interest, (© Acta Gastro-Enterologica Belgica.)

Introduction: Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management., Aim: To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details., Materials and Method: All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied., Results: The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively., Conclusion: 3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery., Level of Evidence: Treatment study level IV., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Of all varieties, Type I Choledochal cyst causing saccular or fusiform dilatation of the extra-hepatic biliary ductal system is the commonest (90.0 - 95.0%). Its presentations vary. To restore the continuity of the extra-hepatic biliary tract after excision of type I Choledochal cyst, surgeons have few alternatives to use, with their advantages and disadvantages. Roux en-Y Hepatico-jejunostomy (RYHJ) has been very popular and long studied standard surgical treatment for type I Choledochal cyst. But now Hepatico-duodenostomy (HD) is also being practiced and studied in different centers all over the world for the treatment of the same disease. For the last five years, we, at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh, have been using Hepatico-duodenostomy as preferred anastomotic option in treating type I Choledochal cyst. Here, we are presenting our experience at BSMMU Hospital, regarding operative events and time requirement of Hepaticoduodenostomy for the treatment of type I Choledochal cyst and, to show whether this procedure can be safely practiced, producing acceptable results. It is a retrospective document study, from January 2013 to December 2017, at BSMMU Hospital, on forty two, MRCP confirmed type I Choledochal cyst patients of pediatric age. Patients' particulars, history, physical examination, investigations (including MRCP confirmation), assessment, surgical plan were collected from relevant medical records and documented in duly coded individual data collection sheet maintaining standard privacy protocol. Information regarding presentations, operative findings and procedural events including per-operative mortality, injury to the vital structures during operation, conversion to RYHJ, operative time (minutes), blood loss and transfusion requirements (ml) of Heaticoduodenostomy for type I Choledochal cyst, were specially searched for. There was no operative mortality. None of these patients required per-operative blood transfusion. Nor there was any inadvertent injury to the adjacent structures. The mean operative time required for Hepaticoduodenostomy was 88 minutes with a range of 75 to 125 minutes. Through this study, at BSMMU Hospital, operative events and time requirement of Hepatico-duodenostomy for treating type I Choledochal cyst, was found to be yielding acceptable results, for safe practice.

Background: Duodenal gastrointestinal stromal tumors (GISTs) are uncommon, making up only 3-5% of all GISTs. [1,2] Historically, the treatment of choice for duodenal GIST tumors was pancreaticoduodenectomy. [3]Currently, newer surgical intervention methods including local resection via laparotomy, endoscopic resection, and robotic resection are feasible. When doing a local resection, the defect can be closed either primarily or via a Roux-en-Y duodenojejunostomy. [3] Case presentation: Our patient is a 64-year- old female who presented initially with shortness of breath and was found to have a pulmonary embolism. She then developed upper GI bleeding from anticoagulation and was found to have an ulcerated GIST tumor in the anti-mesenteric border of the third portion of the duodenum (D3). Initial surgery was postponed due to high pulmonary artery pressure from the pulmonary embolism. The patient underwent argon beam coagulation of the bleeding mass to control the bleeding, followed by localized radiotherapy plus Gleevec. Unfortunately, the tumor grew in size during follow-up. The patient was then taken to the OR for a robot-assisted partial duodenal resection (D3) with Roux-en-Y duodenojejunostomy to reconstruct the large defect. She did well post operatively and her final pathology showed a GIST tumor, c-kit and DOG1 positive, 3.5 cm in size, with negative margins., Conclusion: Robotic duodenal resection is a new technique currently being used to resect duodenal GIST tumors. Our video demonstrates the feasibility of D3 partial resection with Roux-en-Y duodenojejunostomy. Duodenal GIST tumor robotic resection offers both decreased morbidity and adequate oncologic outcomes., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Smoking is clinically associated with high postoperative pain scores and increased perioperative analgesic requirements. However, the association between the duration of smoking cessation and postoperative opioid requirements remains unclear. Therefore, this study aimed to evaluate the association between the duration of smoking cessation and postoperative opioid requirements. We retrospectively analyzed the data of 144 male patients who received intravenous patient-controlled analgesia (IV PCA) after laparoscopic distal gastrectomy with gastroduodenostomy. All patients were divided into three groups: G0, nonsmoker; G1, smoker who quit smoking within 1 month preoperatively; G2, smoker who quit smoking over 1 month preoperatively. Analgesic use, pain intensity, and IV PCA side effects were assessed up to postoperative day 2. As the duration of smoking cessation increased, the amount of postoperative opioid consumption decreased ( β  = -0.08; 95% confidence interval (CI), -0.11 to -0.04; P < 0.001). The total postoperative opioid requirements in G1 were significantly higher than those in G0 and G2 (G0, 75.5 ± 15.9 mg; G1, 94.6 ± 20.5 mg; and G2, 79.9 ± 19.4 mg ( P < 0.001)). A multivariate regression analysis revealed that G1 was independently associated with increased postoperative opioid requirements ( β  = 12.80; 95% CI, 5.81-19.80; P < 0.001). Consequently, male patients who had ceased smoking within 1 month of undergoing a laparoscopic distal gastrectomy with gastroduodenostomy had higher postoperative opioid use than patients who had ceased smoking for more than 1 month and nonsmokers., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Chan-Sik Kim et al.)

Laparoscopic cholecystectomy is the routine method to treat gallbladder polyps. Nowadays, endoscopic ultrasound (EUS)-guided cholecystostomy as a bridge for per-oral transmural endoscopic resection of gallbladder polyps is introduced because preservation of gallbladder is increasingly getting attention. The aim of our study was to evaluate the approach in the treatment of patients with gallbladder polyps and symptomatic gallstones.EUS-guided cholecystostomy with the placement of a lumen-apposing metal stent (LAMS) was performed for those patients with accompanying gallbladder polyps and symptomatic gallstones. Several days after the cholecystostomy with LAMS, a gastroscope was introduced into the gallbladder to remove gallbladder polyps.All patients were successfully performed with the procedures of EUS-guided cholecystoduodenostomy (n = 3) or cholecystogastrostomy (n = 1) and endoscopic resection of gallbladder polyps. One patient experienced severe peritonitis. During the follow-up at 3 months, 1 patient was performed with laparoscopic cholecystectomy because ultrasonography examination showed the reappeared gallstones. No stone recurrence was found in other patients. During the follow-up of 3 to 15 months, no polyp recurrence was found in all the patients.The approach is novel for performing EUS-guided gallbladder fistulization, which can subsequently allow procedures of per-oral transmural endoscopic resection of gallbladder polyps to avoid cholecystectomy in the patients with gallbladder polyps and gallstones. However, further studies are needed before clinical recommendation because of the complications and stone recurrence.

Introduction: Robotic distal gastrectomy (RDG) is now thought to be less invasive than conventional laparoscopic distal gastrectomy (LDG) for gastric cancer. Although the delta-shaped anastomosis is an established, widely performed procedure for intracorporeal Billroth-I (B-I) gastroduodenostomy after LDG, it has some difficulties and is performed in the ischemic region of the duodenum. We therefore developed a novel overlap B-I gastroduodenostomy after RDG. Materials and Methods: We started using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) for RDG in May 2017. The robotic overlap B-I reconstruction was performed via side-to-side anastomosis, as follows: Two small incisions were made, one on the greater curvature of the remnant stomach, 5 cm from the edge of the remnant gastric stump, and one on the superior edge of the anterior wall of the duodenal stump. A 45-mm EndoWrist linear stapler device (EWLS) loaded with a blue cartridge was inserted through the incision. After the remnant stomach and duodenum were attached to the V-shaped form by the EWLS, the incisions were closed by the EWLS. Results: Seven patients underwent RDG followed by a robotic overlap B-I procedure up to March 2019. Short-term outcomes were determined from medical records and operative videos. No intraoperative complications or conversions to open or conventional laparoscopic surgery occurred. The mean time for the anastomosis was 37 (range 29-45 minutes) minutes. No postoperative complications occurred following the robotic overlap B-I procedure. Discussion: RDG followed by an overlap B-I gastroduodenostomy might be feasible and safe. However, long-term follow-up is required to identify additional benefits.

Background and Aims: Segregated right intrahepatic duct dilatation (IHD) results from complete obstruction of the biliary tract proximal to the hilar level. We aimed to evaluate long-term efficacy and safety of endoscopic ultrasound (EUS) hepaticoduodenostomy (HDS) in segregated right IHD., Methods: Consecutive patients who had undergone EUS-guided HDS with a fully covered self-expandable metal stent (FCSEMS) in an academic tertiary center were recruited. All patients had segregated right hepatic duct and failed drainage by endoscopic retrograde cholangiopancreatography (ERCP). Demographic data, endoscopic findings, procedure details, and outcome data were extracted from a prospectively maintained database., Results: From 2013 to 2017, there were 35 patients who had undergone EUS-guided HDS with a median follow-up duration of 169 (3-2091) days. Malignancy accounted for 71.4% of the ductal segregation, followed by surgical complication (17.1%). Technical and clinical success rate was 97.1% and 80%, respectively. Early adverse event (AE) happened in seven patients (20%), two of them required endoscopic reintervention, and no percutaneous transhepatic biliary drainage (PTBD) or surgery was performed because of AE. The median stent patency duration was 331 (3-1202) days. The median duration of fistula tract keeping was 1280 (3-1280) days. There was no significant difference in terms of patency rate with respect to whether the underlying pathology was benign or malignant (P = 0.776). EUS-guided HDS for right posterior sectional duct segregation was associated with higher 3-month stent patency rate when compared with right anterior sectional duct (79.1% vs 38.1%, P = 0.012)., Conclusion: Endoscopic ultrasound-guided HDS with an FCSEMS appears to be a safe and effective treatment as a viable alternative option to PTBD after failed ERCP. It creates a durable and reliable fistula tract for permanent access to an isolated ductal system, and this application deserves more attention., (© 2020 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Endoscopic ultrasound-guided choledochoduodenostomy (CDD) is emerging as an alternative technique for biliary drainage in patients who fail conventional endoscopic retrograde cholangiopancreatography (ERCP). The lumen-apposing metal stents (LAMS) are being increasingly used for CDD. We performed a systematic review and meta-analysis to evaluate the effectiveness and safety of CDD using LAMS., Methods: We performed a systematic search of multiple databases through May 2019 to identify studies on CDD using covered self-expanding metal stents. Pooled rates of technical success, clinical success, adverse events, and recurrent jaundice associated with CDD using LAMS were estimated. A subgroup analysis was performed based on use of LAMS with electrocautery-enhanced delivery system (EC-LAMS)., Results: Seven studies on CDD using LAMS (with 284 patients) were included in the meta-analysis. Pooled rates of technical and clinical success (per-protocol analysis) were 95.7% (95% CI 93.2-98.1) and 95.9% (95% CI 92.8-98.9), respectively. Pooled rate of post-procedure adverse events was 5.2% (95% CI 2.6-7.9). Pooled rate of recurrent jaundice was 8.7% (95% CI 4.5-12.8). On subgroup analysis of CDD using EC-LAMS (5 studies with 201 patients), the pooled rates of technical and clinical success (per-protocol analysis) were 93.8% (95% CI 90.4-97.1) and 95.9% (95% CI 91.9-99.9), respectively. Pooled rate of post-procedure adverse events was 5.6% (95% CI 1.7-9.5). Pooled rate of recurrent jaundice was 11.3% (95% CI 6.9-15.7). Heterogeneity (I 2 ) was low to moderate in the analyses., Conclusion: CDD using LAMS/EC-LAMS is an effective and safe technique for biliary decompression in patients who failed ERCP. Further studies are needed to assess CDD using LAMS as primary treatment modality for biliary obstruction.

Background: Choledochal cysts are congenital dilations of the biliary tree. Complete cyst excision and biliary-enteric reconstruction have been the standard operations. In our center, more than 95% of choledochal cyst excision is now performed laparoscopically. Majority of current studies describe laparoscopic-assisted reconstruction using Roux-en-Y hepaticojejunostomy (HJ). However, only a few have studied laparoscopic hepaticoduodenostomy (HD) as an alternative method of biliary-enteric reconstruction. In this study, we focused on comparing longer-term outcomes between laparoscopic HJ and HD reconstruction following choledochal cyst excision., Methods: We performed retrospective analysis of 54 children who had undergone laparoscopic choledochal cyst excision and biliary-enteric reconstruction between October 2004 and April 2018. Short-term outcomes including operative time, complications such as anastomotic leakage and bleeding, and hospital stays were included. Long-term outcomes including contrast reflux into biliary tree, cholangitis, anastomotic strictures, and need of reoperation were analyzed., Results: Of the 54 patients, 21 of them underwent laparoscopic HD and 33 underwent laparoscopic Roux-en-Y HJ anastomosis reconstruction. There were no significant differences in gestation, gender, age at operation, antenatal diagnosis, and Todani type of choledochal cyst between HD and HJ group. Operative time was significantly shortened in HD group (p = 0.001). Median time to enteral feeding was 3 days in both groups. Median intensive care unit (p = 0.001) and hospital stay (p = 0.019) were significantly shorter in HD group. There was no perioperative mortality. There was no significant difference in anastomotic leakage requiring reoperation (p = 0.743). There were no significant differences in long-term outcomes including anastomotic stricture (p = 0.097), cholangitis (p = 0.061), symptoms of recurrent abdominal pain or gastritis (p = 0.071), or need of reoperation (p = 0.326). All patients had normal postoperative serum bilirubin level., Conclusions: Laparoscopic excision of choledochal cyst with HD reconstruction is safe and feasible with better short-term outcomes and comparable long-term outcomes compared to Roux-en-Y HJ reconstruction.

Aim: Superior mesenteric artery (SMA) syndrome is a rare reason of small bowel obstruction (SBO). İt is a complicated sickness. We aim to analyze the diagnosis, clinical presentation, SMAS management and postoperative outcomes after laparoscopic duodenojejunostomy., Material and Methods: A total of 19 patients who were diagnosed with SMAS and did not respond to the traditional treatment between January 2010 and November 2017 in Afyon Health Sciences University Hospital were included in the study., Results: Their average age was 22.3 years (17-31 years). Number of males and females were 6 and 13, respectively. Clinical presentations of patients are as follow: 14 patients were referred to as postprandial distress syndrome, 3 were unexplained weight loss, and 2 were gastroesophageal reflux disease. Considering CT angiography findings, 14 patients had duodenal dilatation. The mean aortamesenteric angle was 10.6 mm. The mean of aorta-SMA distance was 5.1 mm. The mean hospital stay and follow-up times were 3.7 days and 40.2 months, respectively. No morbidity or mortality was found within patients. Preoperative, postoperative 6th month and postoperative 12th month CONUT scores were 9.1, 3.7, and 0.8, respectively., Conclusions: Laparoscopic duodenojejunostomy can be performed safely to the patients who do not benefit from conservative treatment., Key Words: Aortamesenteric angle, Duodenojejunostomy, Weight loss.

Benign bile duct stricture poses a significant challenge for gastroenterologists and general surgeons due to the inherent nature of the disease, difficulty in sustaining long-term solutions and fear of pitfalls in performing biliary tract operations. Operative management with an open biliary bypass is mainly reserved for patients who have failed multiple attempts of endoscopic and percutaneous treatments. However, recent advances in minimally invasive technology, notably in the form of the robotics, have provided a new approach to tackling biliary disease. In this technical report, we describe our standardized method of robotic choledochoduodenostomy in a 59-year-old woman with history of Roux-en-Y gastric bypass who presents with benign distal common bile duct stricture following failure of non-operative management. Key steps in this approach involved adequate duodenal Kocherization, robotic portal dissection and creation of a side-to-side choledochoduodenal anastomosis. The operative time was 200 min with no intraoperative complications and estimated blood loss was less than 50 mL. No abdominal drains were placed. The patient was discharged home on postoperative day 1 tolerating regular diet and able to resume her usual activities within 1 week of her operation. A video is attached to this report.

Competing Interests: M. A. Khashab is a consultant for Boston Scientific, Olympus, and Medtronic.

Purpose: The authors outline their stapling technique and retrospectively compare outcomes of laparoscopic staplers versus robotic staplers in patients undergoing robotic distal gastrectomy (RDG) with Billroth I gastroduodenostomy for gastric cancers., Materials and Methods: Of our 28 consecutive patients who underwent RDG, 18 underwent Billroth I gastroduodenostomy using laparoscopic staplers (fusion group); robotic staplers were used in the remaining 10 patients (robot group). All RDG procedures were performed using the da Vinci Surgical System., Results: The duration of reconstruction was significantly longer for the robot group than for the fusion group. There were no conversions to conventional laparoscopy or open surgery in the fusion group, but 1 patient in the robot group required conversion to laparoscopic reconstruction for duodenal injury during anastomosis. No postoperative complications developed in the fusion group., Conclusion: Regarding short-term surgical outcomes, robotic-assisted laparoscopic stapling techniques for reconstruction after RDG are both feasible and safe for gastric cancers.

Duodenal stenosis is one of the leading causes of duodenal obstruction in the pediatric population, usually diagnosed in newborns and in Down syndrome patients. It has historically been treated with duodeno-duodenostomy, an operation that is now commonly performed laparoscopically. We present a case of a 10-year-old child with a rare chromosomal abnormality who was diagnosed with a duodenal stricture after presenting with failure to thrive and inability to tolerate tube feeds. Duodeno-duodenostomy was performed using the da Vinci ® robot, allowing for improved intra-operative range of motion and control during anastomosis creation, with the same cosmetic benefits of laparoscopic surgery, and subsequent improvement in symptoms postoperatively. This case highlights the utility of robotic surgery in complex operations in the pediatric population.

Competing Interests: The authors declare no conflict of interest.

Background: Duodenal switch and single anastomosis modifications continue to gain greater interest among bariatric surgeons. Limiting factors to adoption include concerns around the nutritional management, patient compliance and follow-up, and the technical challenge of the operation. The majority of techniques offered currently use a hand-sewn duodenoileostomy. This approach is limited by the steep learning curve as well as longer operating times., Objectives: We present a video demonstrating the fully stapled technique for duodenoileostomy and ileileostomy. We offer technical pearls around the technique, specifically focused on maintaining a widely patent anastomosis, open biliopancreatic limb, safe duodenal dissection, and correct loop orientation., Methods: Laparoscopic fully stapled duodenoileostomy for duodenal switch and single anastomosis modification., Setting: Community hospital, single institution, 3 surgeons., Conclusion: Triple staple offers a reproducible and safe technique for the duodenoileostomy and specifically for construction of a Roux or loop anastomosis in duodenal switch., (Copyright © 2019 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical management of traumatic duodenal injury remains challenging. While various surgical techniques have been described in the attempt to reduce complications and mortality, recent data suggests that surgical approach using less invasive procedures might be associated with improved patient outcomes. The purpose of this study was to determine the recent trend of surgical procedures performed for patients with duodenal injury and their outcome., Methods: A retrospective analysis of the National Trauma Data Bank (NTDB) from 2002 to 2014 was performed. A total of 2163 patients who sustained a traumatic duodenal injury requiring surgical intervention were included. Patient characteristics, injury data, procedures, and outcomes were examined. Types of duodenal procedures and patient outcomes were compared between two study periods (2002-2006 vs. 2007-2014)., Results: The median age was 27 (IQR 20-39), 78.9% were male, and 63.8% sustained penetrating duodenal injury. The median injury severity score was 18 (IQR 13-26). In patients with isolated duodenal injury, the later study period (2007-2014) was significantly associated with the increased use of primary repair (OR 1.77; 95% CI 1.11-2.83, p = 0.017). Overall mortality was 11.7%. Patients in the later study group were significantly associated with lower odds of inhospital mortality (OR 0.47, 95% CI 0.22-0.95, p = 0.041)., Conclusions: A progressive trend toward less invasive procedures for duodenal injury was noted in the current study. Inhospital mortality has improved in the late study period.

Competing Interests: Disclosure The authors report no conflicts of interest in this work., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Laparoscopic duodenoduodenostomy can be performed to repair congenital duodenal obstructions from atresia or duodenal web. There are only a few published case series in the literature. We are reporting on a single surgeon's experience with the operation and discuss the technical aspects of the operation. Material and Methods: A retrospective chart review was performed using the electronic medical record identifying all patients who underwent laparoscopic duodenoduodenostomy or duodenojejunostomy at two institutions by a singular surgeon. Results: Fifteen patients were identified as having undergone laparoscopic duodenoduodenostomy from 2010 until 2017. The weight at the time of the operation ranged from 1.5 to 8.7 kg (median 2.5 kg). The age ranged from 0 days to 15 months (median 3 days). Operative time (including other procedures) ranged from 2 hours 10 minutes to 3 hours 45 minutes with a median of 2 hours 55 minutes. One case was converted to open due to poor visualization. One patient developed a stricture that required open anastomotic revision 4 weeks after the initial surgery. In 1 patient, an enterotomy in the first portion of the duodenum was created from a retraction stitch-this was immediately recognized and repaired by primary laparoscopic closure. One patient had a small anastomotic leak that was treated with antibiotics. There were no mortalities and no intraoperative blood loss requiring transfusion. Conclusion: Laparoscopic duodenoduodenostomy is an operation that can be performed with excellent outcomes following simple steps that are easily taught in a teaching setting.

Background: Gastroduodenostomy is preferred as a method of reconstruction following distal subtotal gastrectomy. However, in initial reports on reduced-port gastrectomy, gastroduodenostomy has rarely been performed therein because of technical difficulties. The present study describes a novel intracorporeal gastroduodenostomy technique applicable during reduced-port robotic distal subtotal gastrectomy., Methods: Data were retrospectively reviewed for cases of reduced-port (three-port) robotic distal subtotal gastrectomy with intracorporeal delta-shaped gastroduodenostomy performed from February 2016 to December 2016. The reduced-port approach used a Single-Site™ port via a 25-mm infraumbilical incision and two additional ports. We performed intracorporeal gastroduodenostomy using a 45-mm robotic or laparoscopic endolinear stapler. All staplers were inserted via a port on the left lower abdomen., Results: In our initial experience with intracorporeal gastroduodenostomy, 28 consecutive patients underwent successful surgery with the technique without needing to convert to open, laparoscopic, or conventional five-port robotic surgery. Mean operation time was 201.1 min (110-282 min), and no major complications, including anastomosis-related problems, were recorded., Conclusions: Intracorporeal delta-shaped gastroduodenostomy was safely and feasibly applied during reduced-port robotic gastrectomy with acceptable operative outcomes and no major complications. Intracorporeal gastroduodenostomy should be considered during reduced-port distal subtotal gastrectomy.

Objectives: The aim of this retrospective observational study was to clarify the usefulness and safety of percutaneous sonographically assisted endoscopic gastrostomy or duodenostomy (PSEGD) using the introduction method., Methods: The information for the sequential 22 patients who could not undergo standard percutaneous endoscopic gastrostomy (PEG) and underwent PSEGD for 3 y was extracted and was reviewed. In standard PEG, we performed pushing out of the stomach from the mediastinum and full distention to adhere the gastric wall to the peritoneal wall without interposing of the intraperitoneal tissues by air inflation and a turning-over procedure of the endoscope, four-point square fixation of the stomach to the peritoneal wall by using a Funada-style gastric wall fixation kit under diaphanoscopy, extracorporeal thumb pushing, and in difficult cases extracorporeal ultrasound guidance, and if necessary confirmation of fixation of the gastric wall to the peritoneal wall and placement of the PEG tube without any interposed tissues by using ultrasound., Results: Twenty-one patients (95.5%) successfully underwent PSEGD. Early complications (more than grade 2 in Clavien-Dindo classification) just after the procedure occurred in one case (active oozing). We did not encounter a case with mispuncture of the intraperitoneal organs and tissues. Delayed complications occurring within 1 mo were pneumonia in five patients, including death in three cases; bleeding from puncture site in two patients; and atrial fibrilation in one patient., Conclusion: PSEGD using the introduction method is a useful procedure for difficult patients in whom intraperitoneal organ or tissue is suspected to be interposed between the abdominal wall and stomach., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The late postoperative complications of choledochal cyst (CC) surgery are serious and include intrahepatic stones and biliary carcinoma; therefore, long-term follow-up is crucial., Methods: The subjects of this retrospective study were patients who underwent surgery for CC at Kagoshima University Hospital between April, 1984 and December, 2016. We analyzed the operative results, early and late postoperative complications, and postoperative follow-up rate., Results: The study population comprised 110 CC patients (male/female: 33/77) with a median age at surgery of 4 years, 3 months (range 12 days-17 years). The patients underwent hepaticoduodenostomy (n = 1; 0.9%) or hepaticojejunostomy (n = 109; 99.1%). Late complications included intrahepatic bile duct (IHBD) dilatation (n = 1; 0.9%), IHBD stones (n = 3; 2.7%), and adhesive ileus (n = 4; 3.6%). There was no incidence of biliary carcinoma in this series. The rates of follow-up at our institute within 10 years of surgery and more than 20 years after surgery were 69.2% (18 of 26) and 14.5% (8 of 55), respectively., Conclusions: The follow-up rate after definitive surgery declined with time. Late complications were observed within 20 years, but biliary carcinoma was not observed. The follow-up rate should be increased to detect late complications. Moreover, patient education on long-term follow up is essential to prevent life-threatening events after definitive surgery for CC.

Rationale: Annular pancreas (AP) is recognized as a cause of duodenal obstruction in children, while children with Meckel's diverticulum (MD) are usually asymptomatic. Here we present a rare case with both AP and MD, which was identified by abdominal exploration during diamond-shaped duodenoduodenostomy., Patient Concerns: A "double-bubble" sign was found by ultrasound at 35 week of pregnancy. After 39 weeks of pregnancy, the male patient was transferred to the Department of General Surgery, Children's Hospital of Soochow University because of a suspected duodenal stenosis., Diagnoses: Preoperative abdominal X-ray examination indicated "double-bubble" sign. AP was confirmed by exploratory surgery, with an MD located 30 cm above the ileocecal valve., Interventions: Diamond-shaped duodenoduodenostomy and a wedge resection of the intestine with end-to-end anastomosis were performed OUTCOMES:: The patient recovered and his appetite was good without vomiting., Lessons: Our experience demonstrates that abdominal exploration is essential for children with gastrointestinal malformations.

Inflammatory bowel disease, vascular disease, volvulus, adhesions, or abdominal trauma may necessitate extensive small-bowel resection resulting in an ultra-short distal duodenal or jejunal stump. If this distal duodenal or short jejunal stump is too short for stoma creation and bowel continuity restoration is hazardous or not possible at all, a distal duodenogastrostomy or proximal jejunogastrostomy in combination with drainage of the stomach is an option to prevent stump leakage. Although successful, this distal duodenogastrostomy has been described only in very few patients and in older records. We reintroduced this technique and describe a recent series of patients that confirms its usefulness in certain conditions. The technique of the distal duodenogastrostomy or proximal jejunogastrostomy with gastric drainage was used for the management of the difficult distal duodenum stump in five critically ill patients undergoing extensive bowel resection. Four patients with small-bowel ischemia and one patient suffering from perforating Crohn's disease and small-bowel volvulus were treated  successfully. The gastrostomies were subsequently converted to a duodenotransversostomy (in two patients) or the patients underwent small-bowel transplantation (two patients). One patient still has a jejunogastrostomy just after the duodenal-jejunal transition. In all five patients, the distal duodenogastrostomy or proximal jejunogastrostomy in combination with gastric drainage functioned well up to restoration of bowel continuity. In one patient, distal duodenogastrostomy and transabdominal gastric drainage functioned well for 5 years. No anastomotic leakage occurred. This procedure provides a feasible solution for an ultra-short bowel at emergency laparotomy. It enhances the surgical armamentarium and provides treatment options for these patients that were perhaps previously deemed unsalvageable.

Aim: A single center study was conducted to compare the short-term clinical outcome between laparoscopic surgery (LS) and open surgery (OS) repair for neonates with congenital duodenal obstruction (CDO)., Methods: Medical records of all neonates with bodyweight at surgery over 1500g and without other gastrointestinal anomalies that underwent surgery (duodeno-duodenostomy or duodeno-jejunostomy) for CDO at our center between January 2009 and July 2015 were reviewed. The choice of OS or LS was surgeon-dependent., Results: One hundred twelve patients were identified, with a median age and weight at surgery 8.5days and 2500g respectively. Forty-four patients underwent OS and 68 patients LS. There were no significant differences between the two groups regarding patient age, gender, weight at surgery, associated anomalies, and mean operative time. Compared to OS, the LS group had lower postoperative complications (5.9% vs 36.4%, p<0.0001), shorter mean time to initial oral feeding and mean postoperative hospital stay (3.9 vs. 7.1days and 8.6 vs. 12.9days respectively, p<0.0001) and better postoperative cosmesis., Conclusions: LS treatment for neonatal CDO is associated with lower postoperative morbidity, shorter recovery time and postoperative hospital stay and better postoperative cosmesis than OS., Type of Study: Retrospective Comparative Study., Level of Evidence: Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Graft injuries sometimes occur and may cause complications such as the leakage of pancreatic secretions, which is often lethal. We report our experience of a case of successful simultaneous pancreas-kidney transplantation using injured pancreas graft., Patients and Methods: The recipient was a 57-year-old woman with type 1 diabetes mellitus, and the donor was a 30-year-old man with a brain injury. In the donation, the pancreas parenchyma, splenic artery, and gastroduodenal artery were injured iatrogenically. We therefore reconstructed these arteries using vessel grafts and then performed simultaneous pancreas-kidney transplantation., Results: Five days after transplantation, we noted a high titer of amylase in the ascites; therefore, we performed an urgent laparotomy. The origin of the amylase was the injured pancreatic parenchyma, and continued washing and drainage were carried out. We reconstructed the duodenojejunostomy using the Roux-en-Y technique to separate the passage of food from the pancreas graft to prevent injury to other organs due to exposure to pancreatic secretions. Thereafter, we inserted a decompression tube into the anastomosis thorough the blind end of the jejunum. Finally, we inserted 3 drainage tubes for lavage. Following this procedure, the patient recovered gradually and no longer required hemodialysis and insulin therapy. She was discharged from our hospital 56 days after transplantation., Conclusion: The restoration of the injured graft was possible by management of pancreatic secretions and use of the donor's vessel grafts. Shortage of donors is a problem throughout the world; thus, it is important to use injured grafts for transplantation if possible., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Controversy exists regarding the best anastomotic method for pancreaticoduodenectomy (PD). We aimed to evaluate the perioperative outcomes of PD with stapled anastomosis (SA) versus hand-sewn anastomosis (HA) of gastrojejunostomy or duodenojejunostomy., Methods: We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), anastomotic bleeding, anastomotic leak, intra-abdominal abscess and mortality were defined as the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models., Results: We identified 1 randomised controlled trial (RCT) and 5 observational studies reporting a total of 890 patients who underwent PD with SA (n = 300) or conventional HA (n = 590). Our analysis demonstrated that SA significantly reduced postoperative DGE (OR: 0.37, 95% CI 0.25-0.54, P < 0.00001) but significantly increased anastomotic bleeding (OR: 13.4, 95% CI 2.96-57.41, P = 0.0007) compared to HA. No significant difference was found in POPF (OR: 0.83, 95% CI 0.56-1.21, P = 0.33); anastomotic leak (OR: 0.50, 95% CI 0.09-3.79, P = 0.58); intra-abdominal abscess (OR: 1.39, 95% CI 0.71-2.70, P = 0.34); or mortality (RD: -0.01, 95% CI 0.03-0.02, P = 0.65) between two groups., Conclusions: Our analysis demonstrated that compared to conventional HA, SA may be associated with lower incidence of DGE after PD without increasing the risk of clinically significant POPF, anastomotic leak or mortality. However, it is associated with higher rate of anastomotic bleeding which mandates careful and precise haemostasis of the stapled line. Considering the current limited evidence, no definitive conclusion can be drawn. Future research is required., (Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.)

Introduction Cholelithiasis usually can be managed successfully by endoscopic sphincterotomy. Choledochoduodenostomy (CDD) is one of the surgical treatment options but its acceptance remains debated because of the risk of reflux cholangitis and sump syndrome. The aim of this study was to assess the current features and outcomes of patient undergoing CDD. Patients and methods We retrospectively analysed the surgical results of consecutive 130 patients treated by CDD between 1991 and 2013 and excluded five cases with a malignant disorder. Indications for surgery included endoscopic management where stones were difficult or failed to pass and primary common bile duct stones with choledochal dilatation. Incidences of reflux cholangitis, stone recurrence, pancreatitis or sump syndrome were investigated and the data between end-to-side and side-to-side CDD were compared. Results Reflux cholangitis and stone recurrence was 1.6% (2/125) and 0% (0/125) of cases by CDD. There is no therapeutic-related pancreatitis in CDD. Sump syndrome was not also observed in side-to-side CDD. Conclusions This study is a first comparative study between end-to-side and side-to-side CDD. The surgical outcomes for CDD treatment of choledocholithiasis were acceptable. The incidence of reflux cholangitis, stone recurrence, pancreatitis and sump syndrome was very low.

Purpose: The surgical management of neonates with duodenal atresia (DA) involves re-establishment of intestinal continuity, either by duodeno-duodenostomy (DD) or by duodeno-jejunostomy (DJ). Although the majority of pediatric surgeons perform DD repair preferentially, we aimed to analyze the outcome of DA neonates treated with either surgical technique., Methods: Following ethical approval (REB:1000047737), we retrospectively reviewed the charts of all patients who underwent DA repair between 2004 and 2014. Patients with associated esophageal/intestinal atresias and/or anorectal malformations were excluded. Outcome measures included demographics (gender, gestational age, and birth weight), length of mechanical ventilation, time to first and full feed, length of hospital admission, weight at discharge (z-scores), and postoperative complications (anastomotic stricture/leak, adhesive obstruction, and need for re-laparotomy). Both DD and DJ groups were compared using parametric or non-parametric tests, with data presented as mean ± SD or median (interquartile range)., Results: During the study period, 92 neonates met the inclusion criteria. Of these, 47 (51%) had DD and 45 (49%) DJ repair. All procedures were performed open, apart from one laparoscopic DJ. Overall, DD and DJ groups had similar demographics. Likewise, we found no differences between the two groups for length of ventilation (p = 0.6), time to first feed (p = 0.5), time to full feed (p = 0.4), length of admission (p = 0.6), prokinetic use (p = 0.5), nor weight at discharge (p = 0.1). When the 30/92 (33%) patients with trisomy-21 (DD = 16, DJ = 14) were excluded from analysis, the groups still had similar weight at discharge (p = 0.2). Postoperative complication rate was not different between the two groups. One patient per group died, due to respiratory failure (DD) and sepsis (DJ)., Conclusions: This study demonstrates that in neonates with duodenal atresia, duodeno-duodenostomy and duodeno-jejunostomy have similar outcomes. These findings are relevant for surgeons who repair duodenal atresia laparoscopically, as duodeno-jejunostomy had equal clinical outcomes and may be easier to perform.

BACKGROUND The surgical technique used in pancreas transplant is essential for patient safety and graft survival, and problems exist with conventional strategies. When enteric exocrine drainage is performed, there is no method of immunologic monitoring other than direct graft pancreas biopsy. The most common cause of early graft failure is graft thrombosis, and adequate preventive and treatment strategies are unclear. To overcome these disadvantages, we suggest a modified surgical technique. MATERIAL AND METHODS Eleven patients underwent pancreas transplant with our modified technique. The modified surgical techniques are as follows: 1) graft duodenum was anastomosed with recipient duodenum to enable endoscopic immunological monitoring, and 2) the inferior vena cava was chosen for vascular anastomosis and a diamond-shaped patch was applied to prevent graft thrombosis. RESULTS No patient mortality or graft failure occurred. One case of partial thrombosis of the graft portal vein occurred, which did not affect graft condition, and resolved after heparin treatment. All patients were cured from diabetes mellitus. There were no cases of pancreatic rejection, but 2 cases of graft duodenal rejection occurred, which were adequately treated with steroid therapy. CONCLUSIONS This modified surgical technique for pancreas transplant represents a feasible method for preventing thrombosis and allows for direct graft monitoring through endoscopy.

Objective: To evaluate the feasibility of laparoscopic cholecystoduodenostomy in canine cadavers using barbed self-locking sutures., Study Design: In vivo experimental study., Animals: Fresh male Beagle cadavers (n=5)., Methods: Surgery was performed by a single veterinary surgeon. Dogs were placed in dorsal recumbency and 15° reverse Trendelenburg position. The surgical procedure was performed with four 5 mm entry ports and a 5 mm 30° telescope. The cholecystoduodenostomy technique included dissection, incision of the gallbladder, and lavage, followed by gallbladder transposition over the duodenum, incision of the duodenum, and anastomosis. The latter was performed with a 4-0 barbed self-locking suture (V-Loc ® 180). Subsequently, a leak test was performed by submerging the anastomosis in saline and insufflating air into the duodenum through a catheter. Total operative time and completion times for each procedural step were recorded., Results: The median total operative time was 151 minutes (range, 129-159). One conversion to open surgery occurred because of vascular hemorrhage. The 3 longest intraoperative steps were posterior wall anastomosis, gallbladder dissection, and anterior wall anastomosis. Intraoperative anastomotic leakage sites were identified in 3 of 5 dogs. Leaks were managed by placement of a single reinforcing conventional intracorporeal suture, which was adequate to obtain a watertight anastomosis., Conclusion: This technique cannot be recommended in clinical practice until further studies are performed and the technique is further refined., (© Copyright 2016 by The American College of Veterinary Surgeons.)

Background: Although delta-shaped gastroduodenostomy (DSGD) is used increasingly as an intracorporeal Billroth I anastomosis after distal gastrectomy, worries about anatomical distortion always exist in twisting stomach and making an oblique incision on duodenum. We developed a new method of intracorporeal gastroduodenostomy, the linear-shaped gastroduodenostomy (LSGD), in which anastomosis is done using endoscopic linear staplers only without any complicated rotation. In this report, we introduced LSGD and compared its short-term and long-term outcomes with DSGD., Methods: We analyzed 261 consecutive gastric cancer patients who underwent the intracorporeal gastroduodenostomy between January 2009 and May 2014 (LSGD: 190, DSGD: 71), retrospectively. All of them underwent a laparoscopic or robotic distal gastrectomy with regional lymph node dissection. Early surgical outcomes such as operation time, postoperative complications, days until soft diet began, length of hospital stay, and endoscopic findings in postoperative 6 and 12 months were evaluated., Results: Although the proportion of robotic approach and D2 lymphadenectomy were significantly higher in LSGD group, the rates for overall complications (13.2 % [LSGD] vs. 9.9 % [DSGD], p = 0.470) and major complications (5.8 vs. 5.6 %, p = 1.0) were similar between two groups. There were no differences in anastomotic bleeding (1.1 vs. 1.4 %, p = 1.0), stenosis (3.2 vs. 2.8 %, p = 1.0), and leakage (0.5 vs. 0.0 %, p = 1.0). Endoscopy performed 6 months postoperatively showed that residual food (p = 0.022), gastritis (p = 0.018), and bile reflux (42.0 vs. 63.2 %, p = 0.003) were significantly decreased in LSGD and there were no significant differences in postoperative 12 months., Conclusion: LSGD is an innovative reconstruction technique with comparable short-term outcomes to DSGD. In addition, reduced residual food, gastritis, and bile reflux were seen in LSGD.

Background: Laparoscopic total gastrectomy is not widely performed because of the difficulty of esophagojejunal reconstruction. This study analyzed complication rates of two different methods for reconstruction by a circular stapler after totally laparoscopic total gastrectomy (TLTG)., Methods: Between 2010 and 2014, clinical data of 19 patients who underwent TLTG for gastric adenocarcinoma were collected retrospectively. There were two methods to fix the anvil of a circular stapler into the distal esophagus: In the single-stapling technique (SST) group, Endo-PSI(II) was used for purse-suturing on the distal esophagus for reconstruction, and in the hemi-double-stapling technique (hemi-DST) group, the esophagus was cut by linear stapler with the entry hole of the anvil shaft opened after inserting the anvil tail. In both groups, surgical procedures were the same, except for the reconstruction., Results: All TLTGs were performed securely without mortality. Intracorporeal laparoscopic esophagojejunal anastomosis was performed successfully for all the patients. In the hemi-DST group, four patients experienced anastomotic stenosis, three of whom required endoscopic balloon dilation. In contrast, no stenosis was seen in the SST group (p = 0.033)., Conclusions: Anastomosis with SST is preferred to that with hemi-DST to minimize postoperative complications.

In addition to the poor prognosis associated with pancreatic adenocarcinoma, it can also lead to several other conditions including obstructive jaundice that can affect a patient's quality of life. This is a major concern in non-operative patients where palliation is considered the main therapeutic goal. Traditionally, there are several ways to pursue palliative biliary drainage including endoscopic methods, a variety of surgical procedures, and percutaneous techniques. Generally, endoscopic methods such as endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement are considered first-line therapies. Unfortunately, ERCP is not always possible due to several potential reasons. Although endoscopic ultrasound-guided biliary puncture has been well described for several years, there are limitations to its usefulness in biliary drainage, in part due to complication concerns. However, more recently a lumen-apposing, self-expandable fully covered metal stent has been employed for such situations. We describe two cases in which this type of stent was used in patients for palliative biliary drainage in pancreatic adenocarcinoma where standard ERCP was not feasible. In both cases, stent deployment was successful without immediate complications related to the procedure or the stent. Furthermore, the main goal of these therapies was palliation and in both cases the patient chose this procedure for quality of life reasons. In the future, randomized trials are needed to better define the long-term effectiveness and safety of these stents compared to more standard therapies.

Background and Study Aims: Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) has gained popularity as an alternative to percutaneous biliary drainage for patients in whom endoscopic retrograde cholangiopancreatography has failed. There are no previous studies comparing EUS-CDS with endoscopic transpapillary stenting (ETS) as first-line treatment for distal malignant obstruction. The aim of this study was to compare the clinical efficacy and safety of EUS-CDS and ETS as first-line treatment in patients with distal malignant biliary obstruction., Patients and Methods: A total of 82 patients with distal malignant biliary obstruction underwent initial biliary drainage using self-expandable metal stents at a tertiary care university hospital. ETS was performed between June 2009 and May 2012, and EUS-CDS was performed between May 2012 and March 2014. Clinical success rates, adverse event rates, and reintervention rates were retrospectively evaluated for EUS-CDS and ETS., Results: A total of 26 patients underwent EUS-CDS and 56 underwent ETS. Clinical success rates were equivalent between the groups (EUS-CDS 96.2 %, ETS 98.2 %; P = 0.54). The mean procedure time was significantly shorter with EUS-CDS than with ETS (19.7 vs. 30.2 minutes; P < 0.01). The rate of overall adverse events was not significantly different between the groups (EUS-CDS 26.9 %, ETS 35.7 %; P = 0.46). Post-procedural pancreatitis was only observed in the ETS group (0 % vs. 16.1 %; P = 0.03). The reintervention rate at 1 year was 16.6 % and 13.6 % for EUS-CDS and ETS, respectively (P = 0.50)., Conclusions: EUS-CDS performed by expert endoscopists was associated with a short procedure time and no risk of pancreatitis, and would therefore be feasible as a first-line treatment for patients with distal malignant biliary obstruction., (© Georg Thieme Verlag KG Stuttgart · New York.)