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Martinet E, Gonzalez JM, Thobois M, Hamouda I, Hardwigsen J, Chopinet S, Pauleau G, Vanbiervliet G, Onana P, Moutardier V, Gasmi M, Barthet M, Birnbaum DJ. Surgical versus endoscopic gastroenterostomy for gastric outlet obstruction: a retrospective multicentric comparative study of technical and clinical success. Langenbecks Arch Surg 2024; 409:192. [PMID: 38900214 DOI: 10.1007/s00423-024-03365-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/25/2024] [Indexed: 06/21/2024]
Abstract
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.
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Affiliation(s)
- Eugénie Martinet
- Department of Digestive Surgery, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | | | - Maxime Thobois
- Department of Gastroenterology and Hepatology, Hôpital L'Archet 2, Nice, France
| | - Ilyes Hamouda
- Public Health Laboratory of the Faculty of Medical and Paramedical Sciences; Epidemiology and Health Economics Department, Hôpital Timone, Marseille, France
| | | | | | - Ghislain Pauleau
- Department of Digestive Surgery, Hôpital d'Instruction des Armées Laveran, Marseille, France
| | | | - Philippe Onana
- Department of Gastroenterology and Hepatology, Hôpital L'Archet 2, Nice, France
| | | | | | | | - David Jérémie Birnbaum
- APHM Digestive Department, Marseille, France.
- Hôpital Nord, Chemin des Bourrely, Marseille cedex 20, 13915, France.
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De Ponthaud C, Bozkirli B, Rizzo GEM, Robinson S, Vilas-Boas F, Capurso G, Gaujoux S, Vanella G. Management of malignant Gastric Outlet Obstruction (mGOO) due to pancreatic cancer in the era of EUS-Gastrojejunostomy: an international practice survey and case vignette study by Pancreas 2000 from the European Pancreatic Club. Surg Endosc 2024; 38:3231-3240. [PMID: 38649494 DOI: 10.1007/s00464-024-10803-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/17/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical Gastrojejunostomy (S-GJ) or Endoscopic Stenting (ES). Recently, EUS-Gastrojejunostomy (EUS-GJ) has emerged as an alternative, despite its worldwide diffusion is heterogeneous. The aim of this survey was to assess clinical decision-making around mGOO and to explore current opinions regarding EUS-GJ. METHODS An online survey, spread through social networks and EPC newsletter, was created exploring opinions regarding indications, contraindications, benefits/risks, availability of mGOO treatments; 2 case vignettes explored clinical decision-making in different scenarios. RESULTS Overall, 290 pancreatologists from 44 countries responded, of whom 35% surgeons and 65% gastroenterologists. The most common treatment for mGOO was ES (86%), followed by laparoscopic GJ (76%). EUS-GJ was accessible to 59% of respondents, with 10% proficient in this technique. Gold-standard treatment for mGOO varied by specialty; 45% of gastroenterologists preferred ES, 20% EUS-GJ, and 10% surgical GJ, while among surgeons, these were 24%, 8%, and 25%, respectively. A higher annual volume of mGOO treated correlated with increased EUS-GJ adoption and reduced surgical advice. For 51%, EUS-GJ will become the primary treatment for mGOO, notably higher among gastroenterologists and high-volume centers. For 14%, EUS-GJ spread will be limited in the future, or used only when ES fails (19%). Life expectancy, disease stage and patient's frailty are the main decision driver in therapeutic choice, whereas future surgical resectability does not contraindicate any treatment for 75%. EUS-GJ's main advantages were its minimally invasive nature and clinical efficacy, offset by its steep learning curve. CONCLUSIONS This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms. Life expectancy and patients' frailty are the main decision drivers. Regarding EUS-GJ, its availability remains suboptimal, with learning curve as the main perceived barrier.
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Affiliation(s)
- Charles De Ponthaud
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
- Department of General, Visceral, and Endocrine Surgery, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
- HeKA, Inria, Paris, France
| | - Bahadir Bozkirli
- Department of General Surgery, HPB-Unit, Acıbadem Maslak Hospital, Istanbul, Türkiye
| | - Giacomo Emanuele Maria Rizzo
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy
| | - Stuart Robinson
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, UK
| | - Filipe Vilas-Boas
- Department of Gastroenterology, São João University Hospital, Alameda Professor Hernâni Monteiro, 4200-427, Porto, Portugal
| | - Gabriele Capurso
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy
- Vita Salute San Raffaele University, Milan, Italy
| | - Sébastien Gaujoux
- Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
- Department of General, Visceral, and Endocrine Surgery, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France
| | - Giuseppe Vanella
- Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
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3
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Pawa R, Koutlas NJ, Russell G, Shen P, Pawa S. Endoscopic ultrasound-guided gastrojejunostomy versus robotic gastrojejunostomy for unresectable malignant gastric outlet obstruction. DEN OPEN 2024; 4:e248. [PMID: 37228709 PMCID: PMC10204173 DOI: 10.1002/deo2.248] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/10/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Rishi Pawa
- Department of MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Nicholas J Koutlas
- Department of MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Greg Russell
- Biostatistics and Data ScienceWake Forest School of MedicineWinston‐SalemUSA
| | - Perry Shen
- Department of SurgeryWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
| | - Swati Pawa
- Department of MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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Kalsi H, Jue TL. Endoscopic Ultrasound-Guided Gastroenterostomy for Malignant Gastric Outlet Obstruction: A Minimally Invasive Alternative to Palliative Surgical Bypass. Cureus 2024; 16:e59084. [PMID: 38803783 PMCID: PMC11128328 DOI: 10.7759/cureus.59084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2024] [Indexed: 05/29/2024] Open
Abstract
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.
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Affiliation(s)
- Harsimran Kalsi
- Internal Medicine, UCF-HCA Florida North Florida Hospital, Gainesville, USA
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Şentürk H, Köker İH, Koçhan K, Kiremitçi S, Seven G, İnce AT. Endoscopic ultrasound-guided gastrojejunostomy with a direct technique without previous intestinal filling using a tubular fully covered self-expandable metallic stent. Clin Endosc 2024; 57:209-216. [PMID: 37430402 PMCID: PMC10984750 DOI: 10.5946/ce.2023.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic ultrasonography-guided gastrojejunostomy is a minimally invasive method for the management of gastric outlet obstruction. Conventionally, a lumen-apposing metal stent (LAMS) is used to create an anastomosis. However, LAMS is expensive and not widely available. In this report, we described a tubular fully covered self-expandable metallic stent (T-FCSEMS) for this purpose. METHODS Twenty-one patients (15 men [71.4%]; median age, 66 years; range, 40-87 years) were included in this study. A total of 19 malignant (12 pancreatic, 6 gastric, and 1 metastatic rectal cancer) and 2 benign cases were observed. The proximal jejunum was punctured with a 19 G needle. The stomach and jejunum walls were dilated with a 6 F cystotome, and a 20×80 mm polytetrafluoroethylene T-FCSEMS (Hilzo) was deployed. Oral feeding was initiated after 12 to 18 hours and solid foods after 48 hours. RESULTS The median procedure time was 33 minutes (range, 23-55 minutes). After two weeks, 19 patients tolerated oral feeding. In patients with malignancy, the median survival time was 118 days (range, 41-194 days). No serious complications or deaths occurred. All patients with malignancy tolerated oral food intake until they expired. CONCLUSION T-FCSEMS is safe and effective. This stent should be considered as an alternative to LAMS for gastric outlet obstruction.
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Affiliation(s)
- Hakan Şentürk
- Department of Gastroenterology, Bezmialem Vakif University Medicine Faculty, Istanbul, Turkiye
| | - İbrahim Hakkı Köker
- Department of Gastroenterology, Baskent University Istanbul Hospital, Baskent University Medicine Faculty, Istanbul, Turkiye
| | - Koray Koçhan
- Department of Gastroenterology, Bezmialem Vakif University Medicine Faculty, Istanbul, Turkiye
| | - Sercan Kiremitçi
- Gastroenterology Clinic, Nevsehir Training and Education Hospital, Nevsehir, Turkiye
| | - Gülseren Seven
- Department of Gastroenterology, Bezmialem Vakif University Medicine Faculty, Istanbul, Turkiye
| | - Ali Tüzün İnce
- Department of Gastroenterology, Bezmialem Vakif University Medicine Faculty, Istanbul, Turkiye
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Conti Bellocchi MC, Gasparini E, Stigliano S, Ramai D, Bernardoni L, Di Matteo FM, Facciorusso A, Frulloni L, Crinò SF. Endoscopic Ultrasound-Guided Gastroenterostomy versus Enteral Stenting for Malignant Gastric Outlet Obstruction: A Retrospective Propensity Score-Matched Study. Cancers (Basel) 2024; 16:724. [PMID: 38398115 PMCID: PMC10887005 DOI: 10.3390/cancers16040724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
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.
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Affiliation(s)
- Maria Cristina Conti Bellocchi
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Enrico Gasparini
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Serena Stigliano
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, 00128 Rome, Italy; (S.S.); (F.M.D.M.)
| | - Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Hospital, Salt Lake City, UT 84112, USA;
| | - Laura Bernardoni
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Francesco Maria Di Matteo
- Unit of Gastroenterology and Digestive Endoscopy, Campus Bio Medico University, 00128 Rome, Italy; (S.S.); (F.M.D.M.)
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, 00161 Foggia, Italy;
| | - Luca Frulloni
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
| | - Stefano Francesco Crinò
- Diagnostic and Interventional Endoscopy of Pancreas, The Pancreas Institute, G.B. Rossi University Hospital, 37134 Verona, Italy; (E.G.); (L.B.); (L.F.); (S.F.C.)
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Canakis A, Irani SS. Endoscopic Treatment of Gastric Outlet Obstruction. Gastrointest Endosc Clin N Am 2024; 34:111-125. [PMID: 37973223 DOI: 10.1016/j.giec.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Endoscopic management of gastric outlet obstruction includes balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to relieve mechanical blockage and reestablish per oral intake. Based on the degree of obstruction, patients may experience debilitating symptoms that can quickly lead to malnutrition and delays in chemotherapy. Compared with surgery, minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations. EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates. This article aims to describe endoscopic treatment options and future considerations.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD 21201, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, 1100 Ninth Avenue, Mailstop: C3-GAS, Seattle, WA 98101, USA.
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Li JS, Lin K, Tang J, Liu F, Fang J. EUS-guided gastroenterostomy for gastric outlet obstruction: a comprehensive meta-analysis. MINIM INVASIV THER 2023; 32:285-299. [PMID: 37310282 DOI: 10.1080/13645706.2023.2221336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/18/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVE A comprehensive meta-analysis was performed to evaluate the efficacy and safety of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for benign and malignant gastric outlet obstruction (GOO). MATERIAL AND METHODS PubMed, Embase, Web of Science and Cochrane Library were searched to identify relevant studies. The primary outcomes evaluated technical success, clinical success, and adverse events (AEs). RESULTS Twenty‑six studies with 1493 patients were included in this meta-analysis. The pooled rates of technical success, clinical success, and overall AEs of EUS-GE were 94.0%, 89.9%, and 13.1%, respectively. Eight studies were included in the subgroup meta-analysis for comparative evaluation of EUS-GE and surgical gastroenterostomy (SGE), while seven studies were for EUS-GE and enteral stenting (ES). Compared with SGE, the pooled odds ratios (ORs) of technical success, clinical success, and overall AEs of EUS-GE were 0.17 (p = .003), 1.42 (p = .40), and 0.15 (p < .00001), respectively. When compared with ES, the above corresponding pooled ORs were 0.55 (p = .11), 2.64 (p < .0001), and 0.41 (p = .01), respectively. CONCLUSION Although it is technically challenging, this largest meta-analysis indicates that EUS‑GE has comparable and high technical and clinical success rates and hence a very effective minimally invasive procedure for GOO.
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Affiliation(s)
- Jia-Su Li
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kun Lin
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Jian Tang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jun Fang
- Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China
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Rizzo GEM, Carrozza L, Rancatore G, Binda C, Fabbri C, Anderloni A, Tarantino I. The Role of Endoscopy in the Palliation of Pancreatico-Biliary Cancers: Biliary Drainage, Management of Gastrointestinal Obstruction, and Role in Relief of Oncologic Pain. Cancers (Basel) 2023; 15:5367. [PMID: 38001627 PMCID: PMC10670525 DOI: 10.3390/cancers15225367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/20/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
Therapeutic endoscopy permits many and various treatments for cancer palliation in patients with bilio-pancreatic cancers, enabling different options, supporting patients during their route to oncologic treatments, and trying to improve their quality of life. Therefore, both endoscopic and endoscopic ultrasound (EUS)-guided techniques are performed in this scenario. We performed a literature review focusing on the role of endoscopy in the palliation of those advanced pancreatic and biliary cancers developing malignant biliary obstruction (MBO), gastric outlet obstruction (GOO), and pain unresponsive to medical therapies. Therefore, we explored and focused on the clinical outcomes of endoscopic procedures in this scenario. In fact, the endoscopic treatment is based on achieving biliary drainage in the case of MBO through endoscopic retrograde cholangiopancreatography (ERCP) or EUS-guided biliary drainage (EUS-BD), while GOO is endoscopically treated through the deployment of an enteral stent or the creation of EUS-guided gastro-entero-anastomosis (EUS-GEA). Furthermore, untreatable chronic abdominal pain is a major issue in patients unresponsive to high doses of painkillers, so EUS-guided celiac plexus neurolysis (CPN) or celiac ganglia neurolysis (CGN) helps to reduce dosage and have better pain control. Therefore, therapeutic endoscopy in the palliative setting is an effective and safe approach for managing most of the clinical manifestations of advanced biliopancreatic tumors.
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Affiliation(s)
- Giacomo Emanuele Maria Rizzo
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
- Ph.D. Program, Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, 90133 Palermo, Italy
| | - Lucio Carrozza
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Gabriele Rancatore
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, 48100 Forlì-Cesena, Italy; (C.B.); (C.F.)
| | - Andrea Anderloni
- Gastroenterology and Digestive Endoscopy Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi 19, 27100 Pavia, Italy;
| | - Ilaria Tarantino
- Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT Palermo, 90127 Palermo, Italy; (G.E.M.R.); (L.C.); (G.R.)
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Rimbaș M, Lau KW, Tripodi G, Rizzatti G, Larghi A. The Role of Luminal Apposing Metal Stents on the Treatment of Malignant and Benign Gastric Outlet Obstruction. Diagnostics (Basel) 2023; 13:3308. [PMID: 37958205 PMCID: PMC10648116 DOI: 10.3390/diagnostics13213308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/01/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Gastric outlet obstruction (GOO) is a clinical syndrome traditionally managed by surgical gastrojejunostomy or enteral stenting. The surgical approach is burdened with a high rate of adverse events (AEs), while enteral stenting has a limited long-term clinical effectiveness, with the need for repeat procedures. The availability of lumen-apposing metal stents (LAMSs) has resulted a shift in the treatment paradigm of GOO. Indeed, endoscopists are now able to create a stable anastomosis between the stomach and small bowel under endosonographic guidance. EUS-guided gastro-enteroanastomosis (EUS-GE) has the theoretical advantage of a durable luminal patency resulting from stent placement away from the site of obstruction, free from surgical-related AEs. This approach could be especially valuable in terminally ill patients with a limited life expectancy. The present paper reviews procedural techniques and clinical outcomes of EUS-GE in the context of both malignant and benign GOOs.
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Affiliation(s)
- Mihai Rimbaș
- Gastroenterology Department, Colentina Clinical Hospital, Carol Davila University of Medicine, 020125 Bucharest, Romania;
| | - Kar Wai Lau
- Department of Gastroenterology, Royal Stoke University Hospital, Stoke-on-Trent ST4 6QG, UK;
| | - Giulia Tripodi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (G.T.); (G.R.)
| | - Gianenrico Rizzatti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (G.T.); (G.R.)
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, 00168 Rome, Italy; (G.T.); (G.R.)
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Harb M, Kamath A, Marx G, Gupta S. Outcomes of endoscopic ultrasound-guided gastro-enterostomy for gastric outlet obstruction in a two-centre Australian Cohort (with video). Asia Pac J Clin Oncol 2023. [PMID: 37771144 DOI: 10.1111/ajco.14013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 08/02/2023] [Accepted: 09/22/2023] [Indexed: 09/30/2023]
Abstract
PURPOSE Endoscopic ultrasound-guided gastro-enterostomy (EUS-GE) is a relatively novel technique that has been shown to require less re-intervention than standard endoscopic enteral stenting for gastric outlet obstruction and is less invasive, quicker, and more cost-effective than surgery. This study evaluated the outcomes and safety of EUS-GE in patients treated for gastric outlet obstruction across two Australian centers. METHODS Retrospective data on demographics, presenting symptoms, disease, endoscopic and clinical outcomes, and safety were collected on all patients who underwent EUS-GE from 2021 to 2022. Descriptive statistics were used to evaluate outcomes and safety and survival were calculated using Kaplan-Meier analysis. RESULTS Eleven patients underwent EUS-GE during the defined period, 10 of whom had a malignant etiology (median age 73 years, interquartile range [IQR] 13; 63.6% male). Technical success was 90.9%. Of those patients, clinical success (the ability to tolerate at least a full liquid diet during follow-up) was 100%. The median length of hospital stay post-procedure was 6 days (IQR 14 days). No severe adverse events occurred, and one patient (10%) required a repeat endoscopy. Median survival post-EUS-GE was 298 days (95% confidence interval 0-730.1 days) CONCLUSION: EUS-GE is an effective, safe, and durable therapy for patients with gastric outlet obstruction. This study presents Australian data on outcomes and safety that is comparable to international literature. EUS-GE should be considered for patients where local expertise allows.
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Affiliation(s)
- Martin Harb
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- The University of New South Wales, Sydney, Australia
| | - Arvind Kamath
- The Australian National University, Canberra, Australia
- Department of Gastroenterology and Hepatology, The Sydney Adventist Hospital, Sydney, Australia
| | - Gavin Marx
- The Australian National University, Canberra, Australia
- Medical Oncology, The Sydney Adventist Hospital, Sydney, Australia
| | - Saurabh Gupta
- Department of Gastroenterology and Hepatology, Concord Repatriation General Hospital, Sydney, Australia
- The Australian National University, Canberra, Australia
- Department of Gastroenterology and Hepatology, The Sydney Adventist Hospital, Sydney, Australia
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12
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Kastelijn JB, van de Pavert YL, Besselink MG, Fockens P, Voermans RP, van Wanrooij RLJ, de Wijkerslooth TR, Curvers WL, de Hingh IHJT, Bruno MJ, Koerkamp BG, Patijn GA, Poen AC, van Hooft JE, Inderson A, Mieog JSD, Poley JW, Bijlsma A, Lips DJ, Venneman NG, Verdonk RC, van Dullemen HM, Hoogwater FJH, Frederix GWJ, Molenaar IQ, Welsing PMJ, Moons LMG, van Santvoort HC, Vleggaar FP. Endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for palliation of malignant gastric outlet obstruction (ENDURO): study protocol for a randomized controlled trial. Trials 2023; 24:608. [PMID: 37749590 PMCID: PMC10518948 DOI: 10.1186/s13063-023-07522-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/17/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Malignant gastric outlet obstruction (GOO) is a debilitating condition that frequently occurs in patients with malignancies of the distal stomach and (peri)ampullary region. The standard palliative treatment for patients with a reasonable life expectancy and adequate performance status is a laparoscopic surgical gastrojejunostomy (SGJ). Recently, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) emerged as a promising alternative to the surgical approach. The present study aims to compare these treatment modalities in terms of efficacy, safety, and costs. METHODS The ENDURO-study is a multicentre, open-label, parallel-group randomized controlled trial. In total, ninety-six patients with gastric outlet obstruction caused by an irresectable or metastasized malignancy will be 1:1 randomized to either SGJ or EUS-GE. The primary endpoint is time to tolerate at least soft solids. The co-primary endpoint is the proportion of patients with persisting or recurring symptoms of gastric outlet obstruction for which a reintervention is required. Secondary endpoints are technical and clinical success, quality of life, gastroenterostomy dysfunction, reinterventions, time to reintervention, adverse events, quality of life, time to start chemotherapy, length of hospital stay, readmissions, weight, survival, and costs. DISCUSSION The ENDURO-study assesses whether EUS-GE, as compared to SGJ, results in a faster resumption of solid oral intake and is non-inferior regarding reinterventions for persistent or recurrent obstructive symptoms in patients with malignant GOO. This trial aims to guide future treatment strategies and to improve quality of life in a palliative setting. TRIAL REGISTRATION International Clinical Trials Registry Platform (ICTRP): NL9592. Registered on 07 July 2021.
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Affiliation(s)
- Janine B Kastelijn
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Yorick L van de Pavert
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Roy L J van Wanrooij
- Cancer Center Amsterdam, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, the Netherlands
| | - Thomas R de Wijkerslooth
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala Clinics, Zwolle, the Netherlands
| | - Alexander C Poen
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Alderina Bijlsma
- Department of Gastroenterology and Hepatology, Martini Hospital, Groningen, the Netherlands
| | - Daan J Lips
- Department of Surgery, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medisch Spectrum Twente, Enschede, the Netherlands
| | - Robert C Verdonk
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Hendrik M van Dullemen
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frederik J H Hoogwater
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Paco M J Welsing
- Division of Internal Medicine and Dermatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Leon M G Moons
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
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13
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On W, Ahmed W, Everett S, Huggett M, Paranandi B. Utility of interventional endoscopic ultrasound in pancreatic cancer. Front Oncol 2023; 13:1252824. [PMID: 37781196 PMCID: PMC10540845 DOI: 10.3389/fonc.2023.1252824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 08/30/2023] [Indexed: 10/03/2023] Open
Abstract
Endoscopic ultrasound (EUS) has an important role in the management algorithm of patients with pancreatic ductal adenocarcinoma (PDAC), typically for its diagnostic utilities. The past two decades have seen a rapid expansion of the therapeutic capabilities of EUS. Interventional EUS is now one of the more exciting developments within the field of endoscopy. The local effects of PDAC tend to be in anatomical areas which are difficult to target and endoscopy has cemented itself as a key role in managing the clinical sequelae of PDAC. Interventional EUS is increasingly utilized in situations whereby conventional endoscopy is either impossible to perform or unsuccessful. It also adds a different dimension to the host of oncological and surgical treatments for patients with PDAC. In this review, we aim to summarize the various ways in which interventional EUS could benefit patients with PDAC and aim to provide a balanced commentary on the current evidence of interventional EUS in the literature.
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Affiliation(s)
- Wei On
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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14
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Canakis A, Bomman S, Lee DU, Ross A, Larsen M, Krishnamoorthi R, Alseidi AA, Adam MA, Kouanda A, Sharaiha RZ, Mahadev S, Dawod S, Sampath K, Arain MA, Farooq A, Hasan MK, Kadkhodayan K, de la Fuente SG, Benias PC, Trindade AJ, Ma M, Gilman AJ, Fan GH, Baron TH, Irani SS. Benefits of EUS-guided gastroenterostomy over surgical gastrojejunostomy in the palliation of malignant gastric outlet obstruction: a large multicenter experience. Gastrointest Endosc 2023; 98:348-359.e30. [PMID: 37004816 DOI: 10.1016/j.gie.2023.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 04/04/2023]
Abstract
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.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Shivanand Bomman
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - David U Lee
- Division of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Andrew Ross
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Larsen
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA
| | | | | | - Abdul Kouanda
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, California, USA
| | - Reem Z Sharaiha
- Division of Gastroenterology and Hepatology, Weill Medical College of Cornell University, New York, New York, USA
| | - SriHari Mahadev
- Division of Gastroenterology and Hepatology, Weill Medical College of Cornell University, New York, New York, USA
| | - Sanad Dawod
- Division of Gastroenterology and Hepatology, Weill Medical College of Cornell University, New York, New York, USA
| | - Kartik Sampath
- Division of Gastroenterology and Hepatology, Weill Medical College of Cornell University, New York, New York, USA
| | | | | | | | | | | | - Petros C Benias
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Michael Ma
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, USA
| | - Andrew J Gilman
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, USA.
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15
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Bronswijk M, Vanella G, van Wanrooij RLJ, Samanta J, Lauwereys J, Pérez-Cuadrado-Robles E, Dell'Anna G, Dhar J, Gupta V, van Malenstein H, Laleman W, Jaekers J, Topal H, Topal B, Crippa S, Falconi M, Besselink MG, Messaoudi N, Arcidiacono PG, Kunda R, Van der Merwe S. Same-session double EUS-guided bypass versus surgical gastroenterostomy and hepaticojejunostomy: an international multicenter comparison. Gastrointest Endosc 2023; 98:225-236.e1. [PMID: 36990124 DOI: 10.1016/j.gie.2023.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/16/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND AND AIMS Gastric outlet and biliary obstruction are common manifestations of GI malignancies and some benign diseases for which standard treatment would be surgical gastroenterostomy and hepaticojejunostomy (ie, "double bypass"). Therapeutic EUS has allowed for the creation of an EUS-guided double bypass. However, same-session double EUS-guided bypass has only been described in small proof-of-concept series and lacks a comparison with surgical double bypass. METHODS A retrospective multicenter analysis was performed of all consecutive same-session double EUS-guided bypass procedures performed in 5 academic centers. Surgical comparators were extracted from these centers' databases from the same time interval. Efficacy, safety, hospital stay, nutrition and chemotherapy resumption, long-term patency, and survival were compared. RESULTS Of 154 identified patients, 53 (34.4%) received treatment with EUS and 101 (65.6%) with surgery. At baseline, patients undergoing EUS exhibited higher American Society of Anesthesiologists scores and a higher median Charlson Comorbidity Index (9.0 [interquartile range {IQR}, 7.0-10.0] vs 7.0 [IQR, 5.0-9.0], P < .001). Technical success (96.2% vs 100%, P = .117) and clinical success rates (90.6% vs 82.2%, P = .234) were similar when comparing EUS and surgery. Overall (11.3% vs 34.7%, P = .002) and severe adverse events (3.8% vs 19.8%, P = .007) occurred more frequently in the surgical group. In the EUS group, median time to oral intake (0 days [IQR, 0-1] vs 6 days [IQR, 3-7], P < .001) and hospital stay (4.0 days [IQR, 3-9] vs 13 days [IQR, 9-22], P < .001) were significantly shorter. CONCLUSIONS Despite being used in a patient population with more comorbidities, same-session double EUS-guided bypass achieved similar technical and clinical success and was associated with fewer overall and severe adverse events when compared with surgical gastroenterostomy and hepaticojejunostomy.
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Affiliation(s)
- Michiel Bronswijk
- Department of Gastroenterology and Hepatology; Department of Gastroenterology and Hepatology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | | | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology; Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Jayanta Samanta
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Jonas Lauwereys
- Department of Gastroenterology and Hepatology; Department of Gastroenterology and Hepatology, Imelda Hospital Bonheiden, Bonheiden, Belgium
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, APHP, Centre, University of Paris Cité, Paris, France
| | | | - Jahnvi Dhar
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Vikas Gupta
- Departments of Gastroenterology and GI Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | | | - Wim Laleman
- Department of Gastroenterology and Hepatology
| | - Joris Jaekers
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Halit Topal
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Baki Topal
- Department of Visceral Surgery, University Hospital Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Stefano Crippa
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Massimo Falconi
- Pancreatic Surgery Unit, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Nouredin Messaoudi
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | | | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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16
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Miller C, Benchaya JA, Martel M, Barkun A, Wyse JM, Ferri L, Chen YI. EUS-guided gastroenterostomy vs. surgical gastrojejunostomy and enteral stenting for malignant gastric outlet obstruction: a meta-analysis. Endosc Int Open 2023; 11:E660-E672. [PMID: 37593104 PMCID: PMC10431974 DOI: 10.1055/a-2098-2570] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 04/21/2023] [Indexed: 08/19/2023] Open
Abstract
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.
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Affiliation(s)
- Corey Miller
- Division of Gastroenterology, Department of Medicine, Jewish General Hospital, Montreal, Canada
- Division of Experimental Medicine, Department of Medicine, McGill University Faculty of Medicine and Health Sciences, Montreal, Canada
| | - Joshua A Benchaya
- Division of Gastroenterology, Department of Medicine, Jewish General Hospital, Montreal, Canada
- Faculty of Medicine, McGill University, Montreal, Canada
| | - Myriam Martel
- Research Institute of the McGill University Health Center, McGill University Health Centre, Montreal, Canada
| | - Alan Barkun
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada
| | - Jonathan M Wyse
- Division of Gastroenterology, Department of Medicine, Jewish General Hospital, Montreal, Canada
| | - Lorenzo Ferri
- Surgery, McGill University Health Centre, Montreal, Canada
| | - Yen-I Chen
- Division of Experimental Medicine, Department of Medicine, McGill University Faculty of Medicine and Health Sciences, Montreal, Canada
- Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Canada
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17
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Alverdy JC. Biologically inspired gastrointestinal stapler design: "Getting to Zero" complications. Am J Surg 2023; 226:48-52. [PMID: 36775790 PMCID: PMC10293041 DOI: 10.1016/j.amjsurg.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Revised: 01/15/2023] [Accepted: 01/31/2023] [Indexed: 02/04/2023]
Abstract
As next generation stapling devices enter the marketplace with robotic adaptations, tri-staple technology, preloaded reinforcement materials, etc., in this perspective piece we assert that a "refresh" in our understanding of the mechanisms of action of these devices is needed. While much attention has been paid to explain the mechanical features of one device versus another, it seems that little to no attention is being paid to understand how an intestinal anastomosis responds biologically to the variations in their use and design. Here we will review various aspects of gastrointestinal stapling in the context of emerging technology in the field and expose the gaps in knowledge that exist regarding the effect of gastrointestinal stapling on the biology of healing.
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Affiliation(s)
- John C Alverdy
- University of Chicago, 5841 S Maryland MC 6090, Chicago, Illinois, 60637, USA.
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18
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Radlinski MJ, Strand DS, Shami VM. Evolution of interventional endoscopic ultrasound. Gastroenterol Rep (Oxf) 2023; 11:goad038. [PMID: 37398926 PMCID: PMC10313421 DOI: 10.1093/gastro/goad038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/19/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.
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Affiliation(s)
- Mark J Radlinski
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Vanessa M Shami
- Corresponding author. Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA 22908, USA. Tel: +1-434-989-4381;
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19
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Wu CCH, Brindise E, Abiad RE, Khashab MA. The Role of Endoscopic Management in Afferent Loop Syndrome. Gut Liver 2023; 17:351-359. [PMID: 36578193 PMCID: PMC10191797 DOI: 10.5009/gnl220205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/11/2022] [Accepted: 10/07/2022] [Indexed: 12/30/2022] Open
Abstract
Afferent loop syndrome (ALS) is a morbid complication that may occur after gastrectomy and gastrojejunostomy reconstruction. The aim of this article is to review the different endoscopic treatment options of ALS. We describe the evolution of the endoscopic treatment of ALS and its limitations despite the overall propitious profile. We analyze the advantages of endoscopic ultrasound-guided entero-enterostomy (EUS EE) over enteroscopy-guided intervention, and the clinical outcomes of EUS EE. We expound on pre-procedural considerations, intra-procedural techniques and post-procedural care following EUS EE. We conclude that given the simplification of the technique and the ability to place a stent away from the tumor, EUS EE is a promising technique that will likely be established as the treatment of choice for ALS.
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Affiliation(s)
- Clement Chun Ho Wu
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Elizabeth Brindise
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - Rami El Abiad
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Iowa, Iowa City, IA, USA
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
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20
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Jaruvongvanich V, Mahmoud T, Abu Dayyeh BK, Chandrasekhara V, Law R, Storm AC, Levy MJ, Vargas EJ, Marya NB, Abboud DM, Ghazi R, Matar R, Rapaka B, Buttar N, Truty MJ, Aerts M, Messaoudi N, Kunda R. Endoscopic ultrasound-guided gastroenterostomy for the management of gastric outlet obstruction: A large comparative study with long-term follow-up. Endosc Int Open 2023; 11:E60-E66. [PMID: 36644538 PMCID: PMC9839427 DOI: 10.1055/a-1976-2279] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Barham K. Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Andrew C. Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Eric J. Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Neil B. Marya
- Division of Gastroenterology, University of Massachusetts Medical School, Worcester, Massachusetts, United States
| | - Donna M. Abboud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Rabih Ghazi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Reem Matar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Babusai Rapaka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Navtej Buttar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Mark J. Truty
- Division of Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Maridi Aerts
- Department of Gastroenterology-Hepatology, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Nouredin Messaoudi
- Department of Surgery, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology-Hepatology, Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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21
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Martins RK, Brunaldi VO, Fernandes AL, Otoch JP, Artifon ELDA. 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. Ther Adv Gastrointest Endosc 2023; 16:26317745221149626. [PMID: 36698443 PMCID: PMC9869232 DOI: 10.1177/26317745221149626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 12/13/2022] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Rafael Krieger Martins
- Postgraduate Program of Anesthesiology, Surgical Sciences and Perioperative Medicine, University of São Paulo, Rua Dr. Ovídio Pires de Campos, 255 - Cerqueira César, São Paulo, São Paulo 05403-000, Brazil
| | - Vitor Ottoboni Brunaldi
- Surgery and Anatomy Department, Division of Gastrointestinal Surgery, Faculty of Medicine of Ribeirão Preto, Ribeirão Preto, Brazil
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of São Paulo Medical School, São Paulo, SP, Brazil
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22
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Sánchez-Aldehuelo R, Subtil Iñigo JC, Martínez Moreno B, Gornals J, Guarner-Argente C, Repiso Ortega A, Peralta Herce S, Aparicio JR, Rodríguez de Santiago E, Bazaga S, Juzgado D, González-Panizo F, Albillos A, Vázquez-Sequeiros E. EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video). Gastrointest Endosc 2022; 96:1012-1020.e3. [PMID: 35870508 DOI: 10.1016/j.gie.2022.07.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 06/29/2022] [Accepted: 07/08/2022] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Rubén Sánchez-Aldehuelo
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | | | - Belén Martínez Moreno
- Unidad de Endoscopia, ISABIAL, Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Joan Gornals
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Carlos Guarner-Argente
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Alejandro Repiso Ortega
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Complejo Hospitalario de Toledo, Toledo, Spain
| | - Sandra Peralta Herce
- Unidad de Endoscopia, Servicio de Digestivo, Clínica Universidad de Navarra, Pamplona, Spain
| | - José Ramón Aparicio
- Unidad de Endoscopia, ISABIAL, Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Alicante, Spain
| | - Enrique Rodríguez de Santiago
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Sergio Bazaga
- Unidad de Endoscopia, Servicio de Aparato Digestivo, Hospital Universitario de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Barcelona, Spain
| | - Diego Juzgado
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
| | - Fernando González-Panizo
- Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
| | - Agustín Albillos
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Enrique Vázquez-Sequeiros
- Unidad de Endoscopia. Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Fundación para la Investigación Biomédica del Hospital Universitario Ramón y Cajal (IRYCIS), Universidad de Alcalá, Madrid, Spain; Unidad de Endoscopia, Servicio de Gastroenterología y Hepatología, Hospital Quirón Salud, Madrid, Spain
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23
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van Wanrooij RLJ, Vanella G, Bronswijk M, de Gooyer P, Laleman W, van Malenstein H, Mandarino FV, Dell'Anna G, Fockens P, Arcidiacono PG, van der Merwe SW, Voermans RP. Endoscopic ultrasound-guided gastroenterostomy versus duodenal stenting for malignant gastric outlet obstruction: an international, multicenter, propensity score-matched comparison. Endoscopy 2022; 54:1023-1031. [PMID: 35325931 DOI: 10.1055/a-1782-7568] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic duodenal stenting is the current standard treatment for malignant gastric outlet obstruction (GOO) in patients with limited life expectancy. However, duodenal stenting is prone to stent dysfunction. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel technique with potentially superior stent patency. We compared clinical success, safety, and stent dysfunction of EUS-GE and duodenal stenting in patients with malignant GOO using propensity score matching. METHODS This international, multicenter, retrospective study analyzed consecutive patients undergoing EUS-GE or duodenal stenting for GOO between 2015 and 2021 in three European centers. Primary outcomes were clinical success (GOO scoring system [GOOSS] ≥ 2) and stent dysfunction (GOOSS ≤ 1 after initial clinical success). A propensity score matching (1:1) analysis was performed using age, sex, underlying disease, disease stage, ascites, and peritoneal carcinomatosis as variables. RESULTS 214 patients underwent EUS-GE (n = 107) or duodenal stenting (n = 107). After propensity score matching, 176 patients were matched and compared. Technical success rates for EUS-GE and duodenal stenting were 94 % (95 %CI 89 %-99 %) vs. 98 % (95 %CI 95 %-100 %), respectively (P = 0.44). Clinical success rates were 91 % (95 %CI 85 %-97 %) vs. 75 % (95 %CI 66 %-84 %; P = 0.008). Stent dysfunction occurred in 1 % (95 %CI 0-4 %) vs. 26 % (95 %CI 15 %-37 %) of patients (P < 0.001). Adverse event rate was 10 % (95 %CI 4 %-17 %) vs. 21 % (95 %CI 12 %-29 %; P = 0.09). CONCLUSION EUS-GE had higher clinical success and lower stent dysfunction, with similar safety, compared with duodenal stenting, suggesting that EUS-GE may be preferred over duodenal stenting in patients with malignant GOO.
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Affiliation(s)
- Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Giuseppe Vanella
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Peter de Gooyer
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Wim Laleman
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Hannah van Malenstein
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Francesco Vito Mandarino
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Giuseppe Dell'Anna
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
| | - Paolo G Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCCS San Raffaele Scientific Institute and University, Milan, Italy
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Gasthuisberg, University of Leuven, Leuven, Belgium
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, The Netherlands
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24
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Ribas PHBV, De Moura DTH, Proença IM, Do Monte Júnior ES, Yvamoto EY, Hemerly MC, De Oliveira VL, Ribeiro IB, Sánchez-Luna SA, Bernardo WM, De Moura EGH. Endoscopic Ultrasound-Guided Gastroenterostomy for the Palliation of Gastric Outlet Obstruction (GOO): A Systematic Review and Meta-analysis of the Different Techniques. Cureus 2022; 14:e31526. [PMID: 36540454 PMCID: PMC9754671 DOI: 10.7759/cureus.31526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Gastric outlet obstruction (GOO) is usually associated with a poor prognosis and a significant decrease in a patient's quality of life. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMS) has emerged as a safe and effective palliation procedure for GOO in patients that are unfit for surgery. Without an exclusive gold-standard technique for EUS-GE, we aimed to compare the currently available ones in this systematic review and meta-analysis, the first on this subspecialty. METHODS A comprehensive search from multiple electronic databases was performed. The search had a particular emphasis on the techniques used in performing EUS-GE. We identified all the studies in which EUS-GE was performed as palliation for GOO from its inception to the current date. The outcomes analyzed were the following: technical and clinical success, total and severe adverse events (AEs), procedure duration, and length of hospital stay (LOHS). RESULTS Twenty studies involving 863 patients were the basis of this statistical analysis. Patients underwent the following techniques: direct gastroenterostomy (DGE) (n=718), balloon-assisted gastroenterostomy (BAGE) (n=27), and endoscopic ultrasound (EUS)-guided double-balloon-occluded gastrojejunostomy bypass (n=118). In comparison to balloon-assisted techniques, DGE had a lower rate of AEs, -0.121 (95% CI -0.191 to -0.051 p=0.001); and LOHS for the DGE group, -2.684 (95% CI -1.031 to -4.337 p=0.001). The other analyzed outcomes presented no statistically significant differences. On a sub-analysis, BAGE showed a lower rate of AEs than EUS-guided double-balloon-occluded gastrojejunostomy bypass, -0.196 (95% CI -0.061 to -0.331 p=0.004). CONCLUSIONS EUS-GE is a safe and effective procedure for palliating GOO. When correctly administered, any of the analyzed techniques may be used to palliate GOO with similar technical and clinical outcomes. DGE had significantly lower rates of AEs and LOHS, which can be inferred as a safer procedure. These results should be interpreted cautiously due to the limited few studies that are available and accessible. Therefore, further well-designed, randomized clinical studies on the topic are warranted to compare the different techniques from more sources.
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Affiliation(s)
| | - Diogo Turiani H De Moura
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Igor M Proença
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Epifânio S Do Monte Júnior
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Erika Y Yvamoto
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Matheus C Hemerly
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Victor L De Oliveira
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Igor B Ribeiro
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Sergio A Sánchez-Luna
- Gastroenterology, University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Birmingham, USA
| | - Wanderley M Bernardo
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
| | - Eduardo Guimarães H De Moura
- Gastroenterology, Hospital das Clínicas HCFMUSP Faculdade de Medicina, Universidade de São Paulo, São Paulo, BRA
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25
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Mangiavillano B, Repici A. EUS-guided gastro-enteral anastomosis for the treatment of gastric outlet obstruction: is the end of the enteral stent? Expert Rev Gastroenterol Hepatol 2022; 16:587-589. [PMID: 35772181 DOI: 10.1080/17474124.2022.2097071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Benedetto Mangiavillano
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Humanitas Clinical and Research Center IRCCS, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano (MI), Italy
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26
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Bejjani M, Ghandour B, Subtil JC, Martínez-Moreno B, Sharaiha RZ, Watson RR, Kowalski TE, Benias PC, Huggett MT, Weber T, D'Souza LS, Anderloni A, Lajin M, Khara HS, Pham KDC, Pleskow D, Fabbri C, Nieto JM, Kumta NA, Pawa R, Jovani M, Khashab MA. Clinical and technical outcomes of patients undergoing endoscopic ultrasound-guided gastroenterostomy using 20-mm vs. 15-mm lumen-apposing metal stents. Endoscopy 2022; 54:680-687. [PMID: 34569611 DOI: 10.1055/a-1654-6914] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Most studies on endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) for palliation of malignant gastric outlet obstruction (GOO) utilized a 15-mm lumen-apposing metal stent (LAMS). More recently, a 20-mm LAMS has become available. This study aimed to compare rates of technical and clinical success and adverse events (AEs) in patients undergoing EUS-GE using a 20-mm vs. 15-mm LAMS. METHODS Patients who underwent EUS-GE with 15-mm or 20-mm LAMS for malignant GOO during the period from January 2018 to October 2020 were included. The primary outcome was clinical success, defined as an increase in the gastric outlet obstruction score (GOOS) by at least 1 point during follow-up. Secondary outcomes were technical success, maximum tolerated diet, re-intervention rate, and rate/severity of AEs. RESULTS 267 patients (mean age 67 years, 43 % women) with malignant GOO from 19 centers underwent EUS-GE. Clinical success rates were similar for the 15-mm and 20-mm stents (89.2 % [95 %CI 84.2 %-94.2 %] vs. 84.1 % [77.4%-90.6 %], respectively). However, a significantly higher proportion of patients in the 20-mm group tolerated a soft solid/complete diet at the end of follow-up (91.2 % [84.4 %-95.7 %] vs. 81.2 % [73.9 %-87.2 %], P = 0.04). Overall, AEs occurred in 33 patients (12.4 % [8.4 %-16.3 %]), with similar rates for 15-mm and 20-mm stents (12.8 % [7.5 %-18.2 %] vs. 11.8 % [6 %-17.6 %]), including incidence of severe/fatal AEs (2 % [0.4 %-5.8 %] vs. 3.4 % [0.9 %-8.4 %]). CONCLUSIONS The 20-mm and 15-mm LAMS show similar safety and efficacy for patients undergoing EUS-GE for malignant GOO. The 20-mm LAMS allows a more advanced diet and is, thus preferred for EUS-GE.
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Affiliation(s)
- Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | | | | | - Reem Z Sharaiha
- Weill Cornell Medicine, New York, New York State, United States
| | - Rabindra R Watson
- California Pacific Medical Center, San Francisco, California, United States
| | - Thomas E Kowalski
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
| | - Petros C Benias
- Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, United States
| | | | - Tobias Weber
- University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Lionel S D'Souza
- Stony Brook University Hospital, Stony Brook, New York, United States
| | - Andrea Anderloni
- Division of Gastroenterology and Digestive Endoscopy, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Lajin
- Sharp Grossmont Hospital, La Mesa, California, United States
| | - Harshit S Khara
- Geisinger Medical Center, Danville, Pennsylvania, United States
| | | | - Douglas Pleskow
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forli-Cesena Hospitals, AUSL Romagna, Romagna, Italy
| | - Jose M Nieto
- Borland Groover Clinic, Jacksonville, Florida, United States
| | - Nikhil A Kumta
- Icahn School of Medicine at Mount Sinai, New York, New York State, United States
| | - Rishi Pawa
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States
| | - Manol Jovani
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Maryland, USA
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27
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Krishnamoorthi R, Bomman S, Benias P, Kozarek RA, Peetermans JA, McMullen E, Gjata O, Irani SS. Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis. Endosc Int Open 2022; 10:E874-E897. [PMID: 35692924 PMCID: PMC9187371 DOI: 10.1055/a-1794-0635] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background and study aims Malignant disease accounts for up to 80 % of gastric outlet obstruction (GOO) cases, which may be treated with duodenal self-expanding metal stents (SEMS), surgical gastrojejunostomy (GJ), and more recently endoscopic-ultrasound-guided gastroenterostomy (EUS-GE). These three treatments have not been compared head-to-head in a randomized trial. Methods We searched the Embase and MEDLINE databases for studies published January 2015-February 2021 assessing treatment of malignant GOO using duodenal SEMS, endoscopic (EUS-GE) or surgical (laparoscopic or open) GJ. Efficacy outcomes assessed included technical and clinical success rates, GOO recurrence and reintervention. Safety outcomes included procedure-related bleeding or perforation, and stent-related events for the duodenal SEMS and EUS-GE arms. Results EUS-GE had a lower rate of technical success (95.3%) than duodenal SEMS (99.4 %) or surgical GJ (99.9%) ( P = 0.0048). For duodenal SEMS vs. EUS-GE vs. surgical GJ, rates of clinical success (88.9 % vs. 89.0 % vs. 92.3 % respectively, P = 0.49) were similar. EUS-GE had a lower rate of GOO recurrence based on limited data ( P = 0.0036), while duodenal SEMS had a higher rate of reintervention ( P = 0.041). Overall procedural complications were similar (duodenal SEMS 18.7 % vs. EUS-GE 21.9 % vs. surgical GJ 23.8 %, P = 0.32), but estimated bleeding rate was lowest ( P = 0.0048) and stent occlusion rate was highest ( P = 0.0002) for duodenal SEMS. Conclusions Duodenal SEMS, EUS-GE, and surgical GJ showed similar clinical efficacy for the treatment of malignant GOO. Duodenal SEMS had a lower procedure-related bleeding rate but higher rate of reintervention.
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Affiliation(s)
- Rajesh Krishnamoorthi
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shivanand Bomman
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Petros Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, United States
| | - Richard A. Kozarek
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Joyce A. Peetermans
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Edmund McMullen
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Ornela Gjata
- Endoscopy Division, Boston Scientific Corporation, Marlborough, Massachusetts, United States
| | - Shayan S. Irani
- Department of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington, United States
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A Wolf in LAMS Clothing: The Expansion of Off-Label Indications for Lumen-Apposing Metal Stents. Dig Dis Sci 2022; 67:1917-1919. [PMID: 34718904 DOI: 10.1007/s10620-021-07271-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 12/09/2022]
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Bomman S, Ghafoor A, Sanders DJ, Jayaraj M, Chandra S, Krishnamoorthi R. Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy in treatment of malignant gastric outlet obstruction: Systematic review and meta-analysis. Endosc Int Open 2022; 10:E361-E368. [PMID: 35433211 PMCID: PMC9010108 DOI: 10.1055/a-1783-8949] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 10/12/2021] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Shivanand Bomman
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Adil Ghafoor
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - David J. Sanders
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Mahendran Jayaraj
- Department Gastroenterology and Hepatology, University of Nevada, Las Vegas, Nevada, United States
| | - Shruti Chandra
- Department of Gastroenterology and hepatology, Mayo Clinic, Rochester, Minnnesota, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
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Kumar A, Chandan S, Mohan BP, Atla PR, McCabe EJ, Robbins DH, Trindade AJ, Benias PC. EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2022; 10:E448-E458. [PMID: 35433208 PMCID: PMC9010090 DOI: 10.1055/a-1765-4035] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/25/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Anand Kumar
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Saurabh Chandan
- Division of Gastroenterology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Pradeep R. Atla
- Palmdale Regional Medical Center, Palmdale, California, United States
| | - Evin J. McCabe
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - David H. Robbins
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Arvind J. Trindade
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States
| | - Petros C. Benias
- Division of Gastroenterology, Lenox Hill Hospital, New York, New York, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Division of Gastroenterology, North Shore University Hospital, Manhasset, New York, United States
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Abstract
AbstractInterventional endoscopy is now considered an effective minimally invasive treatment modality for the management of pancreatic diseases. It is important for the clinician to know the indications and contraindications as well as the timing of various endoscopic interventions. This will help in its safe and effective use and consequently decrease morbidity and mortality from various pancreatic diseases. This review will provide a broad overview of the indications, techniques, and outcomes of pancreatic endotherapy.
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Affiliation(s)
- Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder S. Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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van der Merwe SW, van Wanrooij RLJ, Bronswijk M, Everett S, Lakhtakia S, Rimbas M, Hucl T, Kunda R, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M, Perez-Miranda M, van Hooft JE. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54:185-205. [PMID: 34937098 DOI: 10.1055/a-1717-1391] [Citation(s) in RCA: 184] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
1: ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available.Strong recommendation, moderate quality evidence. 2: ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers.Weak recommendation, moderate quality evidence. 3: ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible.Strong recommendation, low quality evidence. 4: ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events.Strong recommendation, low quality evidence. 5: ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD.Strong recommendation, high quality of evidence. 6: ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery.Strong recommendation, low quality evidence. 7: ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8: ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP.Weak recommendation, low quality evidence.
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Affiliation(s)
- Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, AGEM Institute, Amsterdam, The Netherlands
| | - Michiel Bronswijk
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, Imelda General Hospital, Bonheiden, Belgium
| | - Simon Everett
- Department of Gastroenterology and Hepatology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Sundeep Lakhtakia
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology Hospitals, Gachibowli, Hyderabad, India
| | - Mihai Rimbas
- Gastroenterology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Tomas Hucl
- Department of Gastroenterology and Hepatology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, and Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Abdenor Badaoui
- Department of Gastroenterology and Hepatology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Ryan Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Paolo G Arcidiacono
- Pancreatobiliary Endoscopy and Endosonography Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, and Center for Endoscopic Research Therapeutics and Training (CERTT), Catholic University, Rome, Italy
| | - Marc Giovannini
- Paoli-Calmettes Institute, Department of Gastrointestinal Disease, Marseille, France
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Kenneth F Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - Marc Barthet
- Department of Gastroenterology, Aix-Marseille Université, APHM, Hôpital Nord, Marseille, France
| | - Manuel Perez-Miranda
- Gastroenterology Department, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Fabbri C, Binda C, Fugazzola P, Sbrancia M, Tomasoni M, Coluccio C, Jung CFM, Prosperi E, Agnoletti V, Ansaloni L. Hybrid gastroenterostomy using a lumen-apposing metal stent: a case report focusing on misdeployment and systematic review of the current literature. World J Emerg Surg 2022; 17:6. [PMID: 35065661 PMCID: PMC8783442 DOI: 10.1186/s13017-022-00409-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 12/08/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Carlo Fabbri
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Cecilia Binda
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy.
| | - Paola Fugazzola
- General, Emergency and Trauma Surgery Department, M. Bufalini Hospital, Cesena, Italy
| | - Monica Sbrancia
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Matteo Tomasoni
- General, Emergency and Trauma Surgery Department, M. Bufalini Hospital, Cesena, Italy
| | - Chiara Coluccio
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Carlo Felix Maria Jung
- Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì, Italy
| | - Enrico Prosperi
- Department of Medical and Surgical Sciences, University of Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, M. Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, M. Bufalini Hospital, Cesena, Italy
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Futuristic Developments and Applications in Endoluminal Stenting. Gastroenterol Res Pract 2022; 2022:6774925. [PMID: 35069729 PMCID: PMC8767390 DOI: 10.1155/2022/6774925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 12/22/2021] [Indexed: 11/17/2022] Open
Abstract
Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent.
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35
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Endoscopic Ultrasound–Guided Gastrojejunostomy for Malignant Gastric Outlet Obstruction in a Patient With a Previous Liver Transplant and Pancreaticoduodenectomy. ACG Case Rep J 2022. [DOI: 10.14309/crj.0000000000000731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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36
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Talat A, Troy S, Rau P, Hanscom M, Singh A, Zivny J, Marshall C, Marya NB. Single-session EUS-guided gastroenterostomy and EUS-guided gallbladder drainage in a patient with concomitant gastric outlet obstruction and acalculous cholecystitis. VideoGIE 2021; 7:71-73. [PMID: 35146229 PMCID: PMC8819480 DOI: 10.1016/j.vgie.2021.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Cominardi A, Tamanini G, Brighi N, Fusaroli P, Lisotti A. Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasound-guided gastroentero-anastomosis. World J Gastrointest Oncol 2021; 13:1086-1098. [PMID: 34616514 PMCID: PMC8465451 DOI: 10.4251/wjgo.v13.i9.1086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/16/2021] [Accepted: 07/21/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Anna Cominardi
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Giacomo Tamanini
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Nicole Brighi
- Department of Medical Oncology, Istituto Scientifico Romagnolo Per Lo Studio Dei Tumori “Dino Amadori” (IRST) IRCCS, Meldola 47014, FC, Italy
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, University of Bologna/Hospital of Imola, Bologna 40121, Italy
| | - Andrea Lisotti
- Department of Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
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Itoi T, Tsuchiya T, Teoh AYB. A new era of gastroenterostomy bypass using a lumen-apposing metal stent: A paradigm shift from laparoscopy to EUS? Gastrointest Endosc 2021; 94:537-539. [PMID: 34275610 DOI: 10.1016/j.gie.2021.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/19/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
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Lesmana CRA, Paramitha MS, Gani RA. Therapeutic interventional endoscopic ultrasound in pancreato-biliary disorders: Does it really replace the surgical/percutaneous approach? World J Gastrointest Surg 2021; 13:537-547. [PMID: 34194612 PMCID: PMC8223705 DOI: 10.4240/wjgs.v13.i6.537] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/29/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Pancreato-biliary disorders are still incredibly challenging in the field of gastroenterology, as they would sometimes require multi-approach interventional procedures. Recently, therapeutic interventional endoscopic ultrasound (EUS) has emerged as a potential alternative to surgical or percutaneous approaches. Unfortunately, considering the high cost of EUS, lack of facility and expertise, most gastroenterologists still often refer cases to undergo surgical interventions without contemplating the possibility of utilizing EUS first. EUS-guided biliary drainage has become one of the best choices for establishing access to biliary system, given the clear visualization of pancreas, gallbladder, and common bile duct. Although there are still only a few studies which directly compare EUS-guided and surgical approaches for biliary drainage, current evidence demonstrated the superiority of EUS-guided approach in terms of adverse events and re-intervention rates, with similarly high technical and clinical success rates compared to percutaneous and surgical approaches, especially in patients with history of failed endoscopic retrograde cholangiopancreatography attempt. Comparable success rates with shorter length of hospital stay between endoscopic and surgical approaches have also been exhibited for pancreatic pseudocysts and walled-off necrosis. Recent findings about the progress of EUS approach in gastroenterostomy/jejunostomy also indicated a promising potential of EUS, as a less invasive approach, for managing gastric outlet obstruction.
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Affiliation(s)
- Cosmas Rinaldi Adithya Lesmana
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, Indonesia
- Digestive Disease and GI Oncology Center, Medistra Hospital, Jakarta 12950, Indonesia
| | - Maria Satya Paramitha
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, Indonesia
| | - Rino Alvani Gani
- Department of Internal Medicine, Hepatobiliary Division, Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta 10430, Indonesia
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Boghossian MB, Funari MP, De Moura DTH, McCarty TR, Sagae VMT, Chen YI, Mendieta PJO, Neto FLP, Bernardo WM, Dos Santos MEL, Chaves FT, Khashab MA, de Moura EGH. EUS-guided gastroenterostomy versus duodenal stent placement and surgical gastrojejunostomy for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis. Langenbecks Arch Surg 2021; 406:1803-1817. [PMID: 34121130 DOI: 10.1007/s00423-021-02215-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Mateus Bond Boghossian
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil.
| | - Mateus Pereira Funari
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Diogo Turiani Hourneaux De Moura
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Thomas R McCarty
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Vitor Massaro Takamatsu Sagae
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Yen-I Chen
- Division of Gastroenterology and Hepatology, McGill University Health Center, Montreal, QC, Canada
| | - Pastor Joaquín Ortiz Mendieta
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Fernando Lopes Ponte Neto
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Marcos Eduardo Lera Dos Santos
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
| | - Filipe Tomishige Chaves
- Rua Isabel Schmidt, Universidade Santo Amaro, 349 - Santo Amaro, São Paulo, SP, 04743-030, Brazil
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, MD, USA
| | - Eduardo Guimarães Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Universidade de São Paulo Hospital das Clínicas, Av. Dr Enéas de Carvalho Aguiar, 255. 6° andar, bloco 3, Cerqueira César, Sao Paulo, 05403-000, Brazil
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