Introduction: Necrotizing pancreatitis management is complex and varies significantly among clinicians. Minimally invasive approaches like transgastric necrosectomy via laparoscopy are emerging as effective treatment ...Introduction: Necrotizing pancreatitis management is complex and varies significantly among clinicians. Minimally invasive approaches like transgastric necrosectomy via laparoscopy are emerging as effective treatment options. This case report underscores the technique’s efficacy, clinical outcomes, and role in reducing complications. Clinical Observation: A 59-year-old male with a history of smoking and alcoholism presented with severe abdominal pain, nausea, and vomiting. Over the following weeks, he developed symptoms including asthenia, weight loss, and melena. Diagnostic workup revealed severe anemia and Balthazar E necrotizing pancreatitis, with significant intra-abdominal fluid collections and signs of infection. After initial conservative management, the patient underwent transgastric necrosectomy via laparoscopy due to deteriorating clinical status. The procedure involved removing necrotic tissue and performing a cystogastroanastomosis and jejunostomy. Postoperative care included fasting, parenteral nutrition, broad-spectrum antibiotics, and enzymatic replacement. The patient recovered well, with reduced necrotic tissue on follow-up imaging, and was discharged twelve days post-surgery [1]. Conclusion: Transgastric necrosectomy by laparoscopy is a valuable first-line surgical option for patients with symptomatic necrotizing pancreatitis, particularly in cases without prior interventions. This minimally invasive technique helps reduce major complications and mortality, offering a less invasive alternative to traditional open necrosectomy. The multidisciplinary approach and careful postoperative management were crucial to the patient’s favorable outcome. The case highlights the potential of transgastric necrosectomy as an effective treatment strategy in managing complex pancreatitis cases, including those with associated duodenal perforation [2].展开更多
Background The infection risk of natural orifice transluminal endoscopic surgery （NOTES） is of concern. The aim of this study was to assess the safety of NOTES by investigating the intraperitoneal bacterial load dur...Background The infection risk of natural orifice transluminal endoscopic surgery （NOTES） is of concern. The aim of this study was to assess the safety of NOTES by investigating the intraperitoneal bacterial load during transgastric and transvaginal procedures with antiseptic or controling perioperative preparation.Methods Forty-five female pigs were randomly assigned to five equal groups： the transgastric （TG） control group （group A）, the TG middle volume gastric lavage group （group B）, the TG high volume lavage group （group C）, the transvaginal （TV） control group （group D） and the TV study group （group E）. The study groups received gastric or vaginal lavage and abdominal antimicrobial irrigation, while the control groups received neither. All animals were administered intravenous antibiotics, underwent NOTES peritoneoscopy and transumbilical laparoscopic cholecystectomy under NOTES view with sterile instruments. The viscerotomy was closed by laparoscopic suture. The animals were observed until necropsy was performed 14 days postoperatively. Quantitative bacteriologic cultures were taken from the gastric or vaginal aspirate before and after lavage; peritoneal fluid was collected before and after peritoneal irrigation and at necropsy. Results The surgical procedures were completed for all the pigs and all of them survived. The mean operative time of the TG group and the TV group was （81±27） minutes and （66±12） minutes, respectively. All animals survived for 14 days.At necropsy, significantly more peritoneal infections were noted in group A than in group D （5：9 vs. 0：9; P 〈0.05）. Nogross evidence of intra-peritoneal infection was found in groups B, C, D and E. Bacteriological evidence was seen in all pigs in group A, 7 pigs in group B, 6 pigs in group D, and none in groups C and E.Conclusions Without gastric or vaginal lavage and antibiotic peritoneal irrigation, the TG procedure has a higher infection rate than the TV access. After antiseptic preparation, the b展开更多
A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer.Endoscopic submucosal dissection(ESD)was successfully performed for complete resection ...A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer.Endoscopic submucosal dissection(ESD)was successfully performed for complete resection of the tumor.On the first post-ESD day,the patient suddenly complained of abdominal pain after an episode of vomiting.Abdominal computed tomography(CT)showed delayed perforation after ESD.The patient was conservatively treated with an intravenous proton pump inhibitor and antibiotics.On the fifth post-ESD day,CT revealed a gastric wall abscess in the gastric body.Gastroscopy revealed a gastric fistula at the edge of the post-ESD ulcer,and pus was found flowing into the stomach.An intradrainage stent and an extradrainage nasocystic catheter were successfully inserted into the abscess for endoscopic transgastric drainage.After the procedure,the clinical symptoms and laboratory test results improved quickly.Two months later,a follow-up CT scan showed no collection of pus.Consequently,the intradrainage stent was removed.Although the gastric wall abscess recurred 2 wk after stent removal,it recovered soon after endoscopic transgastric drainage.Finally,after stent removal and oral antibiotic treatment for 1 mo,no recurrence of the gastric wall abscess was found.展开更多
BACKGROUND Percutaneous drainage(PCD)and endoscopic approaches have largely replaced surgical drainage as the initial approach for(peri)pancreatic fluid collections(PFC)s,while complications associated with endoscopic...BACKGROUND Percutaneous drainage(PCD)and endoscopic approaches have largely replaced surgical drainage as the initial approach for(peri)pancreatic fluid collections(PFC)s,while complications associated with endoscopic stent implantation are common.AIM To introduce a novel endoscopic therapy named endoscopic transgastric fenestration(ETGF),which involves resection of tissue by endoscopic accessory between gastric and PFCs without stent implantation,and to evaluate its efficacy and safety compared with PCD for the management of PFCs adjacent to the gastric wall.METHODS Patients diagnosed with PFCs adjacent to the gastric wall and who subsequently received ETGF or PCD were restrospectively enrolled.Indications for intervention were consistent with related guidelines.We analyzed patients baseline characteristics,technical and clinical success rate,recurrence and reintervention rate,procedure-related complications and adverse events.RESULTS Seventy-two eligible patients were retrospectively identified(ETGF=34,PCD=38)from October 2017 to May 2021.Patients in the ETGF group had a significantly higher clinical success rate than those in the PCD group(97.1 vs 76.3%,P=0.01).There were no statistically significant differences regarding recurrence,reintervention and incidence of complication between the two groups.While long-term catheter drainage was very common in the PCD group.CONCLUSION Compared with PCD,ETGF has a higher clinical success rate in the management of PFCs adjacent to the gastric wall.ETGF is an alternative effective strategy for the treatment of PFCs adjacent to the gastric wall.展开更多
Minimally invasive surgery started spreading worldwide in 1987,when the first laparoscopic cholecystectomy was performed.Meanwhile,improvement of endoscopic equipment and instruments allowed gastroenterologists to att...Minimally invasive surgery started spreading worldwide in 1987,when the first laparoscopic cholecystectomy was performed.Meanwhile,improvement of endoscopic equipment and instruments allowed gastroenterologists to attempt more aggressive endoluminal interventions,even beyond the wall barrier.The first transgastric peri-toneoscopy,in 2004,brought to light the concept of natural orifice transluminal endoscopic surgery(NOTES).The idea of incisionless surgery is attractive and has become a new goal for both surgeons and other people interested in this field of investigation.The authors present a review of all developments concerning NOTES,including animal studies and human experience.展开更多
BACKGROUND Endoscopic ultrasound guided gallbladder drainage(EUS-GBD)is being increasingly used in practice(either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patient...BACKGROUND Endoscopic ultrasound guided gallbladder drainage(EUS-GBD)is being increasingly used in practice(either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients).Stents are used to create a conduit between the lumen of the gallbladder(GB)and the intestinal lumen through the gastric or enteric routes.Among the various types of stents used,cautery-enhanced lumen apposing metallic stents(LAMS)may be associated with fewer adverse events(AEs).AIM To compare the clinical success,technical success,and rate of AEs between transgastric(TG)and trans-enteric[transduodenal(TD)/transjejunal(TJ)]approach to GB drainage.Further,we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.METHODS Study was registered in PROSPERO(CRD42022319019)and comprehensive literature review was conducted.Manuscripts were reviewed for the data collection:Rate of AEs,clinical success,and technical success.Random effects model was utilized for the analysis.RESULTS No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches(P>0.05)were noted.There was no statistically significant difference in the rate of AEs when comparing two-arm studies only.However,when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach.When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS,a statistically significant difference in the rate of AEs was observed when all the studies were included,with the rate being higher in non-cautery enhanced stents(14.0%vs 37.8%;P<0.01).CONCLUSION As per our study results,TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD.Additionally,use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS.Though the approach chosen depends on several patient and physician factors,the above fi展开更多
Endoscopic retrograde cholangiopancreatography(ERCP)is the mainstay procedure of choice for management of obstructive biliary disease.While ERCP is widely performed with high success rates,the procedure is not feasibl...Endoscopic retrograde cholangiopancreatography(ERCP)is the mainstay procedure of choice for management of obstructive biliary disease.While ERCP is widely performed with high success rates,the procedure is not feasible in every patient such as cases of non-accessible papilla.In the setting of unsuccessful ERCP,endoscopic ultrasound-guided biliary drainage(EUS-BD)has become a promising alternative to surgical bypass and percutaneous biliary drainage(PTBD).A variety of different forms of EUS-BD have been described,allowing for both intrahepatic and extrahepatic approaches.Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage,with fewer adverse events when compared to PTBD.Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure.The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists.The aim of our review is to highlight the different EUSguided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.展开更多
BACKGROUND Natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving surgery by flexible endoscopy is an emerging technology.However,the gallbladder fails to obtain traction and positioning function...BACKGROUND Natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving surgery by flexible endoscopy is an emerging technology.However,the gallbladder fails to obtain traction and positioning functions during the operation.AIM To evaluate the feasibility and safety of a new surgical method,“snare-assisted pure NOTES gallbladder-preserving surgery”.METHODS Eight miniature pigs were randomly divided into the experimental group[NOTES gallbladder-preserving surgery using the snare device,snare assisted(SA)]and the control group(NOTES gallbladder-preserving surgery without using the snare device,NC),with four cases in each group.The differences between the two groups of animals in operating time,operating workload,complications,adverse events,white blood cells,and liver function were determined.RESULTS No differences were found in the surgical success rate,gallbladder incision closure,white blood cell count,or liver function between the two groups.The total operating time,gallbladder incision blood loss,gallbladder disorientation time,gallbladder incision closure time,and workload scores on the National Aeronautics and Space Administration-Task Load Index were significantly reduced in the SA group(P<0.05).CONCLUSION These results indicated that snare-assisted pure NOTES gallbladder-preservation surgery using standard endoscopic instruments reduced the difficulty of operation,shortened operation time,and did not increase complications in pigs.A new method for pure NOTES gallbladder-preservation surgery was provided.展开更多
BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery.Furthermore,acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previous...BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery.Furthermore,acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously.Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach.Traditionally,this necessitates surgical intervention.Recently,however,the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension,nausea,and melena of two days duration.His imaging illustrated a massively distended stomach.A nasogastric tube did not result in drainage of fluid or decompression of his abdomen.His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended"fluid"-filled gastric remnant.An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant.Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum.The patient underwent emergent angiography with embolization of the gastroduodenal artery.He was discharged with a stable hemoglobin level and resolution of symptoms.Healing superficial gastric ulcers were visualized on a follow-up endoscopy.Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated,and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound directed transgastric intervention.展开更多
文摘Introduction: Necrotizing pancreatitis management is complex and varies significantly among clinicians. Minimally invasive approaches like transgastric necrosectomy via laparoscopy are emerging as effective treatment options. This case report underscores the technique’s efficacy, clinical outcomes, and role in reducing complications. Clinical Observation: A 59-year-old male with a history of smoking and alcoholism presented with severe abdominal pain, nausea, and vomiting. Over the following weeks, he developed symptoms including asthenia, weight loss, and melena. Diagnostic workup revealed severe anemia and Balthazar E necrotizing pancreatitis, with significant intra-abdominal fluid collections and signs of infection. After initial conservative management, the patient underwent transgastric necrosectomy via laparoscopy due to deteriorating clinical status. The procedure involved removing necrotic tissue and performing a cystogastroanastomosis and jejunostomy. Postoperative care included fasting, parenteral nutrition, broad-spectrum antibiotics, and enzymatic replacement. The patient recovered well, with reduced necrotic tissue on follow-up imaging, and was discharged twelve days post-surgery [1]. Conclusion: Transgastric necrosectomy by laparoscopy is a valuable first-line surgical option for patients with symptomatic necrotizing pancreatitis, particularly in cases without prior interventions. This minimally invasive technique helps reduce major complications and mortality, offering a less invasive alternative to traditional open necrosectomy. The multidisciplinary approach and careful postoperative management were crucial to the patient’s favorable outcome. The case highlights the potential of transgastric necrosectomy as an effective treatment strategy in managing complex pancreatitis cases, including those with associated duodenal perforation [2].
文摘Background The infection risk of natural orifice transluminal endoscopic surgery （NOTES） is of concern. The aim of this study was to assess the safety of NOTES by investigating the intraperitoneal bacterial load during transgastric and transvaginal procedures with antiseptic or controling perioperative preparation.Methods Forty-five female pigs were randomly assigned to five equal groups： the transgastric （TG） control group （group A）, the TG middle volume gastric lavage group （group B）, the TG high volume lavage group （group C）, the transvaginal （TV） control group （group D） and the TV study group （group E）. The study groups received gastric or vaginal lavage and abdominal antimicrobial irrigation, while the control groups received neither. All animals were administered intravenous antibiotics, underwent NOTES peritoneoscopy and transumbilical laparoscopic cholecystectomy under NOTES view with sterile instruments. The viscerotomy was closed by laparoscopic suture. The animals were observed until necropsy was performed 14 days postoperatively. Quantitative bacteriologic cultures were taken from the gastric or vaginal aspirate before and after lavage; peritoneal fluid was collected before and after peritoneal irrigation and at necropsy. Results The surgical procedures were completed for all the pigs and all of them survived. The mean operative time of the TG group and the TV group was （81±27） minutes and （66±12） minutes, respectively. All animals survived for 14 days.At necropsy, significantly more peritoneal infections were noted in group A than in group D （5：9 vs. 0：9; P 〈0.05）. Nogross evidence of intra-peritoneal infection was found in groups B, C, D and E. Bacteriological evidence was seen in all pigs in group A, 7 pigs in group B, 6 pigs in group D, and none in groups C and E.Conclusions Without gastric or vaginal lavage and antibiotic peritoneal irrigation, the TG procedure has a higher infection rate than the TV access. After antiseptic preparation, the b
文摘A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer.Endoscopic submucosal dissection(ESD)was successfully performed for complete resection of the tumor.On the first post-ESD day,the patient suddenly complained of abdominal pain after an episode of vomiting.Abdominal computed tomography(CT)showed delayed perforation after ESD.The patient was conservatively treated with an intravenous proton pump inhibitor and antibiotics.On the fifth post-ESD day,CT revealed a gastric wall abscess in the gastric body.Gastroscopy revealed a gastric fistula at the edge of the post-ESD ulcer,and pus was found flowing into the stomach.An intradrainage stent and an extradrainage nasocystic catheter were successfully inserted into the abscess for endoscopic transgastric drainage.After the procedure,the clinical symptoms and laboratory test results improved quickly.Two months later,a follow-up CT scan showed no collection of pus.Consequently,the intradrainage stent was removed.Although the gastric wall abscess recurred 2 wk after stent removal,it recovered soon after endoscopic transgastric drainage.Finally,after stent removal and oral antibiotic treatment for 1 mo,no recurrence of the gastric wall abscess was found.
基金Zhongyuan Talent Program,No.ZYYCYU202012113The Key R and D Program of Henan Province,No.222102310038.
文摘BACKGROUND Percutaneous drainage(PCD)and endoscopic approaches have largely replaced surgical drainage as the initial approach for(peri)pancreatic fluid collections(PFC)s,while complications associated with endoscopic stent implantation are common.AIM To introduce a novel endoscopic therapy named endoscopic transgastric fenestration(ETGF),which involves resection of tissue by endoscopic accessory between gastric and PFCs without stent implantation,and to evaluate its efficacy and safety compared with PCD for the management of PFCs adjacent to the gastric wall.METHODS Patients diagnosed with PFCs adjacent to the gastric wall and who subsequently received ETGF or PCD were restrospectively enrolled.Indications for intervention were consistent with related guidelines.We analyzed patients baseline characteristics,technical and clinical success rate,recurrence and reintervention rate,procedure-related complications and adverse events.RESULTS Seventy-two eligible patients were retrospectively identified(ETGF=34,PCD=38)from October 2017 to May 2021.Patients in the ETGF group had a significantly higher clinical success rate than those in the PCD group(97.1 vs 76.3%,P=0.01).There were no statistically significant differences regarding recurrence,reintervention and incidence of complication between the two groups.While long-term catheter drainage was very common in the PCD group.CONCLUSION Compared with PCD,ETGF has a higher clinical success rate in the management of PFCs adjacent to the gastric wall.ETGF is an alternative effective strategy for the treatment of PFCs adjacent to the gastric wall.
文摘Minimally invasive surgery started spreading worldwide in 1987,when the first laparoscopic cholecystectomy was performed.Meanwhile,improvement of endoscopic equipment and instruments allowed gastroenterologists to attempt more aggressive endoluminal interventions,even beyond the wall barrier.The first transgastric peri-toneoscopy,in 2004,brought to light the concept of natural orifice transluminal endoscopic surgery(NOTES).The idea of incisionless surgery is attractive and has become a new goal for both surgeons and other people interested in this field of investigation.The authors present a review of all developments concerning NOTES,including animal studies and human experience.
基金The authors have read the PRISMA 2009 Checklist,and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
文摘BACKGROUND Endoscopic ultrasound guided gallbladder drainage(EUS-GBD)is being increasingly used in practice(either as a bridge to cholecystectomy in high-risk patients or as destination therapy in non-surgical patients).Stents are used to create a conduit between the lumen of the gallbladder(GB)and the intestinal lumen through the gastric or enteric routes.Among the various types of stents used,cautery-enhanced lumen apposing metallic stents(LAMS)may be associated with fewer adverse events(AEs).AIM To compare the clinical success,technical success,and rate of AEs between transgastric(TG)and trans-enteric[transduodenal(TD)/transjejunal(TJ)]approach to GB drainage.Further,we analyzed whether using cautery enhanced stents during EUS-GBD impacts the above parameters.METHODS Study was registered in PROSPERO(CRD42022319019)and comprehensive literature review was conducted.Manuscripts were reviewed for the data collection:Rate of AEs,clinical success,and technical success.Random effects model was utilized for the analysis.RESULTS No statistically significant difference in clinical and technical success between the TD/TJ and TG approaches(P>0.05)were noted.There was no statistically significant difference in the rate of AEs when comparing two-arm studies only.However,when all studies were included in the analysis difference was almost significant favoring the TD/TJ approach.When comparing cautery-enhanced LAMS with non-cautery enhanced LAMS,a statistically significant difference in the rate of AEs was observed when all the studies were included,with the rate being higher in non-cautery enhanced stents(14.0%vs 37.8%;P<0.01).CONCLUSION As per our study results,TD/TJ approach appears to be associated with lower rate of adverse events and comparable efficacy when compared to the TG approach for the EUS-GBD.Additionally,use of cautery-enhanced LAMS for EUS-GBD is associated with a more favorable adverse event profile compared to cold LAMS.Though the approach chosen depends on several patient and physician factors,the above fi
文摘Endoscopic retrograde cholangiopancreatography(ERCP)is the mainstay procedure of choice for management of obstructive biliary disease.While ERCP is widely performed with high success rates,the procedure is not feasible in every patient such as cases of non-accessible papilla.In the setting of unsuccessful ERCP,endoscopic ultrasound-guided biliary drainage(EUS-BD)has become a promising alternative to surgical bypass and percutaneous biliary drainage(PTBD).A variety of different forms of EUS-BD have been described,allowing for both intrahepatic and extrahepatic approaches.Recent studies have reported high success rates utilizing EUS-BD for both transpapillary and transluminal drainage,with fewer adverse events when compared to PTBD.Advancements in novel technologies designed specifically for EUS-BD have led to increased success rates as well as improved safety profile for the procedure.The techniques of EUS-BD are yet to be fully standardized and are currently performed by highly trained advanced endoscopists.The aim of our review is to highlight the different EUSguided interventions for achieving biliary drainage and to both assess the progress that has been made in the field as well as consider what the future may hold.
基金Supported by National Natural Science Foundation of China,No. 82060104Construction of Guangxi Clinical Medical Research Center for Digestive Diseases,No. AD17129027
文摘BACKGROUND Natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving surgery by flexible endoscopy is an emerging technology.However,the gallbladder fails to obtain traction and positioning functions during the operation.AIM To evaluate the feasibility and safety of a new surgical method,“snare-assisted pure NOTES gallbladder-preserving surgery”.METHODS Eight miniature pigs were randomly divided into the experimental group[NOTES gallbladder-preserving surgery using the snare device,snare assisted(SA)]and the control group(NOTES gallbladder-preserving surgery without using the snare device,NC),with four cases in each group.The differences between the two groups of animals in operating time,operating workload,complications,adverse events,white blood cells,and liver function were determined.RESULTS No differences were found in the surgical success rate,gallbladder incision closure,white blood cell count,or liver function between the two groups.The total operating time,gallbladder incision blood loss,gallbladder disorientation time,gallbladder incision closure time,and workload scores on the National Aeronautics and Space Administration-Task Load Index were significantly reduced in the SA group(P<0.05).CONCLUSION These results indicated that snare-assisted pure NOTES gallbladder-preservation surgery using standard endoscopic instruments reduced the difficulty of operation,shortened operation time,and did not increase complications in pigs.A new method for pure NOTES gallbladder-preservation surgery was provided.
文摘BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery.Furthermore,acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously.Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach.Traditionally,this necessitates surgical intervention.Recently,however,the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension,nausea,and melena of two days duration.His imaging illustrated a massively distended stomach.A nasogastric tube did not result in drainage of fluid or decompression of his abdomen.His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended"fluid"-filled gastric remnant.An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant.Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum.The patient underwent emergent angiography with embolization of the gastroduodenal artery.He was discharged with a stable hemoglobin level and resolution of symptoms.Healing superficial gastric ulcers were visualized on a follow-up endoscopy.Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated,and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound directed transgastric intervention.
