Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction

Treatment of choice for malignant gastric outlet obstruction: More than clearing the road

In this editorial, we comment on the in-press article in the World Journal of Gastrointestinal Endoscopy concerning the treatment of malignant gastric outlet obstruction (mGOO). The original theory of treatment involves bypassing the obstruction or reenabling the patency of the passage. Conventional surgical gastroenterostomy provides long-term relief of symptoms in selected patients, with substantial morbidity and a considerable rate of delayed gastric emptying. Endoscopic stenting was introduced as an alternative minimally invasive procedure with less procedural morbidity and rapid clinical improvement; however, it presented a high rate of long-term recurrence. Therefore, challenges remain in the treatment of mGOO patients to improve clinical outcomes. Endoscopic ultrasound-guided gastroenterostomy has recently emerged as a promising method because of the combined effects of surgery and endoscopy, whereas stomach-partitioning gastrojejunostomy has been reported as a modified surgical procedure to reduce the rate of delayed gastric emptying. In decision-making regarding the treatment of choice, it should be taken into account that mGOO might be accompanied by a variety of pathological conditions, including cancer cachexia, anorexia, malabsorption, and etc., all of which can also lead to the characteristic symptoms and poor nutritional status of mGOO. The treatment plan should consider comprehensive aspects of patients to achieve practical improvements in prognosis and the quality of life.

Biliary drainage in patients with malignant distal biliary obstruction: results of an Italian consensus conference

BACKGROUND

Malignant Distal Biliary Obstruction (MBDO) is a common event occurring along the natural history of both pancreatic cancer and cholangiocarcinoma. Epidemiological and biological features make MBDO one of the key elements of the clinical management of patients suffering for of pancreatic cancer or cholangiocarcinoma. The development of dedicated biliary lumen-apposing metal stents (LAMS) is changing the clinical work up of patients with MBDO. i-EUS is an Italian network of clinicians and scientists with a special interest in biliopancreatic endoscopy, EUS in particular.

METHODS

The scientific methodology was chosen in line with international guidance and in a fashion similar to those applied by broader scientific associations. PICO questions were elaborated and subsequently voted by a broad panel of experts within a simplified Delphi process.

RESULTS AND CONCLUSIONS

The manuscripts describes the results of a consensus conference organized by i-EUS with the aim of providing an evidence based-guidance for the appropriate use of the techniques in patients with MBDO.

Is endoscopic ultrasound-guided gastroenterostomy better than surgical gastrojejunostomy or duodenal stenting?

OBJECTIVES

Gastrojejunostomy is a critical procedure for managing gastric outlet obstruction. While surgical gastrojejunostomy has traditionally been the standard approach, endoscopic ultrasound (EUS)-guided gastroenterostomy has emerged as a promising endoscopic alternative. This comprehensive review aims to explore the development, techniques, outcomes, and comparative effectiveness of EUS-guided gastroenterostomy in comparison to duodenal stenting and surgical gastrojejunostomy.

METHODS

A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to April 2024. The search included keywords related to EUS-guided gastrojejunostomy, surgical gastrojejunostomy, and duodenal stenting. Studies reporting on technical success, clinical success, complications, recurrence rates, quality of life, and long-term outcomes were included for analysis.

RESULTS

The development of EUS-guided gastroenterostomy has evolved significantly over the years, driven by device advancements and improved endoscopic techniques. Comparative studies have shown that the technique offers several advantages, including the ability to create an anastomosis without the need for surgery, reduced invasiveness, shorter hospital stays, and potentially improved patient outcomes as compared to duodenal stenting and surgical gastrojejunostomy.

CONCLUSION

Endoscopic ultrasound-guided gastroenterostomy represents a promising alternative to surgical gastrojejunostomy and duodenal stenting for the management of gastric outlet obstruction. The technique has evolved significantly, offering a less invasive and more effective treatment option.

Endoscopic ultrasound-guided gastroenterostomy versus duodenal stenting for gastric outlet obstruction: A systematic review, meta-analysis, and meta-regression

BACKGROUND

Gastric outlet obstruction (GOO) refers to mechanical obstruction at the level of the gastric outlet and is associated with significantly impacted quality of life and mortality. Duodenal stenting (DS) offers a minimally invasive approach to managing GOO but is associated with a high risk of stent obstruction. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel intervention that uses lumen-apposing metal stents to open the restricted lumen. The current evidence comparing EUS-GE to DS is limited and inconsistent.

METHODS

We conducted a systematic literature search on PubMed, Embase, Cochrane, Scopus, and clinicaltrials.gov to retrieve studies comparing EUS-GE to DS for GOO. Odds ratios (OR) and mean differences (MD) with their 95% confidence intervals (CI) were pooled using the DerSimonian-Laird inverse variance random-effects model. Statistical significance was set at P < .05.

RESULTS

Ten studies with a total of 1275 GOO patients (585: EUS-GE and 690: DS) were included. EUS-GE was associated with statistically significant higher clinical success [OR: 2.52; 95% CI: 1.64, 3.86; P < .001], lower re-intervention rate [OR: 0.12; 95% CI: 0.06, 0.22; P < .00001], longer procedural time [MD: 20.91; 95% CI: 15.48, 26.35; P < .00001], and lower risk of adverse events [OR: 0.49; 95% CI: 0.29, 0.82; P = .007] than DS. Technical success [OR: 0.62; 95% CI: 0.31, 1.25] and the length of hospital stay [MD: -2.12; 95% CI: -5.23, 0.98] were comparable between the 2 groups.

CONCLUSION

EUS-GE is associated with higher clinical success, longer total procedural time, lower re-intervention rate, and lower risk of adverse events than DS. Technical success and the length of hospital stay were comparable between the 2 groups. EUS-GE appears to be a safe and effective procedure for managing GOO. Further large, multicentric randomized controlled trials are warranted to investigate the safety and outcomes of EUS-GE in patients with malignant GOO.

Surgical versus endoscopic gastroenterostomy for gastric outlet obstruction: a retrospective multicentric comparative study of technical and clinical success

PURPOSE

Gastric outlet obstruction (GOO) is mainly due to advanced malignant disease. GOO can be treated by surgical gastroenterostomy (SGE), endoscopic enteral stenting (EES), or endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to improve the quality of life.

METHODS

Between 2009 and 2022, patients undergoing SGE or EUS-GE for GOO were included at three centers. Technical and clinical success rates, post-procedure adverse events (AEs), length of hospital stay (LOS), 30-day all-cause mortality, and recurrence of GOO were retrospectively analyzed and compared between SGE and EUS-GE. Predictive factors for technical and clinical failure after SGE and EUS-GE were identified.

RESULTS

Of the 97 patients included, 56 (57.7%) had an EUS-GE and 41 (42.3%) had an SGE for GOO, with 62 (63.9%) GOO due to malignancy and 35 (36.1%) to benign disease. The median follow-up time was 13,4 months (range 1 days-106 months), with no difference between the two groups (p = 0.962). Technical (p = 0.133) and clinical (p = 0.229) success rates, severe morbidity (p = 0.708), 30-day all-cause mortality (p = 0.277) and GOO recurrence (p = 1) were similar. EUS-GE had shorter median procedure duration (p < 0.001), lower post-procedure ileus rate (p < 0.001), and shorter median LOS (p < 0.001) than SGE. In univariate analysis, no risk factors for technical or clinical failure in SGE were identified and abdominal pain reported before the procedure was a risk factor for technical failure in the EUS-GE group. No risk factor for clinical failure was identified for EUS-GE. In the subgroup of GOO due to benign disease, SGE was associated with better technical success (p = 0.035) with no difference in clinical success rate compared to EUS-GE (p = 1).

CONCLUSION

EUS-GE provides similar long-lasting symptom relief as SGE for GOO whether for benign or malignant disease. SGE may still be indicated in centers with limited experience with EUS-GE or may be reserved for patients in whom endoscopic technique fails.

Role of Endoscopic Ultrasound in Pancreatic Cancer Diagnosis and Management

The emergence of endoscopic ultrasound (EUS) has significantly impacted the diagnosis and management of pancreatic cancer and its associated sequelae. While the definitive role of EUS for pancreatic cancer remains incompletely characterized by currently available guidelines, EUS undoubtedly offers high diagnostic accuracy, the precise staging of pancreatic neoplasms, and the ability to perform therapeutic and palliative interventions. However, current challenges to EUS include limited specialized expertise and variability in operator proficiency. As the technology and techniques continue to evolve and become more refined, EUS is poised to play an increasingly integral role in shaping pancreatic cancer care.

Management of Malignant Gastric Outlet Obstruction: A Comprehensive Review on the Old, the Classic and the Innovative Approaches

Gastrojejunostomy is the principal method of palliation for unresectable malignant gastric outlet obstructions (GOO). Gastrojejunostomy was traditionally performed as a surgical procedure with an open approach butrecently, notable progress in the development of minimally invasive procedures such as laparoscopic gastrojejunostomies have emerged. Additionally, advancements in endoscopic techniques, including endoscopic stenting (ES) and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), are becoming more prominent. ES involves the placement of self-expandable metal stents (SEMS) to restore luminal patency. ES is commonly the first choice for patients deemed unfit for surgery or at high surgical risk. However, although ES leads to rapid improvement of symptoms, it carries limitations like higher stent dysfunction rates and the need for frequent re-interventions. Recently, EUS-GE has emerged as a potential alternative, combining the minimally invasive nature of the endoscopic approach with the long-lasting effects of a gastrojejunostomy. Having reviewed the advantages and disadvantages of these different techniques, this article aims to provide a comprehensive review regarding the management of unresectable malignant GOO.

Endoscopic Ultrasound-Guided Gastroenterostomy for Malignant Gastric Outlet Obstruction: A Minimally Invasive Alternative to Palliative Surgical Bypass

Gastric outlet obstruction is a mechanical obstruction to the flow of gastric contents to the intestines. The most common causes of malignant gastric outlet obstruction (MGOO) are pancreatic and gastric cancers. MGOO is associated with reduced quality of life and poor prognosis due to malnourishment from the inability to tolerate oral intake. Surgical gastrojejunostomy and endoscopic placement of enteral stents are palliative options with different advantages and disadvantages. We present a case of MGOO treated with endoscopic ultrasound-guided gastroenterostomy, a minimally invasive alternative to palliative surgical bypass.

Endoscopic ultrasound-guided gastrojejunostomy versus robotic gastrojejunostomy for unresectable malignant gastric outlet obstruction

Objectives

Malignant gastric outlet obstruction (GOO) has traditionally been managed with enteral stenting and surgical gastrojejunostomy. Our study aimed to compare outcomes between endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent and robotic GJ (R-GJ) for unresectable malignant GOO.

Methods

Patients undergoing EUS-GJ or R-GJ for unresectable malignant GOO were retrospectively analyzed. The primary outcome was clinical success defined by the ability to tolerate oral intake at the time of discharge. Secondary outcomes included technical success, procedure duration, adverse events, and post-procedure length of stay (LOS).

Results

A total of 44 patients met the inclusion criteria. Of the 44, 29 underwent EUS-GJ and 15 underwent R-GJ. Age, gender, malignant etiology, and presence of ascites were similar between the two groups. Patients treated with EUS-GJ had a higher mean Charlson comorbidity index (10.3 vs. 7.0; p ≤ 0.0001) and a lower preoperative body mass index (22.3 vs. 27.2; p = 0.007). Technical and clinical success was achieved in 100% of patients in both groups (p > 0.99). EUS-GJ was associated with shorter procedure duration (57.5 vs. 146.3 min; p < 0.0001), hospital LOS (4.3 vs. 8.2 days, p = 0.0009), and time to oral intake (1.0 vs. 5.8 days; p < 0.0001) when compared to R-GJ. Adverse events occurred in 5 of the R-GJ patients and none of the EUS-GJ patients (p = 0.003).

Conclusions

EUS-GJ has similar efficacy and superior clinical outcomes compared to R-GJ in the management of malignant GOO. Prospective studies with longer follow-up duration are needed to validate these findings.

Endoscopic Ultrasound-Guided Gastroenterostomy versus Enteral Stenting for Malignant Gastric Outlet Obstruction: A Retrospective Propensity Score-Matched Study

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen apposing metal stent has emerged as a minimally invasive treatment for the management of malignant gastric outlet obstruction (mGOO). We aimed to compare EUS-GE with enteral stenting (ES) for the treatment of mGOO.

METHODS

Patients who underwent EUS-GE or ES for mGOO between June 2017 and June 2023 at two Italian centers were retrospectively identified. The primary outcome was stent dysfunction. Secondary outcomes included technical success, clinical failure, safety, and hospital length of stay. A propensity score-matching analysis was performed using multiple covariates.

RESULTS

Overall, 198 patients were included (66 EUS-GE and 132 ES). The stent dysfunction rate was 3.1% and 16.9% following EUS-GE and ES, respectively (p = 0.004). Using propensity score-matching, 45 patients were allocated to each group. The technical success rate was 100% for both groups. Stent dysfunction was higher in the ES group compared with the EUS-GE group (20% versus 4.4%, respectively; p = 0.022) without differences in clinical efficacy (p = 0.266) and safety (p = 0.085). A significantly shorter hospital stay was associated with EUS-GE compared with ES (7.5 ± 4.9 days vs. 12.5 ± 13.0 days, respectively; p = 0.018). Kaplan-Meier analyses confirmed a higher stent dysfunction-free survival rate after EUS-GE compared with ES (log-rank test; p = 0.05).

CONCLUSION

EUS-GE offers lower rates of stent dysfunction, longer stent patency, and shorter hospital stay compared with ES.

Endoscopic Nutrition of Patients with Cancer

The types of endoscopic interventions available for supporting the nutrition of patients with cancer have expanded in recent years to encompass a wide variety of different techniques and procedures. Many of these procedures reflect refinements of technique that have existed for some time, whereas others are implementations of novel technologies and instruments that have only become available in recent years. In this review, the authors seek to summarize the breadth of endoscopic techniques for maintaining nutrition in patients with cancer.

Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stents: a retrospective multicentric comparison of wireless and over-the-wire techniques

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) appears to be effective and safe in gastric outlet obstruction (GOO); however, the EUS-GE procedure is not standardized, with the use of assisted or direct methods still debated. The aim of this study was to compare the outcomes of EUS-GE techniques focusing on an assisted with orointestinal drain wireless endoscopic simplified technique (WEST) and the nonassisted direct technique over a guidewire (DTOG).

METHOD

This was a multicenter European retrospective study involving four tertiary centers. Consecutive patients who underwent EUS-GE for GOO between August 2017 and May 2022 were included. The primary aim was to compare the technical success and adverse event (AE) rates of the different EUS-GE techniques. Clinical success was also analyzed.

RESULTS

71 patients (mean [SD] age 66.2 10 years; 42.3 % men; 80.3 % malignant etiology) were included. Technical success was higher in the WEST group (95.1 % vs. 73.3 %; estimate of relative risk from odds ratio (eRR) 3.2, 95 %CI 0.94-10.9; P = 0.01). The rate of AEs was lower in the WEST group (14.6 % vs. 46.7 %; eRR 2.3, 95 %CI 1.2-4.5; P = 0.007). Clinical success was comparable between the two groups at 1 month (97.5 % vs. 89.3 %). The median follow-up was 5 months (range 1-57).

CONCLUSION

The WEST resulted in a higher technical success rate with fewer AEs, with clinical success comparable with the DTOG. Therefore, the WEST (with an orointestinal drain) should be preferred when performing EUS-GE.

Benefits of EUS-guided gastroenterostomy over surgical gastrojejunostomy in the palliation of malignant gastric outlet obstruction: a large multicenter experience

BACKGROUND AND AIMS

Palliation of malignant gastric outlet obstruction (mGOO) allows resumption of peroral intake. Although surgical gastrojejunostomy (SGJ) provides durable relief, it may be associated with a higher morbidity, interfere with chemotherapy, and require an optimum nutritional status. EUS-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative. We aimed to conduct the largest comparative series to date between EUS-GE and SGJ for mGOO.

METHODS

This multicenter retrospective study included consecutive patients undergoing SGJ or EUS-GE at 6 centers. Primary outcomes included time to resumption of oral intake, length of stay (LOS), and mortality. Secondary outcomes included technical and clinical success, reintervention rates, adverse events (AEs), and resumption of chemotherapy.

RESULTS

A total of 310 patients were included (EUS-GE, n = 187; SGJ, n = 123). EUS-GE exhibited significantly lower time to resumption of oral intake (1.40 vs 4.06 days, P < .001), at lower albumin levels (2.95 vs 3.33 g/dL, P < .001), and a shorter LOS (5.31 vs 8.54 days, P < .001) compared with SGJ; there was no difference in mortality (48.1% vs 50.4%, P = .78). Technical (97.9% and 100%) and clinical (94.1% vs 94.3%) success was similar in the EUS-GE and SGJ groups, respectively. EUS-GE had lower rates of AEs (13.4% vs 33.3%, P < .001) but higher reintervention rates (15.5% vs 1.63%, P < .001). EUS-GE patients exhibited significantly lower interval time to resumption of chemotherapy (16.6 vs 37.8 days, P < .001). Outcomes between the EUS-GE and laparoscopic (n = 46) surgical approach showed that EUS-GE had shorter interval time to initiation/resumption of oral intake (3.49 vs 1.46 days, P < .001), decreased LOS (9 vs 5.31 days, P < .001), and a lower rate of AEs (11.9% vs 17.9%, P = .003).

CONCLUSIONS

This is the largest study to date showing that EUS-GE can be performed among nutritionally deficient patients without affecting the technical and clinical success compared with SGJ. EUS-GE is associated with fewer AEs while allowing earlier resumption of diet and chemotherapy.

Second Covered and Uncovered Self-Expandable Metal Stents for Recurrent Gastric Outlet Obstruction: A Retrospective Comparative Study

Background: Endoscopic self-expandable metal stent (SEMS) placement is a current mainstay for malignant gastric outlet obstruction (GOO), but symptomatic recurrence due to initial SEMS dysfunction commonly occurs. We aimed to compare the safety and effectiveness of second SEMS for recurrent GOO (RGOO). Methods: Between April 2006 and December 2022, a total of 95 cases with malignant RGOO undergoing second endoscopic SEMS placement were enrolled. Technical and clinical success rates, RGOO, time to RGOO (TRGOO), stent patency rate, adverse events (AE), and overall survival (OS) were retrospectively compared between covered and uncovered SEMS (cSEMS/uSEMS) groups. Risk factors for TRGOO were also explored. Results: Baseline characteristics were well balanced between cSEMS (n = 48) and uSEMS (n = 47) groups, except for the causes of the initial SEMS dysfunction. High technical and clinical success rates with a similar incidence of AE (15% vs. 17%, p = 0.78) and OS (median of 101 vs. 102 days, p = 0.68) were achieved in both groups. There were no statistical differences in cumulative incidence of RGOO (19% vs. 13%, p = 0.58), TRGOO (median, not reached in both groups, p = 0.57), and stent patency rates at 1, 2, and 3 months between the groups (60%, 47% and 26%, respectively vs. 70%, 55% and 38%, respectively). However, TRGOO tended to be longer in cSEMS in cases with RGOO due to tumor ingrowth (median, not reached vs. 111 days, p = 0.19). A Cox regression analysis demonstrated that chemotherapy after second SEMS placement was significantly associated with an improved TRGOO (the hazard ratio of 0.27 [95% confidence interval, 0.08-0.93], p = 0.03). Conclusions: Regardless of the type of SEMS, second SEMS placement was similarly safe and effective for RGOO. The type of second SEMS might be considered based on the cause of initial SEMS dysfunction.

EUS-guided gastroenterostomy vs. surgical gastrojejunostomy and enteral stenting for malignant gastric outlet obstruction: a meta-analysis

Background and study aims Malignant gastric outlet obstruction (MGOO) is traditionally treated with surgical gastrojejunostomy (SGJ), which is effective but associated with high rates of morbidity, or endoscopic stenting (ES), which is less invasive but associated with significant risk of stent dysfunction and need for reintervention. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) provides a robust bypass without the invasiveness of surgery. Methods We performed a systematic review and meta-analysis comparing EUS-GE to SGJ and ES for MGOO. Electronic databases were searched from inception through February 2022. A meta-analysis was performed with results reported as odds ratios (ORs) with 95% confidence intervals (CIs) using random effects models. Primary outcomes included clinical success without recurrent GOO and adverse events (AEs). Results Sixteen studies involving 1541 patients were included. EUS-GE was associated with higher clinical success without recurrent GOO compared to ES or SGJ [OR 2.60, 95% CI1.58-4.28] and compared to ES alone [OR 5.08, 95% CI 3.42-7.55], but yielded no significant difference compared to SGJ alone [OR 1.94, 95% CI 0.97-3.88]. AE rates were significantly lower for EUS-GE compared to ES or SGJ grouped together [OR 0.34, 95% CI 0.20-0.58], or SGJ alone [OR 0.17, 95% CI 0.10-0.30] but were not significant different versus ES alone [OR 0.57, 95% CI 0.29-1.14]. Conclusions EUS-GE is the most successful approach to treating MGOO, exhibiting a lower risk of recurrent obstruction compared to ES, and fewer AEs compared to SGJ.

A Meta-Analysis of Endoscopic Stenting Versus Surgical Treatment for Malignant Gastric Outlet Obstruction

BACKGROUND AND AIM

Surgical gastrojejunostomy (GJJ) and endoscopic stenting (ES) are the two most available treatments for palliation of malignant gastric obstruction (MGOO). The aim of this study is to compare these two techniques regarding efficacy, safety, time of hospitalization and survival.

METHODS

We performed a literature search from January 2010 to September 2020 to identify available randomized controlled studies and observational studies that compared ES and GJJ for the treatment of MGOO.

RESULTS

A total of 17 studies were found. ES and GJJ showed similar technical and clinical success rate. ES was superior to obtain early oral re-feeding, shorter length of hospitalization and a lower incidence of complications than GJJ. Surgical palliation had a lower recurrence rate of obstructive symptoms and longer overall survival than ES.

CONCLUSIONS

Both procedures have advantages and disadvantages. Probably we should not find the best palliation but the best approach based on the patient characteristics and tumor type.

Iatrogenic perforation during lumen-apposing metal stent deployment closed using an over-the-scope stent fixation clip device

Video 1Endoscopic closure of an iatrogenic perforation caused during EUS-guided gastrojejunostomy for malignant gastric outlet obstruction treated with an over-the-scope stent fixation clip device.

Endoscopic ultrasound-guided gastroenterostomy for the management of gastric outlet obstruction: A large comparative study with long-term follow-up

Background and study aims  Gastric outlet obstruction (GOO) is traditionally managed with surgical gastroenterostomy (surgical-GE) and enteral stenting (ES). Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is now a third option. Large studies assessing their relative risks and benefits with adequate follow-up are lacking. We conducted a comparative analysis of patients who underwent EUS-GE, ES, or surgical-GE for GOO. Patients and methods  In this retrospective comparative cohort study, consecutive patients presenting with GOO who underwent EUS-GE, ES, or surgical-GE at two academic institutions were reviewed and independently cross-edited to ensure accurate reporting. The primary outcome was need for reintervention. Secondary outcomes were technical and clinical success, length of hospital stay (LOS), and adverse events (AEs). Results  A total of 436 patients (232 EUS-GE, 131 ES, 73 surgical-GE) were included. The median duration of follow-up of the entire cohort was 185.5 days (interquartile range 55.25-454.25 days). The rate of reintervention in the EUS-GE group was lower than in the ES and surgical-GE groups (0.9 %, 12.2 %, and 13.7 %, P  < 0.0001). Technical success was achieved in 98.3 %, 99.2 %, and 100 % ( P  = 0.58), and clinical success was achieved in 98.3 %, 91.6 %, and 90.4 % ( P  < 0.0001) in the EUS-GE, ES, and surgical-GE groups, respectively. The EUS-GE group had a shorter LOS (2 days vs. 3 days vs. 5 days, P  < 0.0001) and a lower AE rate than the ES and surgical-GE groups (8.6 % vs. 38.9 % vs. 27.4 %, P  < 0.0001). Conclusion  This large cohort study demonstrates the safety and palliation durability of EUS-GE as an alternative strategy for GOO palliation in select patients.

Comparison of novel large-bore and conventional-bore covered self-expandable metal stents for malignant gastric outlet obstruction: Multicenter, retrospective study

OBJECTIVES

Covered self-expandable metal stent (cSEMS) for gastric outlet obstruction (GOO) has been developed to overcome tumor ingrowth but is prone to be associated with an increased risk of migration. Clinical impact of the novel large-bore cSEMS for malignant GOO remains unclear.

METHODS

A total of 117 patients undergoing endoscopic cSEMS placement for malignant GOO were enrolled in this multicenter retrospective study. Technical and clinical success, adverse events, recurrent GOO, and survival after stent placement were compared between 24 mm-cSEMS (n = 49) and 20 mm-cSEMS (n = 68).

RESULTS

Patient characteristics were well-balanced and thus similar survival was observed between the two groups (136 days vs. 89 days, P = 0.60). Technical success rate of 100% and clinical success rate of 96% were achieved both in 24 mm-cSEMS and 20 mm-cSEMS, respectively. The median cumulative time to recurrent GOO was significantly longer in 24 mm-cSEMS than in 20 mm-cSEMS (380 days vs. 138 days, P = 0.01). The incidence of adverse events and recurrent GOO was comparable: 12% vs. 15% (P = 0.91), and 16% vs. 31% (P = 0.11); however, no stent migration was observed in 24 mm-cSEMS. In a subgroup analysis, the superiority of 24 mm-cSEMS to 20 mm-cSEMS was demonstrated in extrinsic cancers (380 days vs. 121 days, P = 0.01) but not in intrinsic cancers (151 days vs. not reached, P = 0.47).

CONCLUSIONS

The 24 mm-cSEMS may improve time to recurrent GOO with ensuring acceptable safety in patients with malignant GOO.

Palliative therapy for malignant gastric outlet obstruction: how does the endoscopic ultrasound-guided gastroenterostomy compare with surgery and endoscopic stenting? A systematic review and meta-analysis

Introduction

The gold-standard procedure to address malignant gastric outlet obstruction (MGOO) is surgical gastrojejunostomy (SGJJ). Two endoscopic alternatives have also been proposed: the endoscopic stenting (ES) and the endoscopic ultrasound-guided gastroenterostomy (EUS-G). This study aimed to perform a thorough and strict meta-analysis to compare EUS-G with the SGJJ and ES in treating patients with MGOO.

Materials and Methods

Studies comparing EUS-G to endoscopic stenting or SGJJ for patients with MGOO were considered eligible. We conducted online searches in primary databases (MEDLINE, EMBASE, Lilacs, and Central Cochrane) from inception through October 2021. The outcomes were technical and clinical success rates, serious adverse events (SAEs), reintervention due to obstruction, length of hospital stay (LOS), and time to oral intake.

Results

We found similar technical success rates between ES and EUS-G but clinical success rates favored the latter. The comparison between EUS-G and SGJJ demonstrated better technical success rates in favor of the surgical approach but similar clinical success rates. EUS-G shortens the LOS by 2.8 days compared with ES and 5.8 days compared with SGJJ. Concerning reintervention due to obstruction, we found similar rates for EUS-G and SGJJ but considerably higher rates for ES compared with EUS-G. As to AEs, we demonstrated equivalent rates comparing EUS-G and SGJJ but significantly higher ones compared with ES.

Conclusion

Despite being novel and still under refinement, the EUS-G has good safety and efficacy profiles compared with SGJJ and ES.

Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice

Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.

"Orphaned" Stomach-An Infrequent Complication of Gastric Bypass Revision

While generally safe, bariatric operations have a variety of possible complications. We present an uncommon complication after gastric bypass revision, namely the creation of an "orphaned" segment of remnant stomach that was left inadvertently in discontinuity, leading to recurrent intra-abdominal abscesses. Sinogram ultimately proved the diagnosis, and the issue was successfully treated using a combination of surgical and endoscopic methods to control the abscess and to allow internal drainage.

EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video)

BACKGROUND AND AIMS

Traditionally, palliative treatment of malignant gastric outlet obstruction (GOO) has been surgical, but surgical treatment carries significant morbidity and mortality rates. Endoscopic placement of a duodenal self-expandable metal stent (D-SEMS) has been proven to be successful for this indication in the short term. However, D-SEMSs are likely to malfunction over time. EUS-guided gastroenterostomy (EUS-GE) may help overcome these limitations. We aimed to evaluate stent failure-free survival at 3 months.

METHODS

A nationwide multicenter, observational study of D-SEMS and EUS-GE procedures for patients with malignant GOO was conducted at 7 academic centers from January 2015 to June 2020. Stent failure-free survival at 1, 3, and 6 months; technical and clinical success; adverse events (AEs); and patient survival were evaluated in both groups and compared.

RESULTS

Ninety-seven patients were included in the D-SEMS group and 79 in the EUS-GE group. Pancreatic cancer was the main underlying malignancy in 53.4%. No statistically significant differences regarding technical (92.8% vs 93.7%) or clinical success (83.5% vs 92.4%) were found. AE rates did not differ between groups (10.3% vs 10.1%), although 2 events in the EUS-GE group required surgical management. Patients in the EUS-GE group had improved stent patency when compared with those patients in the D-SEMS group at 3 months (92.23% vs 80.6%; adjusted hazard ratio, .37; P = .033).

CONCLUSIONS

EUS-GE seems to have improved patency outcomes when compared with D-SEMS placement for palliative treatment of malignant GOO. Prospective trials are needed to fully compare their efficacy and AE profile.

Endoscopic ultrasound-guided balloon-occluded gastrojejunostomy bypass, duodenal stent or laparoscopic gastrojejunostomy for unresectable malignant gastric outlet obstruction

OBJECTIVES

Malignant gastric outlet obstruction (GOO) can be relieved by either laparoscopic gastrojejunostomy (LGJ), endoscopic stenting (SEMS) or endoscopic ultrasound-guided gastrojejunostomy (endoscopic ultrasound-guided balloon-occluded gastrojejunostomy bypass; EPASS). This study aimed to compare the outcomes of the three treatment methods.

METHODS

This was a retrospective study of patients who suffered from malignant GOO between January 2012 to November 2020 that received either EPASS, LGJ or SEMS. The outcomes included the technical and clinical success, 30-day adverse events and mortality, pre and post stenting GOO scores (GOOSs), stent patency and causes of stent dysfunction.

RESULTS

One hundred and fourteen patients were included (30 EPASS, 35 LGJ, 49 SEMS). The technical success of EPASS, LGJ and SEMS were 93.3%, 100%, 100% (P = 0.058) and clinical success rates were 93.3%, 80%, 87.8% (P = 0.276), respectively. Procedural time was longest for the LGJ group (P < 0.001). The EPASS group had the shortest hospital stay (EPASS 1.5 [1-17], LGJ 7 [2-44], SEMS 5 [2-46] days, P < 0.001). EPASS group also had the lowest rates of recurrent obstruction (EPASS 3.3%, LGJ 17.1%, SEMS 36.7%, P = 0.002) and re-intervention (EPASS 3.3%, LGJ 17.1%, SEMS 26.5%, P = 0.031). The 1-month GOOS was highest in the EPASS group (EPASS 3 [1-3], LGJ 3 [0-3], SEMS 2 [0-3], P = 0.028).

CONCLUSION

Endoscopic ultrasound-guided gastrojejunostomy was associated with better clinical outcomes then the other two procedures. The procedure may be the best option provided that the expertise is available.

Gastrojejunostomy versus endoscopic stenting for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis

BACKGROUND

Though gastrojejunostomy (GJ) has been a standard palliative procedure for gastric outlet obstruction (GOO), endoscopic stenting (ES) has shown to provide benefits due to its non-invasive approach. The aim of this review is to perform a comprehensive evaluation of ES versus GJ for the palliation of malignant GOO.

METHODS

MEDLINE, Embase, and CENTRAL databases were searched and comparative studies of adult GOO patients undergoing ES or GJ were eligible for inclusion. The primary outcomes were survival time and mortality. Secondary outcomes included technical success, clinical success, reinterventions, days until oral food tolerance, postoperative adjuvant palliative chemotherapy, postoperative morbidities, length of stay (LOS), and costs. Pairwise meta-analyses using inverse-variance random effects were performed.

RESULTS

After identifying 2222 citations, 39 full-text articles fit the inclusion criteria. In total, 3128 ES patients (41.4% female, age: 68.0 years) and 2116 GJ patients (40.4% female, age: 66.8 years) were included. ES patients experienced a shorter survival time (mean difference -24.77 days, 95% Cl - 45.11 to  - 4.43, p = 0.02) and were less likely to undergo adjuvant palliative chemotherapy (risk ratio 0.81, 95% Cl 0.70 to 0.93, p = 0.004). The ES group had a shorter LOS, shorter time to oral intake of liquids and solids, and less surgical site infections (risk ratio 0.30, 95% Cl 0.12 to 0.75, p = 0.01). The patients in the ES group were at greater risk of requiring reintervention (risk ratio 2.60, 95% Cl 1.87 to 3.63, p < 0.001).

CONCLUSION

ES results in less postoperative morbidity and shorter LOS when compared to GJ, however, this may be at the cost of decreased initiation of adjuvant palliative chemotherapy and overall survival, as well as increased risk of reintervention. Both techniques are likely appropriate in select clinical scenarios.

Safety of teaching endoscopic ultrasound-guided gastroenterostomy (EUS-GE) can be improved with standardization of the technique

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel technique developed to manage gastric outlet obstruction (GOO). It involves creating a fistula between the stomach and the proximal small bowel using an electric cautery-enhanced lumen-apposing metal stent (ECE-LAMS) with EUS guidance. We aimed to publish our experience in improving teaching of this technique to practicing endoscopists with a wide range of experience by comparing the outcomes before and after standardization of procedural steps.

Methods All EUS-GEs performed for inoperable GOO at a single institution from 2014 to 2021 were retrospectively analyzed. The technique was taught by one experienced endoscopist with prior expertise. Five advanced endoscopists with prior EUS and ECE-LAMS placement experience participated. The impact of standardization on outcomes (clinical and technical success, length of stay [LOS], procedure time, and adverse events [AEs]) was compared.

Results A total 41 EUS-GEs were performed (5 before and 36 after standardization) by endoscopists with practice experience ranging from 2 to 13 years. The patient population was similar in age and sex. Standardization was associated with significantly higher rates of technical success (100 % vs 60 %, P = 0.01) and lower peri-procedural AEs (2.8 % vs 40 %, P = 0.03). Two AEs in the pre-standardized group were gastric perforation and gastrocolic fistula creation. One AE in the post-standardized group was gastric perforation. Procedure time, clinical success, and LOS showed improvement, although it was not statistically significant.

Conclusions Teaching EUS-GE after standardizing the procedure was associated with a significant increase in technical success and a decrease in AEs irrespective of prior total experiences.

The Outcomes of Nutritional Support Techniques in Patients with Gastrointestinal Cancers

Gastrointestinal cancers represent a major cause of morbidity and mortality worldwide. A significant issue regarding the therapeutic management of these patients consists of metabolic disturbances and malnutrition. Nutritional deficiencies have a negative impact on both the death rates of these patients and the results of surgical or oncological treatments. Thus, current guidelines recommend the inclusion of a nutritional profile in the therapeutic management of patients with gastrointestinal cancers. The development of digestive endoscopy techniques has led to the possibility of ensuring the enteral nutrition of cancer patients without oral feeding through minimally invasive techniques and the avoidance of surgeries, which involve more risks. The enteral nutrition modalities consist of endoscopy-guided nasoenteric tube (ENET), percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic gastrostomy with jejunal tube extension (PEG-J), direct percutaneous endoscopic jejunostomy (DPEJ) or endoscopic ultrasound (EUS)-guided gastroenterostomy.

Comparison of gastrojejunostomy to endoscopic stenting for gastric outlet obstruction: An updated Systematic Review and Meta-analysis

BACKGROUND

This study aimed to determine the optimal intervention modality for malignant GOO by comparing clinical outcomes after Gastrojejunostomy and endoscopic stenting.

METHODS

Two authors independently searched Web of Science, PubMed, Embase, and the Cochrane Library for articles before February 2021 to compare the clinical outcomes of GOO patients undergoing GJ or ES.

RESULTS

This meta-analysis included 31 articles with 2444 GOO patients. Although the GJ group outperformed the ES group in technical success (OR,3.79; P = 0.003), clinical success was not significantly different between the two groups (OR,1.25; P = 0.50). The GJ group had a longer hospitalization, lower re-obstruction and lower reintervention. Moreover, GJ had a better survival than ES in the gastric cancer group (HR, 0.33; P = 0.009). However, no significant statistical difference was observed in the pancreatic cancer group (HR, 0.55; P = 0.159).

CONCLUSIONS

Both GJ and ES are safe and effective intervention modalities for malignant GOO. GJ had significantly improved survival in gastric cancer patients with GOO, while no significant difference was observed between the two groups in pancreatic cancer patients with GOO.

Efficacy and safety of endoscopic ultrasound-guided gastrojejunostomy in patients with malignant gastric outlet obstruction and ascites

Background and study aims  Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an endoscopic procedure for treating gastric outlet obstruction (GOO). Limited data exist regarding the safety and efficacy of EUS-GJ in patients with malignant GOO with ascites. Thus, we aimed to study the outcomes and safety of EUS-GJ in GOO patients with vs. without ascites. Patients and methods  This is a retrospective cohort study of patients with malignant GOO who underwent successful EUS-GJ at a tertiary care academic center. Primary outcomes included the efficacy and safety of EUS-GJ. Secondary outcomes included 30-day readmission, reintervention, and survival utilizing Kaplan-Meier analysis. Results  A total of 55 patients (mean age of 67.0 ± 11.3 years, 40.0 % female) who underwent EUS-GJ, of whom 24 had ascites (small in 22, large in 2) were included. Clinical success was achieved in 91.7 % and 93.5 % ( P =  1.00) of patients with and without ascites, respectively. A higher rate of adverse events (AEs) was noted in patients with ascites but this was not statistically significant (37.5 % vs. 19.4 %, P =  0.13). Four patients in the ascites group (16.6 %) developed clinical evidence of peritonitis or sepsis post-EUS-GJ. Eight patients with ascites developed worsening ascites within a month of EUS-GJ. In contrast, only one patient without ascites developed evidence of new ascites. The median survival of patients was not significantly different between the two groups (patients with ascites: 129 days vs. patients without ascites: 180 days, ( P =  0.12). Conclusions  The efficacy EUS-GJ in the presence of ascites is promising; however, the safety profile remains concerning given the high rate of AEs, specifically peritonitis and sepsis.

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy in treatment of malignant gastric outlet obstruction: Systematic review and meta-analysis

Background and study aims  Palliative treatment of malignant gastric outlet obstruction (GOO) has conventionally been with surgical gastrojejunostomy (SGJ). Advent of devices like lumen apposing metal stents has made endoscopic ultrasound-guided gastroenterostomy (EUS-GE) a potential alternative to SGJ for these patients. We performed a systematic review and meta-analysis of studies that compared outcomes of EUS-GE versus SGJ. Methods  We performed a comprehensive systematic search of multiple electronic databases and conference proceedings through January 2021 and identified six studies that compared outcomes of EUS-GE versus SGJ in the management of malignant GOO. The rates of technical success, clinical success, and AEs were analyzed, and pooled odds ratios were calculated using random effects model. Results  Six studies were included in our analysis with a total of 484 patients, of which 291 underwent EUS-GE and 193 underwent SGJ. The technical success rate of SGJ was superior to EUS-GE (OR = 0.195; 95 %CI:0.054-0.702; P  = 0.012; I ²  = 0). The clinical success of EUS-GE was statistically similar to SGJ (OR = 1.566; 95 %CI:0.585-4.197; P  = 0.372; I ²  = 46.68 %). EUS-GE had significantly fewer AEs compared to SGJ (OR = 0.295; 95 %CI:0.172-0.506; P  < 0.005; I ²  = 0). Among studies which reported reintervention rates, EUS-GE was statistically similar to SGJ (OR = 0.587; 95 %CI:0.174-1.979; P  = 0.390, I ²  = 54.91). Minimal to moderate heterogeneity was noted in the analyses. Conclusions  EUS-GE has equivalent clinical success and reintervention rates, but significantly lower adverse events compared to SGJ. When feasible, EUS-GE appears to be an effective and safe alternative to SGJ for palliative management of malignant GOO.

EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis

Background and study aims  Surgical gastroenterostomy (SGE) has been the mainstay treatment for gastric outlet obstruction (GOO). The emergence of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) presents a less invasive alternative for palliation of GOO. We conducted a comprehensive review and meta-analysis to compare the effectiveness and safety of EUS-GE compared to SGE. Methods  Multiple electronic databases and conference proceedings up to April 2021 were searched to identify studies that reported on safety and effectiveness of EUS-GE in comparison to SGE. Pooled odds ratios (ORs) of technical success, clinical success, adverse events (AE) and recurrence, and pooled standardized mean difference (SMD) of procedure time and post-procedure length of stay (LOS) were calculated. Study heterogeneity was assessed using I 2 and Cochran Q statistics. Results  Seven studies including 625 patients (372 EUS-GE and 253 SGE) were included. EUS-GE had lower pooled odds of technical success compared with SGE (OR 0.19, 95 % confidence interval [CI] 0.06-0.60, I 2 0 %). Among the technically successful cases, EUS-GE was superior in terms of clinical success (OR 4.73, 95 % CI 1.83-12.25, I 2 18 %), lower overall AE (OR 0.20, 95 % CI 0.10-0.37, I 2 39 %), and shorter procedure time (SMD -2.4, 95 % CI -4.1, -0.75, I 2 95 %) and post-procedure LOS (SMD -0.49, 95 % CI -0.94, -0.03, I 2 78%). Rates of severe AE (0.89, 95 % CI 0.11-7.36, I 2 67 %) and recurrence (OR 0.49, 95 % CI 0.18-1.38, I 2 49 %) were comparable. Conclusions  Our results suggest EUS-GE is a promising alternative to SGE due to its superior clinical success, overall safety, and efficiency. With further evolution EUS-GE could become the intervention of choice in GOO.

Development and validation of a risk score for prediction of clinical success after duodenal stenting for malignant gastric outlet obstruction

BACKGROUND

To develop and validate a risk score for predicting clinical success after duodenal stenting using self-expanding metallic stents (SEMS) for malignant gastric outlet obstruction (GOO).

RESEARCH DESIGN AND METHODS

Consecutive patients who underwent duodenal stenting for malignant GOO were evaluated. Potential predictors of clinical success were determined by uni/multivariate logistic regression analysis.Multiplication of the regression coefficients of the logistic regression model by a factor of two and rounding to obtain easy-to-use point numbers enabling the calculation of the score. Using 10-fold cross-validation, the model was internally validated.

RESULTS

One hundred twelve patients were included. Clinical success was achieved in 93 (83.0%) patients. On multivariate logistic regression, selected age ≤65 years (p = 0.05, 1.5 points), stenosis type I (p = 0.04, 3 points), and pancreatic cancer (p = 0.01, 3.5 points) were significant predictors of clinical success. On the Receiver Operating Characteristic (ROC) analysis, a score of 5 had higher specificity and sensitivity.

CONCLUSION

Our score could be useful at identifying, among poor surgical candidates, patients more likely to benefit from SEMS.

Hybrid gastroenterostomy using a lumen-apposing metal stent: a case report focusing on misdeployment and systematic review of the current literature

Background

Gastric outlet obstruction can result from several benign and malignant diseases, in particular gastric, duodenal or pancreatic tumors. Surgical gastroenterostomy and enteral endoscopic stenting have represented effective therapeutic options, although recently endoscopic ultrasound-guided gastroenterostomy using lumen-apposing metal stent (LAMS) is spreading improving the outcome of this condition. However, this procedure, although mini-invasive, is burdened with not negligible complications, including misdeployment.

Main body

We report the case of a 60-year-old male with gastric outlet obstruction who underwent ultrasound-guided gastroenterostomy using LAMS. The procedure was complicated by LAMS misdeployment being managed by laparoscopy-assisted placement of a second LAMS.

We performed a systematic review in order to identify all reported cases of misdeployment in EUS-GE and their management. The literature shows that misdeployment occurs in up to 10% of all EUS-GE procedures with a wide spectrum of possible strategies of treatment.

Conclusion

The here reported hybrid technique may offer an innovative strategy to manage LAMS misdeployment when this occurs. Moreover, a hybrid approach may be valuable to overcome this complication, especially in early phases of training of EUS-guided gastroenterostomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00409-z.

The aborted Whipple: Why, and what happens next?

BACKGROUND

For patients with periampullary adenocarcinoma (PAC), pancreatoduodenectomy (PD) provides the best survival. Surgery on a subset of patients is aborted during PD. We analyzed these patients.

METHODS

Patients who underwent laparotomy for planned PD for PAC were identified (2006-2019). From operative notes, we identified the subset with intraoperative decision to abort. Patient, treatment, and outcome data were analyzed. The subset with pancreatic ductal adenocarcinoma (PDAC) was analyzed for survival.

RESULTS

Only 6.7% (n = 55/819) of cases were aborted. Majority 78% (n = 43) had pathologically-confirmed diagnoses at time of surgery, and 18.2% (n = 10) received preoperative chemotherapy. Reasons for aborted PD included: distant metastases (65.5%, n = 36) and local invasion (34.5%, n = 19). Of patients with metastatic disease, 75% (n = 27) had liver metastases. Eighty-nine percent (n = 49) of patients underwent at least one palliative bypass procedure and 81.8% (n = 45) had both gastric and biliary bypass. Patients with computed tomography (CT) scans before surgery more commonly had missed metastatic disease (79.2% CT compared to 54.8% magnetic resonance imaging [MRI], χ²  = 3.54, p = 0.059). In PDAC, 61.4% (n = 27/44) were aborted for metastatic disease and 38.7% (n = 17/44) for local invasion. Median overall survival for all PDAC patients after aborted PD was 334 days.

CONCLUSION

Majority of pancreatoduodenectomies for periampullary adenocarcinoma are done to completion. Liver metastases is the most common reason for aborting. Preoperative MRI may help identify hepatic metastases.

Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy

BACKGROUND AND AIMS

Stent misdeployment (SM) has hindered the dissemination of EUS-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction (GOO) management. We aimed to provide a classification system for SM during EUS-GE and study clinical outcomes and management accordingly.

METHODS

This is a retrospective study involving 16 tertiary care centers (8 in the United States, 8 in Europe) from March 2015 to December 2020. Patients who developed SM during EUS-GE for GOO were included. We propose classifying SM into 4 types. The primary outcome was rate and severity of SM (per American Society for Gastrointestinal Endoscopy lexicon), whereas secondary outcomes were clinical outcomes and management of dislodgement according to the SM classification type, in addition to salvage management of GOO after SM.

RESULTS

From 467 EUS-GEs performed for GOO during the study period, SM occurred in 46 patients (9.85%). Most SMs (73.2%) occurred during the first 13 EUS-GE cases by the performing operators. SM was graded as mild (n = 28, 60.9%), moderate (n = 11, 23.9%), severe (n = 6, 13.0%), or fatal (n = 1, 2.2%), with 5 patients (10.9%) requiring surgical intervention. Type I SM was the most common (n = 29, 63.1%), followed by type II (n = 14, 30.4%), type IV (n = 2, 4.3%), and type III (n = 1, 2.2%). Type I SM was more frequently rated as mild compared with type II SM (75.9% vs 42.9%, P = .04) despite an equivalent rate of surgical repair (10.3% vs 7.1%, P = .7). Overall, 4 patients (8.7%) required an intensive care unit stay (median, 2.5 days). The median length of stay was 4 days after SM.

CONCLUSIONS

Although SM is not infrequent during EUS-GE, most are type I, mild/moderate in severity, and can be managed endoscopically with a surgical intervention rate of approximately 11%.

Lumen-apposing metal stents: How far are we from standardization? An Italian survey

Background and Objectives:

EUS-guided transluminal drainage has increasingly developed, especially after the era of lumen-apposing metal stent (LAMS): a fully covered, barbell-shaped, metal stent with anti-migratory properties allowing direct therapeutic interventions through a wide and short channel. The aim of this survey is to investigate the current management of patients undergoing LAMS placement nationwide.

Materials and Methods:

Forty-eight questions were submitted to Italian centers about expertise, peri- and intra-procedural aspects, budget/refund, and future perspectives. Statistical analyzer was SPSS®.

Results:

Thirty-six centers completed the survey. Indications for LAMS positioning are pancreatic fluid collection drainage (PFCD, 97.2%), biliary drainage (BD, 80.5%), gallbladder drainage (GBD, 75%), and gastroentero-anastomosis (GEA, 19.4%). A total of 77.7% of the endoscopists perform only on-label procedures and 22.2% both on-label and off-label. 38.8% attended a training preliminary course, 27.7% were just supported by an expert, 22.2% had both the opportunities, and 8.3% none of them. Management of antiplatelets and sedation protocol is very heterogeneous. Only 50% involves a multidisciplinary meeting and 30.5% has a specialized clinic for follow-up. Acid suppression is usually continued after PFCD. The type and timing of postprocedural imaging varies widely. 8.3% of the endoscopists work without fluoroscopy. Refund for LAMS is mostly not guaranteed. Main future growing indications appear to be BD, GBD, and GEA (69.4%, 55.5%, and 55.5%, respectively).

Conclusions:

This is the first survey assessing the state of the art on LAMS almost 10 years after their advent. There are currently wide variations in practice nationwide, which demonstrates a pressing need to define technical, qualitative, and peri-procedural requirements to carry out this procedure, toward a standardization.

Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasound-guided gastroentero-anastomosis

Gastric outlet obstruction (GOO) is a clinical syndrome characterized by postprandial vomiting, abdominal pain, bloating and, in advanced cases, by weight loss secondary to inadequate oral intake. This clinical entity may be caused by mechanical obstruction, either benign or malignant, or by motility disorders. In this review we will focus on malignant GOO and on its endoscopic ultrasound (EUS)-guided palliative treatment. The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas; other causes include duodenal or ampullary neoplasms, gastric lymphomas, retroperitoneal lymphadenopathies and, more infrequently, gallbladder and bile duct cancers. Surgery represents the treatment of choice when radical and curative resection is potentially feasible; if the malignant cause is not likely to be completely resected, palliative treatments should be proposed. Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent. Both treatments are effective; however, endoscopic stent placement is less invasive and it is associated with good short-term results, while surgery provides longer-lasting effects with a lower frequency of reintervention. In the last few years, EUS-guided gastroenterostomy (GE) has been proposed as palliative treatment for malignant GOO. This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction, through the deployment of a lumen-apposing metal stent under EUS-view. EUS-GE has the advantage of being as minimally invasive as enteral stent placement, and of guaranteeing long-term results similar to those of surgery.

Endoscopic Ultrasound Guided Gastroenterostomy: What Is the Learning Curve?

INTRODUCTION

Endoscopic ultrasound guided gastroenterostomy (EUS-GE) is a minimally invasive option for gastric outlet obstruction. It requires skills in endoscopic ultrasound, fluoroscopy, and lumen-apposing metal stent deployment. The aim of this study was to determine the learning curve for EUS-GE.

METHODS

Consecutive patients undergoing EUS-GE by a single operator were included from a prospective registry over 3 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum analyses were conducted for the learning curve. Clinical success was defined as tolerating a diet postprocedure.

RESULTS

Twenty-three patients were included (39% male, mean age 65.8 y). Technical success was achieved in 22 (96%) patients. Clinical success was achieved in 21/22 (95%) patients. Average follow-up time 10.8 months (9.1 SD). Five patients had minor postprocedure complications; 1 patient had a periprocedural esophageal tear treated with clips. Four patients required repeat intervention for stent revision or removal if no longer needed.Median procedure time was 88 minutes (range: 45 to 140 min). Cumulative sum chart shows 88-minute procedure time was achieved at the seventh procedure indicating efficiency. Even with bridging of a misdeployed lumen-apposing metal stent, the procedure duration further reduced with consequent procedures indicating continued improvement with experience (nonlinear regression P<0.0001).

CONCLUSIONS

Endoscopists experienced in EUS-GE achieve a reduction in procedure time over successive cases, with efficiency reached at 88 minutes and a learning rate of 7 cases. Misdeployed stents that require bridging add to the procedure time even after competency is achieved but do not affect the overall learning curve trend.

Laparoscopic versus EUS-guided gastroenterostomy for gastric outlet obstruction: an international multicenter propensity score-matched comparison (with video)

BACKGROUND AND AIMS

In the management of gastric outlet obstruction (GOO), EUS-guided gastroenterostomy (EUS-GE) seems to be safe and more effective than enteral stent placement. However, comparisons with laparoscopic GE (L-GE) are scarce. Our aim was to perform a propensity score-matched comparison between EUS-GE and L-GE.

METHODS

An international, multicenter, retrospective analysis was performed of consecutive EUS-GE and L-GE procedures in 3 academic centers (January 2015 to May 2020) using propensity score matching to minimize selection bias. A standard maximum propensity score difference of .1 was applied, also considering underlying disease and oncologic staging.

RESULTS

Overall, 77 patients were treated with EUS-GE and 48 patients with L-GE. By means of propensity score matching, 37 patients were allocated to both groups, resulting in 74 (1:1) matched patients. Technical success was achieved in 35 of 37 EUS-GE-treated patients (94.6%) versus 100% in the L-GE group (P = .493). Clinical success, defined as eating without vomiting or GOO Scoring System ≥2, was achieved in 97.1% and 89.2%, respectively (P = .358). Median time to oral intake (1 [interquartile range {IQR}, .3-1.0] vs 3 [IQR, 1.0-5.0] days, P < .001) and median hospital stay (4 [IQR, 2-8] vs 8 [IQR, 5.5-20] days, P < .001) were significantly shorter in the EUS-GE group. Overall (2.7% vs 27.0%, P = .007) and severe (.0% vs 16.2%, P = .025) adverse events were identified more frequently in the L-GE group.

CONCLUSIONS

For patients with GOO, EUS-GE and L-GE showed almost identical technical and clinical success. However, reduced time to oral intake, shorter median hospital stay, and lower rate of adverse events suggest that the EUS-guided approach might be preferable.

EUS-guided gastroenterostomy with a lumen apposing self-expandable metallic stent relieves gastric outlet obstruction - a Scandinavian case series

BACKGROUND

EUS-guided gastroenterostomy (EUS-GE) with lumen-apposing metallic stents (LAMS) in patients with gastric outlet obstruction (GOO) has proven to be an alternative to luminal stenting in the duodenum and surgical gastroenterostomy. In severely ill patients, the method can provide improved quality of life (QoL) and symptom relief by restoration of the luminal passage of fluid and nutrients to the small intestine.

AIM

To assess the technical and clinical success and safety of EUS-GE.

MATERIAL AND METHODS

A dual center retrospective case series of 33 consecutive patients with GOO due to malignant (n = 28) or non-malignant conditions (n = 5). The patients were treated with EUS-GE using cautery enhanced LAMS. Procedures were performed guided by EUS and fluoroscopy in general anesthesia or conscious sedation.

RESULTS

Technical success was achieved in all patients. The median procedure time was 71 min and the median hospital stay was three days. Thirty (91%) patients were able to resume oral nutrition after the procedure. Ten patients (30%) experienced adverse events (AEs), including migration of the stent, bleeding, and infection. Four patients had fatal AEs (12%). All stent-related AEs were handled endoscopically. Five patients (15%) needed re-intervention. The median survival time for patients with malignant obstruction was 8.5 weeks (0.5-76), and 13 patients with obstructing malignancies lived 12 weeks or longer.

CONCLUSION

EUS-GE is a minimally invasive and efficient method for restoration of the gastrointestinal passage and may improve palliative care for patients with GOO. The method has potential hazards and should only be offered in expert centers that regularly perform the procedure.

Endoscopic Gastrointestinal Anastomosis Using Lumen-apposing Metal Stent (LAMS) for Benign or Malignant Etiologies: A Systematic Review and Meta-Analysis

BACKGROUND AND AIM

Endoscopic gastrointestinal anastomosis using lumen-apposing metal stents (EGAL) is a new technique that is used as an alternative method to bypass benign or malignant strictures. Endoscopists take advantage of 2 bowel loops that are close to each other and place a stent between the lumen of these 2 bowel loops. The authors performed this systematic review and meta-analysis to evaluate the efficacy and safety of this rising procedure.

METHODS

Electronic database searches were conducted for full eligible articles that were published from the inception to July 2019 using the EGAL procedure to bypass malignant or benign obstruction or to restore bowel integrity after a gastrointestinal altering surgery. The primary outcome of this meta-analysis was to assess efficacy through technical and clinical success. Secondary outcomes were to assess safety through adverse events and to assess the rate of stent maldeployment and the rate of reintervention during the study period.

RESULTS

Eight studies were eligible, providing data on 269 patients who underwent 271 EGAL procedures. The median age was 65 years (interquartile range: 63 to 66) with 46% male individuals. Out of 269 patients, 203 underwent EGALs because of malignant etiology and 66 underwent EGAL for benign etiology. The median duration of follow-up was 114 days (interquartile range: 78 to 121). Technical success rate was 94.1% [95% confidence interval (CI), 91.4%-96.9%]. Clinical success rate was 91.4% (95% CI, 88.1%-94.7%). Adverse events rate was 8.5% (95% CI, 4.7%-12.3%). Stent maldeployment rate was 9.5% (95% CI, 3.5%-15.4%) of the total performed EGALs and the reintervention rate was 6.0% (95% CI, 2.3%-9.8%).

CONCLUSION

EGAL procedure has high efficacy and a relatively safe profile and it can be performed in selected patients. Comparison between EGAL and other conventional therapies is difficult because of the lack of randomized trials.

EUS-guided gastroenterostomy versus duodenal stent placement and surgical gastrojejunostomy for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis

PURPOSE

Malignant gastric outlet obstruction (GOO) is associated with significant morbidity and decreased quality of life, thereby necessitating effective and safe palliative treatment. As such, we sought to compare endoscopic ultrasound-guided gastroenterostomy (EUS-GE) versus duodenal stent (DS) placement and surgical gastrojejunostomy (SGJ) for palliation of malignant GOO.

METHODS

Searches of electronic databases were performed to identify studies comparing EUS-GE versus DS and/or SGJ for palliative treatment of GOO. Outcomes included technical and clinical success, severe adverse events (SAEs), rate of stent obstruction (including tumor ingrowth), length of hospital stay (LOS), reintervention, and 30-day all-cause mortality. Differences in dichotomous and continuous outcomes were reported as risk difference and mean difference, respectively.

RESULTS

Seven studies (n = 513 patients) were included. When compared to DS placement, EUS-GE was associated with a higher clinical success, fewer SAEs, decreased stent obstruction, lower rate of tumor ingrowth, and decreased need for reintervention. Compared to SGJ, EUS-GE was associated with a lower technical success; however, LOS was significantly decreased. All other outcomes including clinical success, SAEs, reintervention rate, and 30-day mortality were not significantly different between an EUS-guided versus surgical approach.

CONCLUSIONS

EUS-GE was associated with significantly improved outcomes compared to DS placement for palliative treatment of malignant GOO. Despite SGJ possessing a higher technical success compared to EUS-GE, LOS was significantly longer with no difference in clinical success or rate of adverse events.

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.

Assessment of the learning curve for EUS-guided gastroenterostomy for a single operator

BACKGROUND AND AIMS

EUS-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative to surgery and enteral stent placement to manage gastric outlet obstruction (GOO). However, no data are available on the learning curve (LC) for EUS-GE. Defining the LC is necessary to create adequate subspecialty training programs and quality assurance.

METHODS

This study is a retrospective analysis of a prospectively maintained dataset of patients who underwent EUS-GE at 1 tertiary referral center. Primary outcome was the LC for EUS-GE defined by the number of cases needed to achieve proficiency and mastery using cumulative sum (CUSUM) analysis. Moving average graphs and sequential time-block analysis were also performed to assess procedural time. Secondary outcomes included efficacy and safety of EUS-GE.

RESULTS

Eighty-seven consecutive patients underwent EUS-GE, mostly for malignant GOO. For consistency, 14 patients were excluded from analysis (noncautery-assisted EUS-GE, 11; surgical anatomy, 3). The same endoscopist performed all procedures using the same freehand technique. Technical success was achieved in 68 of 73 patients (93%). Immediate adverse events occurred in 4 patients (5.5%), whereas late adverse events occurred only in 1 patient (1%), all managed conservatively or endoscopically. All immediate adverse events occurred during the first 39 cases. Clinical success (defined as resuming at least an oral liquid diet within a week) was achieved in 97% of patients. The mean procedural time was 36 minutes (standard deviation, 24). Evaluation of the CUSUM curve revealed that 25 cases were needed to achieve proficiency and 40 cases to achieve mastery. These results were confirmed with the average moving curve and sequential time-block analysis.

CONCLUSIONS

We report, for the first time, data on the LC for EUS-GE. About 25 procedures can be considered as the threshold to achieve proficiency and about 40 cases are needed to reach mastery of the technique.

Enteral Stents for Malignant Gastric Outlet Obstruction: Low Reintervention Rates for Obstruction due to Pancreatic Adenocarcinoma Versus Other Etiologies

BACKGROUND AND AIM

Enteral stents (ES) have emerged as first-line therapy for the treatment of malignant gastric outlet obstruction (GOO). Stent occlusion arising from tissue ingrowth may require endoscopic or surgical reintervention. The objective of this study was to compare rates of reintervention following palliative ES for patients with GOO due to pancreatic adenocarcinoma (PDAC) versus other malignant etiologies.

METHODS

Patients who had undergone ES for palliation of malignant GOO between 2009 and 2018 were retrospectively identified and demographic, clinical, and procedural data were collected. Primary outcome was procedural reintervention for recurrent symptomatic GOO following ES placement.

RESULTS

Forty-three patients were included in the study cohort. 62.8% (27/43) of patients had PDAC while 37.2% (16/43) of patients had other malignant etiologies. 11.6% (5/43) of patients were alive at follow-up. Thirty-day and 90-day mortality rates were 22.8% and 70.7% for PDAC and 25% and 56.3% for other malignant etiologies, respectively. Seven patients required reintervention for symptomatic GOO: 14.3% (1/7) had PDAC and 85.7% (6/7) had GOO due to other malignancy (P < .01). Ninety-six percent (26/27) of patients with PDAC required no further intervention for GOO prior to death or end of follow-up. On multivariate analysis, patients with PDAC were significantly less likely to require reintervention than patients with other malignant etiologies (OR 0.064, 95% CI 0.01-0.60).

CONCLUSION

ES offer durable symptom palliation without requirement for reintervention for the overwhelming majority of patients with malignant GOO due to PDAC. Reintervention rates are higher following ES placement for GOO due to other malignant etiologies and future study may be needed to define the optimal palliative intervention for this group of patients.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center

INTRODUCTION

EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience.

METHODS

Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure.

RESULTS

Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients.

CONCLUSION

EUS-GE is a promising treatment for patients with GOO.