Endoscopic vs. laparoscopic gastrojejunostomy for duodenal obstruction: a randomized study in a porcine model

We read with interest the article by von Renteln et al. [1], which reported the feasibility of purely endoscopic gastrojejunostomy in a porcine model and further compared the endoscopic gastrojejunostomy with the laparoscopic technique, concluding that endoscopic anastomoses were comparable in size to laparoscopic ones (1.8 cm vs. 2.0 cm).

The innovative success of purely endoscopic gastrojejunostomy relied on two crucial improvements by the authors. First, the mesentery and antimesenteric side of the small-bowel loop were clearly exposed after being pulled into the stomach. Second, through the use of a transmesenteric Penrose drain, the target bowel loop was better stabilized for accurate opening of the small bowel without loss of anatomic orientation. As a result, in the 14 – to 16-day survival experiment, adequate relief of the manmade duodenal obstruction was achieved by purely endoscopic gastrojejunostomy. However, in both the laparoscopic and the endoscopic group anastomotic narrowing was observed, producing a final anastomotic size of about 2 cm, and concerns remain that the narrowing might have progressed given a longer survival period.

We think a yo-yo-like self-expanding metal stent with a 15-mm body and wide flanges such as described by van Hooft et al. [2] might be effective to prevent the anastomotic narrowing if delivered through the anastomosis. Van Hooft et al. used the yo-yo-like stent to maintain the size of the anastomosis created by a magnetic anastomosis device, but a fatal jejunal perforation at the distal end of the stent occurred in one of the 12 patients in that clinical trial, and hence the question of safety or design improvement of the yo-yo stent requires further study if it is to be considered for solving the anastomotic narrowing problem.

Purely endoscopic gastrojejunostomy has been shown to be feasible, but the serious complication of jejunal volvulus with subsequent ischemia occurred, and the endoscopic anastomosis was more time-consuming than its laparoscopic counterpart. However, these problems could very possibly be solved with further development of techniques and devices such as introducing a technique to accurately select an appropriate small-bowel loop or a more efficient suturing system.

• References

• 1 von Renteln D, Vassiliou MC, McKenna D et al. Endoscopic vs. laparoscopic gastrojejunostomy for duodenal obstruction: a randomized study in a porcine model. Endoscopy 2012; 44: 161-168
• 2 van Hooft JE, Vleggaar FP, Le Moine O et al. Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study. Gastrointest Endosc 2010; 72: 530-535