Complete malignant gastro-duodenal outlet obstruction and direct endoscopic ultrasound-guided gastroenterostomy

Gornals, Joan B.; Luna-Rodriguez, Dani
doi:10.1016/j.gastre.2024.04.021
 array:23 [
  "pii" => "S2444382424000889"
  "issn" => "24443824"
  "doi" => "10.1016/j.gastre.2024.04.021"
  "estado" => "S300"
  "fechaPublicacion" => "2024-06-01"
  "aid" => "2123"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;. All rights reserved"
  "copyrightAnyo" => "2023"
  "documento" => "simple-article"
  "crossmark" => 1
  "subdocumento" => "crp"
  "cita" => "Gastroenterol Hepatol. 2024;47:622-4"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:1 [
    "total" => 0
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S2444382424000890"
    "issn" => "24443824"
    "doi" => "10.1016/j.gastre.2024.04.022"
    "estado" => "S300"
    "fechaPublicacion" => "2024-06-01"
    "aid" => "2152"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "sco"
    "cita" => "Gastroenterol Hepatol. 2024;47:625-6"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Image of the month</span>"
      "titulo" => "Enteric infection by <span class="elsevierStyleItalic">Mycobacterium avium</span>"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "625"
          "paginaFinal" => "626"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Infecci&#243;n ent&#233;rica por <span class="elsevierStyleItalic">Mycobacterium avium</span>"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1444
              "Ancho" => 1642
              "Tamanyo" => 263404
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0005"
              "detalle" => "Figure "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Gastroscopy&#46; Multiple yellowish-white oval plaques in the second part of the duodenum&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Laura Andr&#233;s Pascual, Sara Garc&#237;a Mor&#225;n, Gadea Hontoria Bautista, Teresa Lista Araujo, Cristina Labayru Echeverr&#237;a, Manuel Alfonso Jim&#233;nez Moreno, Luis Buz&#243;n Mart&#237;n"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "Laura"
              "apellidos" => "Andr&#233;s Pascual"
            ]
            1 => array:2 [
              "nombre" => "Sara"
              "apellidos" => "Garc&#237;a Mor&#225;n"
            ]
            2 => array:2 [
              "nombre" => "Gadea"
              "apellidos" => "Hontoria Bautista"
            ]
            3 => array:2 [
              "nombre" => "Teresa"
              "apellidos" => "Lista Araujo"
            ]
            4 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Labayru Echeverr&#237;a"
            ]
            5 => array:2 [
              "nombre" => "Manuel Alfonso"
              "apellidos" => "Jim&#233;nez Moreno"
            ]
            6 => array:2 [
              "nombre" => "Luis"
              "apellidos" => "Buz&#243;n Mart&#237;n"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0210570523005046"
        "doi" => "10.1016/j.gastrohep.2023.12.010"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570523005046?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000890?idApp=UINPBA00004N"
    "url" => "/24443824/0000004700000006/v2_202409200854/S2444382424000890/v2_202409200854/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S2444382424000877"
    "issn" => "24443824"
    "doi" => "10.1016/j.gastre.2024.04.020"
    "estado" => "S300"
    "fechaPublicacion" => "2024-06-01"
    "aid" => "2118"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46;U&#46;"
    "documento" => "simple-article"
    "crossmark" => 1
    "subdocumento" => "crp"
    "cita" => "Gastroenterol Hepatol. 2024;47:620-2"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:1 [
      "total" => 0
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>"
      "titulo" => "Complete tumor response after concomitant treatment with lenvatinib and radioembolization with Ytrio-90 of advanced stage hepatocarcinoma"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "620"
          "paginaFinal" => "622"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Respuesta tumoral completa tras el tratamiento concomitante con lenvatinib y radioembolizaci&#243;n con Ytrio-90 de un hepatocarcinoma en estadio avanzado"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:8 [
          "identificador" => "fig0005"
          "etiqueta" => "Figure 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1387
              "Ancho" => 1605
              "Tamanyo" => 316736
            ]
          ]
          "detalles" => array:1 [
            0 => array:3 [
              "identificador" => "at0005"
              "detalle" => "Figure "
              "rol" => "short"
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; Multimodal CT image with intravenous contrast &#40;June 2022&#41;&#58; arterial &#40;A&#41;&#44; portal &#40;P&#41; and late &#40;T&#41; phases&#46; Tumour thrombus in the right posterior portal branch with uptake and lavage&#59; &#40;b&#41; SPECT-CT axial section image &#40;September 2022&#41;&#46; The radiopharmaceutical is deposited at the site of the tumour thrombus&#59; &#40;c&#41; Multimodal contrast-enhanced CT image post-radioembolisation &#40;December 2022&#41;&#46; Arterial &#40;A&#41;&#44; portal &#40;P&#41; and late &#40;T&#41; phases&#46; Absence of uptake of the tumour thrombus&#46; Small areas of infarction in liver segment 7&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Bel&#233;n Mart&#237;nez Benito, V&#237;ctor Gonz&#225;lez Pintor, Lourdes del Campo del Val, Luisa Garc&#237;a-Buey"
          "autores" => array:4 [
            0 => array:2 [
              "nombre" => "Bel&#233;n"
              "apellidos" => "Mart&#237;nez Benito"
            ]
            1 => array:2 [
              "nombre" => "V&#237;ctor"
              "apellidos" => "Gonz&#225;lez Pintor"
            ]
            2 => array:2 [
              "nombre" => "Lourdes"
              "apellidos" => "del Campo del Val"
            ]
            3 => array:2 [
              "nombre" => "Luisa"
              "apellidos" => "Garc&#237;a-Buey"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0210570523004302"
        "doi" => "10.1016/j.gastrohep.2023.09.005"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => false
          "ES2" => false
          "LATM" => false
        ]
        "gratuito" => false
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210570523004302?idApp=UINPBA00004N"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000877?idApp=UINPBA00004N"
    "url" => "/24443824/0000004700000006/v2_202409200854/S2444382424000877/v2_202409200854/en/main.assets"
  ]
  "en" => array:14 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Scientific letters</span>"
    "titulo" => "Complete malignant gastro-duodenal outlet obstruction and direct endoscopic ultrasound-guided gastroenterostomy"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "622"
        "paginaFinal" => "624"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Joan B&#46; Gornals, Dani Luna-Rodriguez"
        "autores" => array:2 [
          0 => array:4 [
            "nombre" => "Joan B&#46;"
            "apellidos" => "Gornals"
            "email" => array:1 [
              0 => "jgornals@bellvitgehospital.cat"
            ]
            "referencia" => array:4 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
              3 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Dani"
            "apellidos" => "Luna-Rodriguez"
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Endoscopy Unit&#44; Department of Digestive Diseases&#44; Hospital Universitari de Bellvitge&#44; Barcelona&#44; Catalonia&#44; Spain"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Bellvitge Biomedical Research Institute &#40;IDIBELL&#41;&#44; Barcelona&#44; Catalonia&#44; Spain"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Universitat de Barcelona&#44; Catalonia&#44; Spain"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Obstrucci&#243;n gastroduodenal maligna completa y gastroenteroanastomosis directa guiada por ecoendoscopia"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2147
            "Ancho" => 3458
            "Tamanyo" => 567798
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case &#35;4&#46; Fluoroscopy and endoscopy view of a completed malignant gastric outlet obstruction &#40;A and B&#41;&#46; Ascites and a collapsed small bowel close to the gastric wall is EUS-guided punctured using a 22G needle &#40;safer and better penetrability for accessing into the enteral lumen&#41;&#44; filling contrast and saline into the target small bowel &#40;C&#41;&#46; Fluoroscopy confirmation &#40;D&#41;&#46; Once enteral lumen gains enough diameter&#44; a second EUS-guided puncture with 19G needle &#40;offering faster flow of liquid&#41; is performed &#40;E&#41;&#46; Fluoroscopy confirmation of the successful gastroenterostomy&#44; after direct &#8220;free-hand&#8221; method using an electrocautery-enhanced lumen-apposing metal stent &#40;HotAxios&#59;15<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Endoscopic ultrasound &#40;EUS&#41;-guided gastroenterostomy &#40;GE&#41; remains an evolving endoscopic technique&#46; Two most reported technical variants include the balloon-assisted gastroenterostomy &#40;BAGE&#41; and the direct gastroenterostomy &#40;DGE&#41; approaches&#46; In both&#44; usually the obstruction grade allows the fluid infusion through the scope&#44; catheter advancement for filling the bowel&#44; or facilitating the localization and puncture of the small bowel&#46; In some centres&#44; a confirmatory EUS-guided puncture is performed to confirm the correct punction site or advancing a guidewire to facilitate the lumen-apposing metal stent &#40;LAMS&#41; deployment&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> In our opinion&#44; this confirmatory step maybe avoided once the distended bowel is well visualized with the direct EUS-guided GE simplified technique using a feeding-tube waterjet system&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In all these previous exposed techniques&#44; locating the distal segment to the gastric outlet obstruction &#40;GOO&#41; is possible through the tumoral lumen&#46; But what to do in cases of complete obstruction when it is not possible to even advance a guidewire through&#63;</p><p id="par0015" class="elsevierStylePara elsevierViewall">From 2021 to 2023&#44; more than 70 EUS-guided GE procedures have been included in a multicenter prospective study conducted at the Barcelona Area &#40;GESICA study&#59; <a href="ctgov:NCT05128604">NCT05128604</a>&#41; by using this simplified direct technique &#40;oro-enteral catheter for filling the bowel followed by &#8216;free-hand&#8217; direct penetration of LAMS&#41;&#46; But&#44; in four cases &#40;5&#46;7&#37;&#41;&#44; it was not possible to apply this technique due to a completed GOO&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Our aim was to report the outcomes of a first-case series &#40;<span class="elsevierStyleItalic">n</span>&#8722;4&#41; for managing complete malignant GOO with EUS-guided GE as a direct-method without additional catheters&#44; only using an FNA needle to access a collapsed small bowel for filling its lumen&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Technical success was defined as correct filling of the collapsed small bowel&#44; and adequate positioning and deployment of the stent by EUS&#47;fluoroscopy view&#46; Clinical success was defined as the ability to tolerate at least a full liquid diet&#46; Feasibility&#44; adverse events &#40;AEs&#41; and efficacy were evaluated&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All the procedures were performed under general anaesthesia by an anaesthesiologist&#46; Written informed consent was obtained for EUS-guided intervention&#46; In all cases&#44; anaesthesia was attempted under endosonography&#47;fluoroscopic guidance&#44; and antiespasmodic agents were administered&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Four patients were referred with complete malignant obstruction and consecutively treated with this endoscopic approach&#46; Firstly&#44; EUS-guided identification of the collapsed small bowel at the Treitz area was performed&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Secondly&#44; EUS-guided puncture using a 22G needle &#40;without stylet and flushed with saline&#41;&#44; filling contrast and saline into the lumen bowel&#46; Sometimes&#44; a submucosal injection of the enteral wall was recognized&#46; In two cases&#44; all procedure was done using a single 22G needle&#46; In the remaining cases&#44; once the lumen gained enough diameters&#44; an exchange to 19G needle was done&#46; Then&#44; a water pump was connected directly to the 22G or 19G needle&#46; Lastly&#44; once the small bowel was largely distended&#44; the direct &#8220;free-hand&#8221; method using an electrocautery-enhanced LAMS &#40;HotAxios&#59; Boston Sc&#41; was successfully used&#46; After intra-LAMS dilation &#40;optional&#41;&#44; spontaneous water drainage and visualization of the enteral lumen confirmed the successful GE&#46; All cases were admitted to our centre for clinical observation&#46; Patients started correctly oral feeding within the next 8<span class="elsevierStyleHsp" style=""></span>h and clinical success was confirmed in all of them&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Regards safety&#44; one AE &#40;aspiration pneumonia&#41; was reported&#44; related to the orotracheal intubation&#46; No AEs were related to the EUS-guided approach&#46; General outcomes are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Patient &#35;2 required two procedures for achieving technical success&#46; In a first failed session&#44; a 19G needle was used as a first attempt to access a collapsed bowel&#46; In a second session&#44; EUS-GE was successfully done using a 22G for all procedures&#46; Though it has been reported the direct use of a 19G needle&#44; given that in most cases the small bowel will collapse&#44; the first attempt to access inside the enteral lumen may be easier using a 22G needle&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; A small sample size&#59; a challenging demand in reaching a collapsed small bowel lumen&#59; and the potential risk of pushing the jejunum away instead of penetrating&#44; resulting in distal flange deployment in the peritoneum&#46; It requires expertise in EUS-guided puncture&#44; knowledge and abilities in salvage methods &#40;as NOTES&#41;&#44; and innovations on designing dedicated devices for stabilizing the targeted loop for puncture&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;5</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In summary&#44; direct EUS-guided GE of complete gastro-duodenal obstruction seems to be feasible&#44; effective&#44; and this strategy may prevent the need for more invasive options such as surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical approval</span><p id="par0060" class="elsevierStylePara elsevierViewall">Informed consent was obtained from the patient for the publication of their information and imaging&#46; This study was conducted in accordance with the principles of the Declaration of Helsinki and the guidelines for Good Clinical Practice&#46; This study was approved by the research and ethics committees &#40;Comit&#233; &#201;tic d&#8217;Investigaci&#243;n Cl&#237;nica&#44; Hospital Universitari de Bellvitge&#59; no&#46; ICPS011&#47;22&#59; May 2022&#41;&#46; Participants are recruited in a multicenter prospective study &#40;GESICA study&#41;&#44; registered at ClinicalTrials&#46;gov on November 2021 &#40;<a href="ctgov:NCT05128604">NCT05128604</a>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors&#8217; contributions</span><p id="par0065" class="elsevierStylePara elsevierViewall">D&#46; Luna-Rodriguez was involved in the analysis and interpretation of the data&#44; critical revision&#44; and final approval&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">J&#46;B&#46; Gornals&#44; involved in the conception and design&#44; analysis and interpretation of the data&#44; drafting of the article&#44; critical revision and final approval&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">No grant support&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">Dr&#46; Gornals is a consultant for BostonSc&#46; The other author has no conflicts of interest to disclose&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:5 [
        0 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Ethical approval"
        ]
        1 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Authors&#8217; contributions"
        ]
        2 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Funding"
        ]
        3 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conflict of interest"
        ]
        4 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2147
            "Ancho" => 3458
            "Tamanyo" => 567798
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Case &#35;4&#46; Fluoroscopy and endoscopy view of a completed malignant gastric outlet obstruction &#40;A and B&#41;&#46; Ascites and a collapsed small bowel close to the gastric wall is EUS-guided punctured using a 22G needle &#40;safer and better penetrability for accessing into the enteral lumen&#41;&#44; filling contrast and saline into the target small bowel &#40;C&#41;&#46; Fluoroscopy confirmation &#40;D&#41;&#46; Once enteral lumen gains enough diameter&#44; a second EUS-guided puncture with 19G needle &#40;offering faster flow of liquid&#41; is performed &#40;E&#41;&#46; Fluoroscopy confirmation of the successful gastroenterostomy&#44; after direct &#8220;free-hand&#8221; method using an electrocautery-enhanced lumen-apposing metal stent &#40;HotAxios&#59;15<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">F&#44; female&#59; G&#44; gauges&#59; HXS&#44; HotAxioS&#59; LAMS&#44; lumen-apposing metal stent&#59; M&#44; male&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age in years&#47;sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Malignant aetiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ascites&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Procedure time&#40;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number and size of EUS needle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LAMS size<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Technical success<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&#40;Y&#47;N&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical success<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&#40;Y&#47;N&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pancreas&#47;duodenum&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">First 22G&#44; secondly 19G&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HXS&#44; 15&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">66&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pancreas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Only 22G&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HXS&#44; 20&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&#40;two attempts&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Aspirationpneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pancreas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">e</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Only 22G&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HXS&#44; 15&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#47;M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gastric&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">First 22G&#44; secondly 19G&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HXS&#44; 15&#8211;15<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3662059.png"
              ]
            ]
          ]
          "notaPie" => array:5 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Technical success&#44; defined as adequate positioning and deployment of the stent as determined by endoscopy view&#46;</p>"
            ]
            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Clinical success defined as the ability to tolerate at least a full liquid diet&#46;</p>"
            ]
            2 => array:3 [
              "identificador" => "tblfn0015"
              "etiqueta" => "c"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">A second endoscopic approach was need&#46; First approach&#44; the small bowel was attempted to be punctured using a 19G but without gaining correct access into the lumen&#46;</p>"
            ]
            3 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "d"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Preference for 15-mm over 20-mm in diameter size&#44; is for safety&#44; since smaller diameter entails less catheter advancement length within the target&#46;</p>"
            ]
            4 => array:3 [
              "identificador" => "tblfn0025"
              "etiqueta" => "e"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Ascites presence is a relative contraindication &#40;previous evacuating paracentesis can be considered&#41;&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">General outcomes summarized&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:5 [
            0 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Therapeutic endoscopic ultrasound&#58; European Society of Gastrointestinal Endoscopy &#40;ESGE&#41; Guideline"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "S&#46;W&#46; van der Merwe"
                            1 => "R&#46;L&#46;J&#46; van Wanrooij"
                            2 => "M&#46; Bronswijk"
                            3 => "S&#46; Everett"
                            4 => "S&#46; Lakhtakia"
                            5 => "M&#46; Rimbas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/a-1717-1391"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endoscopy"
                        "fecha" => "2022"
                        "volumen" => "54"
                        "paginaInicial" => "185"
                        "paginaFinal" => "205"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34937098"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "EUS-guided gastroenterostomy&#58; techniques from East to West"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Irani"
                            1 => "T&#46; Itoi"
                            2 => "T&#46;H&#46; Baron"
                            3 => "M&#46; Khashab"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.vgie.2019.10.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "VideoGIE"
                        "fecha" => "2019"
                        "volumen" => "5"
                        "paginaInicial" => "48"
                        "paginaFinal" => "50"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32051906"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Direct endoscopic ultrasound-guided gastroenterostomy using a feeding-tube waterjet system&#58; a teaching video to facilitate understanding of the technique"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;F&#46; Consiglieri"
                            1 => "D&#46; Luna-Rodriguez"
                            2 => "A&#46; Garcia-Sumalla"
                            3 => "S&#46; Maisterra"
                            4 => "J&#46;G&#46; Velasquez-Rodriguez"
                            5 => "J&#46;B&#46; Gornals"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1055/a-1523-0780"
                      "Revista" => array:6 [
                        "tituloSerie" => "Endoscopy"
                        "fecha" => "2022"
                        "volumen" => "54"
                        "paginaInicial" => "447"
                        "paginaFinal" => "448"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/34087945"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endoscopic ultrasound-guided gastroenterostomy with water-jet filling technique through a 19G needle to treat complete malignant duodenal obstruction"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Collin"
                            1 => "S&#46; Brahmia"
                            2 => "F&#46; Rostain"
                            3 => "A&#46; Lupu"
                            4 => "L&#46; Calavas"
                            5 => "J&#46; Jacques"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Endoscopy"
                        "fecha" => "2021"
                        "volumen" => "53"
                        "paginaInicial" => "7"
                        "paginaFinal" => "8"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Helpful technical notes for intraperitoneal natural orifice transluminal endoscopic surgery &#40;NOTES&#41; salvage in a failed EUS-guided gastroenterostomy scenario"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;B&#46; Gornals"
                            1 => "C&#46;F&#46; Consiglieri"
                            2 => "S&#46; Maisterra"
                            3 => "A&#46; Garcia-Sumalla"
                            4 => "J&#46;G&#46; Velasquez-Rodriguez"
                            5 => "C&#46; Loras"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Endoscopy"
                        "fecha" => "2022"
                        "volumen" => "54"
                        "paginaInicial" => "287"
                        "paginaFinal" => "289"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/24443824/0000004700000006/v2_202409200854/S2444382424000889/v2_202409200854/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "48446"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Scientific letters"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/24443824/0000004700000006/v2_202409200854/S2444382424000889/v2_202409200854/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382424000889?idApp=UINPBA00004N"
]
Indexed in:

Follow us:

Subscribe:

Article

Indexed in:

Follow us:

Subscribe:

Article

Subscribe to our newsletter
