ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Evaluation of a bone's in vivo 24-hour loading history for physical exercise compared with background loading.

The present study sought to answer two research questions. First, how distinctive, as a potential osteogenic stimulus, are short-duration bouts of treadmill exercise relative to sedentary background activity? Second, how well does daily effective strain stimulus relate the loading history for one such exercise program, in comparison with other experimental loading programs, to bone formation? In vivo cortical strains were measured in the tibiotarsus of White Leghorn chickens at a late stage of skeletal growth (14-34 weeks old) under the conditions of a previous investigation of bone formation in response to an exercise program (15 min/day, treadmill gait at 60% maximum speed while carrying 20% body mass) that included sedentary background activity. These strain data were compiled into 24-hour loading histories of peak cyclic strain, demonstrating that strains were statistically different for exercise and background activities (p < 0.0001), with both the magnitude and number of cyclic strain events being greater during exercise (generally greater than 500 microstrain, 2,500 cycles/day) than during background activity (generally less than 500 microstrain, mean: 775 cycles/day). Strains during exercise accounted for more than 97% of the daily effective strain stimulus for bone adaptation, despite the fact that exercise comprised only 1% of the daily period (15 min/day). The levels of the daily effective strain stimulus were similar to those calculated for strains engendered by artificial loading of functionally isolated avian ulnae, which either maintained bone mass or resulted in a 15% increase of cortical cross-sectional area in both sets of studies. These results indicate that short-duration bouts of treadmill exercise and sedentary background activity can represent distinct osteogenic stimuli for adaptive bone modeling. They also provide experimental support for the use of a daily effective strain stimulus to quantify skeletal loading histories for differing programs of physical exercise, although the relative importance of other mechanical and nonmechanical factors requires further investigation.