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Introduction: Gastro-jejunostomy tubes (GJT) are commonly used for enteral nutrition in patients with gastric feeding intolerance, gastroesophageal reflux, and those at high risk of aspiration. Complications are generally minor, however highly morbid complications exist, specifically in younger and smaller infants. Case presentation: A 12 month old male with a history of long gap esophageal atresia presented for management of refractory esophageal stricture and intolerance of enteral feeds. To improve his nutritional status and enteral tolerance, he underwent conversion of his gastrostomy tube to a GJT with fluoroscopic guidance. Eight days later, a computed tomography scan of the chest obtained for preoperative planning incidentally noted a splenic abscess containing the tip of the GJT. The patient was taken to the operating room where diagnostic laparoscopy revealed a small bowel perforation at the ligament of Treitz (LOT), with the tip of the GJT embedded within the spleen. The tube was removed, the abscess was debrided, and the small bowel repaired. He completed a post-operative course of intravenous antibiotics and recovered without further complications. Conclusion: While complications from GJTs are well described, this case uniquely highlights the risk of intestinal perforation from GJT, with a delayed and subtle presentation. We suggest that patients, specifically those under 12 months of age and weighing under 10 kg, be monitored closely for complications post-operatively, and the use of modified GJTs with jejunal limbs employing smaller/thinner feeding tubes that are placed well beyond LOT be strongly considered.

To compare circular stapler (CS) with linear stapler (LS) in a meta-analysis concerning operative time, anastomotic leaks, wound infections, strictures, and length of stay. Pubmed, Medline, and Scopus were searched for articles published since 2006. Four hundred and five articles were assessed, and 13 articles of which only one was a randomized controlled trial were included in all 49,331 patients from different regions of the world. The pooled analysis shows that operative time was shorter in LS than in CS (weighted mean difference 36.2 min; 95% CI 34.7–37.6.; p < 0.0001). No difference was seen concerning leaks or strictures. The relative risk (RR) of leakage after LS was 80% of the risk after CS; however, the 95% confidence interval (CI) showed overlap (0.58–1.11). The RR of anastomotic stricture after LS was 74% of the risk after CS; however, 95% CI (0.52–1.05) showed overlap. Wound infections were less common after LS than after CS; RR was 27% (95% CI 0.21–0.33). Length of stay (LOS) was 0.65 days shorter after LS than after CS (95% CI 0.51–0.78). LS compared with CS results in shorter operative time, less wound infections, and shorter length of stay, but no difference was seen concerning risks of leaks or strictures. [ABSTRACT FROM AUTHOR]

Objectives: During the postoperative phase of lung transplantation, the surgical creation of a gastro-jejunostomy (GJ) may be deemed necessary for patients with severe oesophageal dysmotility, prolonged oral intake difficulties stemming from use of a ventilator or marked malnutrition. We explored the effects of postoperative GJ tube on survival and bronchiolitis obliterans syndrome in lung transplant recipients., Methods: We retrospectively reviewed all lung transplants performed at our institution between 2011 and 2022. Propensity score matching was performed to match patients who required a GJ tube with control patients on a 1:1 ratio. The preoperative, operative and postoperative outcomes of the patients were evaluated., Results: After propensity score matching, 193 patients with GJ were compared to 193 patients without GJ. Patients with GJ had significantly higher rates of delayed chest closure (P = 0.007), and postoperative dialysis (P = 0.016), longer intensive care unit stays (P < 0.001), longer ventilator duration (P < 0.001), higher rates of pneumonia (P = 0.035) and higher rates of being treated for acute cellular rejection within 1 year of transplant (P = 0.008). Overall survival and freedom from bronchiolitis obliterans syndrome were not found to be significantly different between the matched groups (P = 0.09 and P = 0.3)., Conclusions: GJ tube placement during the postoperative phase of lung transplantation did not compromise patient survival or freedom from bronchiolitis obliterans syndrome although the results reflect more difficult and complicated cases. This study indicates that the GJ tube may be a useful option for enteral feeding., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Introduction Gastro-jejunostomy tubes (GJT) are commonly used for enteral nutrition in patients with gastric feeding intolerance, gastroesophageal reflux, and those at high risk of aspiration. Complications are generally minor, however highly morbid complications exist, specifically in younger and smaller infants. Case presentation A 12 month old male with a history of long gap esophageal atresia presented for management of refractory esophageal stricture and intolerance of enteral feeds. To improve his nutritional status and enteral tolerance, he underwent conversion of his gastrostomy tube to a GJT with fluoroscopic guidance. Eight days later, a computed tomography scan of the chest obtained for preoperative planning incidentally noted a splenic abscess containing the tip of the GJT. The patient was taken to the operating room where diagnostic laparoscopy revealed a small bowel perforation at the ligament of Treitz (LOT), with the tip of the GJT embedded within the spleen. The tube was removed, the abscess was debrided, and the small bowel repaired. He completed a post-operative course of intravenous antibiotics and recovered without further complications. Conclusion While complications from GJTs are well described, this case uniquely highlights the risk of intestinal perforation from GJT, with a delayed and subtle presentation. We suggest that patients, specifically those under 12 months of age and weighing under 10 kg, be monitored closely for complications post-operatively, and the use of modified GJTs with jejunal limbs employing smaller/thinner feeding tubes that are placed well beyond LOT be strongly considered. [ABSTRACT FROM AUTHOR]

Alteration in the upper digestive tract or pancreaticobiliary anatomy poses a challenge for successful endoscopic retrograde cholangiopancreatography (ERCP). The alterations can arise either after surgery or because of tumor or diverticulum. In this scenario, the papilla may be unreachable or difficult to cannulate. The situation is further compounded by the lack of dedicated instruments for such procedures. Endoscopic ultrasound–guided biliary intervention and device-assisted enteroscopy are 2 techniques that have been found to be useful for ERCP in patients with altered anatomy. The ability of endoscopic ultrasound to visualize the biliary tree and enteroscope to reach deep into the small intestine has proven to be useful for ERCP in patients with altered anatomy. The technical and functional success rates of both approaches are relatively high. However, they have been associated with complications that are higher than that associated with standard ERCP. This finding is likely related to the learning curve of these advanced therapeutic interventions. With improvement in devices, technique, and accessories, both procedures are emerging as viable alternatives to standard ERCP in patients with altered anatomy. [ABSTRACT FROM AUTHOR]

Jejunogastric intussusception is a rare complication of gastric surgery that is potentially life threatening if it is not diagnosed early. This condition is a surgical emergency and is most commonly seen after gastro-jejunostomy. The authors report a case of an elderly female patient who presented with hematemesis and abdominal pain. Endoscopic evaluation revealed prolapsed small bowel into the stomach which was subsequently reduced intra-operatively. She had an uneventful post operative stay. This entity is fatal without surgical intervention. Diagnostic modalities like CT scan and endoscopy are key in the management of this entity.

Introduction: The introduction of minimally invasive surgery and the use of laparoscopic techniques have significantly improved patient outcomes and have offered a new range of options for the restoration of intestinal continuity. Various reconstruction techniques have been described and various devices employed but none has been established as superior. This study evaluates our experience with, and modifications of, the orally inserted anvil (OrVil™). Methods: We conducted a prospective observational study on 72 consecutive patients who underwent OrVil™-assisted oesophago-gastric or oesophago-jejunal anastomosis between September 2010 and September 2013. We collected data including patient demographics, disease site, type of procedure, location of the anastomosis, involvement of resection margins and peri-operative complications. Results: Seventy-two patients were included in the study. Patient ages ranged from 45 to 92 years (median ± SD = 69 ± 10 years). Total gastrectomy with Roux-en-Y anastomosis was the most-commonly performed procedure ( n = 41; 57 %). R resection was achieved in 67 patients (93 %). There were no Orvil™-related clinical leaks during the study period, and just two patients (2.8 %) demonstrated radiological evidence of leak, both of whom were managed conservatively. There were three in-hospital mortalities during the study period; these were unrelated to the anastomotic technique. Conclusion: Despite a steep learning curve, the OrVil™ device is safe and reliable. It also permits the creation of higher trans-hiatal anastomoses without resorting to thoracotomy in high-risk patients with cardia tumours. Certain shortcomings of the device, that had implications for patient safety, were identified and addressed by intra-operative modification during the study period. We commend the use of a prepared OrVil™ device, as a game changer, for upper gastrointestinal reconstruction. [ABSTRACT FROM AUTHOR]

Abstract: Natural orifice transluminal endoscopic surgery (NOTES) is a new concept that attempts to reduce the impact of surgery on the patient. In surgical oncology several studies have already revealed that a minimally invasive approach provides at least the same, if not a better, long-term outcome. One could hypothesize that a less invasive approach such as NOTES could further enhance such advantages. Since its initial description, NOTES has become clinical reality and today nearly every organ is accessible by a transluminal approach, in at least the experimental setting. Subsequent to published research, first clinical studies on NOTES in oncology were reported and the accuracy of transgastric peritoneoscopy for staging of pancreas cancer was shown to be similar to laparoscopy in humans. A NOTES gastro-jejunostomy via transgastric access has also been proposed to decrease invasiveness of palliative treatment of duodenal, biliary and pancreatic cancers. Colorectal cancer resection via transanal access would offer a clear-cut patient advantage over laparoscopic and would not be subject to the frequent criticism of violating an innocent second organ, as the colon or rectum is always breached in a colectomy. Natural orifice endoluminal therapies, such as endoscopic submucosal dissection, already have been clinically applied for several years. Improved techniques or instruments evolving from NOTES technology might enhance its widespread use for the treatment of early malignancies and thereby again will provide a tremendous benefit for the patient. Although still somewhat controversial, the subject of natural orifice surgery in oncological disease indicates that current laboratory efforts to introduce NOTES into cancer surgery could be ready for cautious clinical investigations. The final determination of patient benefit will need well-constructed prospective study. [Copyright &y& Elsevier]

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A simplified technique to create the gastro-jejunostomy in an open Roux-en-Y gastric bypass is described. The technique of crossing over circular staple-lines with linear hand-sewn suture-lines instead of the traditional purse-string technique, is depicted. The non purse-string technique has been used in 1,928 cases of mini-open Roux-en-Y gastric bypass with only 2 leaks, an incidence of 0.1%. Weight loss and resolution of co-morbidities have been similar to reports by other investigators. [ABSTRACT FROM AUTHOR]

Background: Variations in technique of laparoscopic Roux-en-Y gastric bypass (LRYGBP) have been reported. These changes, mainly in the construction of the gastro-jejunostomy, are intended to decrease complications. Methods: 1,000 consecutive LRYGBPs were performed using the Total Stapled Total Intra-abdominal (TSTI) technique antecolic and antegastric approach. Technical details and results, including perioperative morbidity and mortality, are reported. Results: Although the correction or improvement of the most serious co-morbidities with the use of the TSTI technique were similar to results reported by other gastric bypass surgeons, we noted a considerable difference in the development of leaks using this surgical approach. Current literature on gastric bypass reports a 2-5% incidence of leaks. Using the TSTI approach, the incidence of leaks at our facility was 0.1% (one in 1,000 cases). After analysis of the factors involved, it was concluded that the use of the antecolic and antegastric approach in gastric bypass, as described in the TSTI,should be an important consideration by the surgeon.This technique, which uses a circular stapler, was found to be easy to perform while maintaining a reproducible, controlled opening of the anastomosis. Conclusion: Although this was a non-randomized study, the results found a considerable improvement in the incidence of morbidity and mortality, and a remarkable decrease in the frequency of leaks. [ABSTRACT FROM AUTHOR]

Synchronous biliary and duodenal malignant obstruction is a challenging endoscopic scenario in patients affected with ampullary, peri-ampullary, and pancreatic head neoplasia. Surgical bypass is no longer the gold-standard therapy for these patients, as simultaneous endoscopic biliary and duodenal stenting is currently a feasible and widely used technique, with a high technical success in expert hands. In recent years, endoscopic ultrasonography (EUS) has evolved from a diagnostic to a therapeutic procedure, and is now increasingly used to guide biliary drainage, especially in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). The advent of lumen-apposing metal stents (LAMS) has expanded EUS therapeutic options, and changed the management of synchronous bilioduodenal stenosis. The most recent literature regarding endoscopic treatments for synchronous biliary and duodenal malignant stenosis has been reviewed to determine the best endoscopic approach, also considering the advent of an interventional EUS approach using LAMS., Competing Interests: Conflict-of-interest statement: No conflict of interest to declare.