Endoscopic ultrasound-guided gastroenterostomy using large-diameter (20 mm) lumen apposing metal stent (LLAMS)

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20 mm) LAMS (LLAMS). Patients and methods A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94 %) (mean age: 61.35 ± 16.52 years; 54.84 % males) underwent EUS-GE using LLAMS for malignant (n = 23) and benign (n = 8) GOO. Technical success was achieved in all patients (100 %) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55 % of patients (n = 29). Two patients (6.45 %) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84 ± 160.41 days (median 70, range 4–590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23 %) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.

Jejunal Ulcer Caused by Schistosoma japonicum

Intestinal schistosomiasis can be caused by the trematodes Schistosoma japonicum that mainly exists in East Asia or the S. mansoni in Africa and South America. The adult worms of S. japonicum live in the mesenteric veins and excrete eggs that circulate to the liver and colon; the eggs migrate through the intestinal wall and pass out with the stool. Here, we report a case of jejunal ulcer caused by the infection of Schistosoma japonicum. A 63-year-old woman from Wuhan, China, was admitted with left quadrant abdominal pain and weight loss for more than 6 months. The patient’s computerized tomography reported cirrhotic liver changes, jejunal wall edema, and narrowed lumen; the upper enteroscopy corroborated these findings with the presence of several jejunal ulcers and edema. The pathology report showed chronic inflammation with ulcerative changes and S. japonicum eggs deposition. Schistosomiasis is one of the neglected tropical diseases that affect the poorest. Although a great improvement has been made to control it, there is a lot of work that remains to be fulfilled.

RARE PRIMARY SMALL BOWEL TUMOR IN THE FORM OF CLASSIC KAPOSI’S SARCOMA: CASE PRESENTATION

The small bowel represents a rare site for primary neoplasms, with an incidence of less than 2% ofall that are located in the digestive tract. The early diagnosis of these tumors is often difficult due tothe lack of specificity of the clinical presentation, but it can make a difference in matters of 5-yearsurvival rates: 83% (early detection) versus 14% (late detection). We present the case of a malepatient, aged 66, with an apparently benign jejunal ulcer diagnosed endoscopically. Clinicalpresentation: diffuse abdominal pain, fatigability, melena; paraclinical evaluation: anemia,positive occult gastrointestinal bleeding test, superior and inferior endoscopy withouthemorrhagic lesions. The surgical exploration guided by intramucosal dye discovers a 2 cmtumor, 250 cm distal to the angle of Treitz with multiple mesenteric adenopathies. Segmentalresection is performed keeping oncological safety margins with the removal of the lymphaticdrainage elements. The postoperative evolution is favorable and leads to complete healing. Thehistopathological assay finds pathological changes consistent for Kaposi’s sarcoma and confirmsthe presence of HHV-8 in the nuclei of the tumor cells by means of immunohistochemistry. At theexamination of the skin, multiple purple patches were discovered. The particularity of this case isthat the Kaposi’s sarcoma manifests itself in the absence of an immunosuppressive treatment or animmunodeficiency state induced by an HIV infection. Although rare, the small intestine tumorsshould be considered when non-specific abdominal pain is accompanied by positive occult bleedingtest, with scarce endoscopic evidence. Since the Kaposi’s sarcoma is a highly angiogenic tumor, itis prudent to include it in the differential diagnosis when suspecting a source of gastrointestinalbleeding.