1
|
Lim CH, Lee ZJ, Lye T, Ravishankar A, Yeung B, Ong HS, Tan J. Natural Orifice Transluminal Endoscopic One-Anastomosis Gastric Bypass: a Feasibility Study Using Human Cadavers. Obes Surg 2022; 32:3787-3795. [PMID: 36136170 DOI: 10.1007/s11695-022-06273-9] [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: 07/18/2022] [Revised: 09/04/2022] [Accepted: 09/05/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Endoscopic bariatric therapies (EBT) has emerged as an effective treatment in the management of the patient with obesity. Unfortunately, most procedures involve only the restriction of gastric volume without altering the underlying metabolism. The objective of this study was to investigate the practicability and limitations of the metabolic altering procedures: "One anastomosis gastric bypass (OAGB)" with "natural orifice transluminal endoscopic surgery (NOTES)" on human cadavers. METHODS We performed OAGB with NOTES approach in 3 human cadavers. The steps of the procedure can be divided as follows: step 1, endoscopic sleeve gastroplasty (ESG); step 2, trans-gastric access to peritoneal cavity; step 3, identification of suitable loop of jejunum; step 4, introduction of the jejunal loop into the stomach; step 5, creation of the gastro-jejunostomy with lumen-apposing metal stent (LAMS); step 6, gastric pylorus occlusion with overstitch. RESULTS We performed OAGB with NOTES in 3 human cadavers with bypassed bilio-pancreatic limb of 55, 75, and 105 cm from the pylorus. The average weight for the cadavers was 64.9 kg (61.2-71.7 kg). The mean procedure time was 157 min. The optimal bypassed length for the procedure was 105 cm. CONCLUSIONS This study has provided proof-of-principle in a pre-clinical cadaveric model that NOTES approach can be used to perform OAGB and, therefore, merits additional evaluation and consideration in surviving porcine model.
Collapse
Affiliation(s)
- Chin Hong Lim
- Department of Upper Gastrointestinal & Bariatric Surgery, Division of Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore.
| | - Zhen Jin Lee
- Department of Upper Gastrointestinal & Bariatric Surgery, Division of Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Tiffany Lye
- Department of Upper Gastrointestinal & Bariatric Surgery, Division of Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Asokkumar Ravishankar
- Department of Gastroenterology & Hepatology, Division of Medicine, Singapore General Hospital, Singapore, Singapore
| | - Baldwin Yeung
- Department of Upper Gastrointestinal & Bariatric Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Hock Soo Ong
- Department of Upper Gastrointestinal & Bariatric Surgery, Division of Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| | - Jeremy Tan
- Department of Upper Gastrointestinal & Bariatric Surgery, Division of Surgery, Singapore General Hospital, Academia, 20 College Road, Singapore, 169856, Singapore
| |
Collapse
|
2
|
Duarte-Chavez R, Kahaleh M. Therapeutic endoscopic ultrasound. Transl Gastroenterol Hepatol 2022; 7:20. [PMID: 35548470 PMCID: PMC9081917 DOI: 10.21037/tgh-2020-12] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/12/2020] [Indexed: 08/30/2023] Open
Abstract
Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.
Collapse
Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
| | - Michel Kahaleh
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Prakash S, Elmunzer BJ, Forster EM, Cote GA, Moran RA. Endoscopic ultrasound-directed transgastric ERCP (EDGE): a systematic review describing the outcomes, adverse events, and knowledge gaps. Endoscopy 2022; 54:52-61. [PMID: 33506456 PMCID: PMC8783372 DOI: 10.1055/a-1376-2394] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND : Endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) has emerged as a viable completely endoscopic method for performing pancreaticobiliary interventions in patients with Roux-en-Y gastric bypass anatomy. The aims of this systematic review were: (1) to describe the indications, outcomes, and complications of EDGE; and (2) to identify deficiencies in our knowledge of important technical approaches and clinical outcomes. METHODS : A systematic review was conducted via comprehensive searches of Medline, Scopus, CINAHL, and Cochrane to identify studies focusing on EDGE outcomes. Simple descriptive statistics were derived from case series only. Case reports were only included to qualitatively describe additional indications, techniques, and adverse events. RESULTS : The initial search identified 2143 abstracts. Nine case series and eight case reports were included. In the nine case series, 169 patients underwent EDGE. The technical success rate was 99 % (168 /169) for gastrogastrostomy/jejunogastrostomy creation and 98 % (166 /169) for subsequent ERCP. Minor adverse events specifically related to EDGE occurred in 18 % (31/169) and included intraprocedural stent migration/malposition (n = 27) and abdominal pain (n = 4). Moderate adverse events specific to EDGE occurred in 5 % (9/169): including bleeding (2 %), persistent fistula (1 %), and perforation (1 %). Severe adverse events occurred in one patient with a perforation requiring surgery. Deficiency in reporting on the clinical significance of adverse events was identified. CONCLUSION : Based on limited observational data, in expert hands, EDGE has a high rate of technical success and an acceptable rate of adverse events. As a novel procedure, many knowledge gaps need to be addressed to inform the design of meaningful comparative studies and guide informed consent.
Collapse
Affiliation(s)
- Shaurya Prakash
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - B. Joseph Elmunzer
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Erin M. Forster
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gregory A. Cote
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert A. Moran
- Department of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina, USA
| |
Collapse
|
5
|
Papasavas P, Docimo S, Oviedo RJ, Eisenberg D. Biliopancreatic access following anatomy-altering bariatric surgery: a literature review. Surg Obes Relat Dis 2021; 18:21-34. [PMID: 34688572 DOI: 10.1016/j.soard.2021.09.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 09/19/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Pavlos Papasavas
- Division of Metabolic and Bariatric Surgery, Hartford Hospital, Hartford, Connecticut.
| | - Salvatore Docimo
- Division of Bariatric, Foregut, and Advanced GI Surgery, Stony Brook Medicine, Stony Brook, New York
| | | | - Dan Eisenberg
- Department of Surgery, Stanford University and Palo Alto VA Health Care Center, Palo Alto, California
| | | |
Collapse
|
6
|
Endoscopic Gastrointestinal Anastomosis Using Lumen-apposing Metal Stent (LAMS) for Benign or Malignant Etiologies: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2021; 55:e56-e65. [PMID: 33060441 DOI: 10.1097/mcg.0000000000001453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/14/2020] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIM Endoscopic gastrointestinal anastomosis using lumen-apposing metal stents (EGAL) is a new technique that is used as an alternative method to bypass benign or malignant strictures. Endoscopists take advantage of 2 bowel loops that are close to each other and place a stent between the lumen of these 2 bowel loops. The authors performed this systematic review and meta-analysis to evaluate the efficacy and safety of this rising procedure. METHODS Electronic database searches were conducted for full eligible articles that were published from the inception to July 2019 using the EGAL procedure to bypass malignant or benign obstruction or to restore bowel integrity after a gastrointestinal altering surgery. The primary outcome of this meta-analysis was to assess efficacy through technical and clinical success. Secondary outcomes were to assess safety through adverse events and to assess the rate of stent maldeployment and the rate of reintervention during the study period. RESULTS Eight studies were eligible, providing data on 269 patients who underwent 271 EGAL procedures. The median age was 65 years (interquartile range: 63 to 66) with 46% male individuals. Out of 269 patients, 203 underwent EGALs because of malignant etiology and 66 underwent EGAL for benign etiology. The median duration of follow-up was 114 days (interquartile range: 78 to 121). Technical success rate was 94.1% [95% confidence interval (CI), 91.4%-96.9%]. Clinical success rate was 91.4% (95% CI, 88.1%-94.7%). Adverse events rate was 8.5% (95% CI, 4.7%-12.3%). Stent maldeployment rate was 9.5% (95% CI, 3.5%-15.4%) of the total performed EGALs and the reintervention rate was 6.0% (95% CI, 2.3%-9.8%). CONCLUSION EGAL procedure has high efficacy and a relatively safe profile and it can be performed in selected patients. Comparison between EGAL and other conventional therapies is difficult because of the lack of randomized trials.
Collapse
|
7
|
Natural orifice transluminal endoscopic one-anastomosis gastric bypass: a feasibility study using porcine model. Surg Endosc 2021; 35:5842-5851. [PMID: 34008110 DOI: 10.1007/s00464-021-08547-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Endoscopic bariatric therapies (EBT) are emerging as effective therapies in the management of overweight patient with or without metabolic syndrome. Unfortunately most procedures only restrict the gastric volume without altering the underlying metabolism which is seen in surgical patients. The aim of this study was to investigate the feasibility and limitations of a natural orifice trans-luminal endoscopic surgery (NOTES) one anastomosis gastric bypass (OAGB). METHODS NOTES OAGB was performed in three porcine models. The steps of the procedure can be divide as follows: (1) Endoscopic sleeve gastroplasty. (2) Trans-gastric access to peritoneal cavity. (3) Identification of a loop of jejunum. (4) Introduction of the jejunal loop into the stomach. (5) Creation of the gastro-jejunostomy with lumen-apposing metal stent (LAMS). (6) Closure of gastric pylorus with overstitch system. RESULTS All the animals underwent successful NOTES of OAGB. The mean weight for the animals was 34.3 kg (32-37 kg). The mean procedure time was 250 min (300 min for first animal and 180 min for third animal). The average bypassed bilio-pancreatic limb was 98 cm (range 65-130 cm). CONCLUSIONS This study has provided proof-of-principle in a preclinical model that a NOTES approach can be used to perform OAGB and, therefore, merits additional evaluation and consideration.
Collapse
|
8
|
Auriemma F, Fugazza A, Colombo M, Spadaccini M, Repici A, Anderloni A. Safety issues in endoscopy ultrasound-guided interventions using lumen apposing metal stents: a review of the literature. Minerva Gastroenterol (Torino) 2021; 68:177-185. [PMID: 33871222 DOI: 10.23736/s2724-5985.21.02862-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Lumen-apposing metal stents (LAMS) are recently introduced devices that allow to create anastomoses. The indications for LAMS placement are increasing and currently these stents can be used in multiple clinical situations such as endoscopic drainage of pancreatic fluid collections (PFCs), endoscopic ultrasound-guided choledocho-duodenostomy (EUS-CDS), endoscopic ultrasound gallbladder drainage (EUS-GBD), endoscopic ultrasound gastrojejunostomy (EUS-GJ). Since their introduction, they have revealed to allow a higher rate of technical and clinical success, and potentially lower risk of adverse events (AEs) compared with previously available devices. Despite ongoing innovation, any advanced intervention carries risks of AEs. These AEs may occur during the deployment or can be delayed because of the consequent effects of the procedure and/or stent itself. This review represents an overview of current indications, technical and clinical results, with an extensive focus on safety issues related to placement and on long-term indwelling related ones.
Collapse
Affiliation(s)
- Francesco Auriemma
- Digestive Endoscopy Unit, Humanitas Mater Domini, Castellanza, Varese, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy - .,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| |
Collapse
|
9
|
DeWitt JM, Arain M, Chang KJ, Sharaiha R, Komanduri S, Muthusamy VR, Hwang JH. Interventional Endoscopic Ultrasound: Current Status and Future Directions. Clin Gastroenterol Hepatol 2021; 19:24-40. [PMID: 32950747 DOI: 10.1016/j.cgh.2020.09.029] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
The evolution of endoscopic ultrasound (EUS) from a diagnostic to a therapeutic procedure has resulted in a paradigm shift toward endoscopic management of disease states that previously required percutaneous or surgical approaches. The past few years have seen additional techniques and devices that have enabled endoscopists to expand its diagnostic and therapeutic capabilities. Some of these techniques initially were reported more than a decade ago; however, with further device development and refinement in techniques there is potential for expanding the application of these techniques and new technologies to a broader group of interventional gastroenterologists. Lack of formalized training, devices, and prospective data regarding their use in addition to a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors impeding the growth of the field of interventional EUS. In April 2019, the American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology conducted its annual Tech Summit and a key session focused on interventional EUS. This article is a White Paper generated from the conference, discusses the published literature pertaining to the topic of interventional EUS, and outlines a proposed framework for the implementation of interventional EUS techniques into clinical practice. Three primary areas of interventional EUS are addressed: (1) EUS-guided access; (2) EUS-guided tumor ablation; and (3) endohepatology. There was general agreement among participants on several key components. The introduction of these novel interventions requires better tools, more data on safety/outcomes, and improved training for endoscopists. Participants also agreed that widespread implementation and use of these techniques will require support from Gastrointestinal Societies and other key stakeholders including payers. Continued work by the Gastrointestinal Societies and manufacturers to provide training programs, appropriate equipment/work environments, and policies that motivate endoscopists to adopt new techniques is essential for growing the field of interventional EUS.
Collapse
Affiliation(s)
- John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mustafa Arain
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Kenneth J Chang
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, California
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Sri Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California.
| | | |
Collapse
|
10
|
Endoscopic ultrasound-guided gastro-enteric anastomosis: A systematic review and meta-analysis. Dig Liver Dis 2020; 52:1294-1301. [PMID: 32505567 DOI: 10.1016/j.dld.2020.04.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/04/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided gastro-enteric anastomosis (EUS-GEA) using lumen-apposing metal stents (LAMS) is emerging as a minimally invasive alternative to surgery across several indications. Literature on this subject is heterogeneous, with variable reporting of techniques and outcomes. Our aim was to perform a meta-analysis of published data on EUS-GEA, providing a pooled estimate of technical and clinical outcomes. METHODS The protocol was registered in PROSPERO (Reg. no. CRD42018111110). PubMed, Embase, Scopus, and Web of Science databases were searched until February 2019 for studies describing patients undergoing EUS guided enteric anastomosis. PRISMA methodology was used. Pooled technical and clinical success rates as well as pooled adverse events rates were calculated. Study quality, publication bias, and heterogeneity were explored. RESULTS Twelve studies including 290 patients were included, published between 2016 and 2019. All studies but one were retrospective. Main procedure indication was gastric outlet obstruction (62.4%), followed by ERCP access (27.9%) in patients with gastric bypass surgery. Direct puncture technique was the most frequently adopted (68.2%). Pooled technical success rate (12 studies, 290 patients) was 93.5% [95% confidence interval (CI) 89.7-6.0%; I2:0%], while clinical success rate (11 studies, 260 patients) was 90.1% [95%CI 85.5-93.4%; I2:0%]. Pooled total adverse events rate (11 cohorts, 261 patients) was 11.7% [95%CI 8.2-16.6%; I2:0%], mainly mild/moderate: 10.6% [95%CI 7 - 15.6%]. No publication bias or significant heterogeneity was found. CONCLUSIONS EUS-GEA has a high rate of technical and clinical success when performed in expert centers. The procedure appears to be relatively safe, and might represent a non-inferior minimally invasive alternative to surgery. The paucity of long-term clinical outcomes suggests prudency and need for further research, especially regarding non-malignant indications.
Collapse
|
11
|
Adler DG. The transluminal revolution. Gastrointest Endosc 2020; 92:142-143. [PMID: 32586539 DOI: 10.1016/j.gie.2020.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 03/05/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Douglas G Adler
- University of Utah School of Medicine, Huntsman Cancer Center, Salt Lake City, Utah, USA
| |
Collapse
|
12
|
Balsamo F, Pagano N, Rottoli M, Di Simone MP, Sciannamea A, Poggioli G, Bernante P. Endoscopic Ultrasound-Guided Stented Gastro-Gastrostomy for Strictured Vertical Banded Gastroplasty. Obes Surg 2020; 30:3645-3646. [PMID: 32557385 DOI: 10.1007/s11695-020-04773-0] [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] [Indexed: 11/26/2022]
Abstract
Herein, we make a video presentation of an endoscopic reversal of a strictured vertical banded gastroplasty (VBG), carried out through an endoscopic ultrasonography (EUS)-guided transluminal therapy system, in order to accurately identify the common gastric wall and to allow the application of an endoscopic stent. The operative time was 60 min, and no intraoperative complication was recorded. On postoperative day 1, an upper GI swallow showed the oral contrast easily flowing into the body of the stomach throughout the stent. A semi-solid diet was started on day 1. The postoperative course was uneventful, and the patient was discharged on day 2. At the 3-month follow-up visit, the patient denied further symptoms. The follow-up upper GI swallow and endoscopy showed a patent gastro-gastrostomy and no residual gastric pouch dilation or stagnation of the oral contrast, and the stent was therefore removed. Gastro-gastrostomy by endoscopic stenting appears to be an effective option to relief symptoms in strictured VBG, and EUS guidance has made access to the target structure easier and safer.
Collapse
Affiliation(s)
- Francesca Balsamo
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Center for the Study and Research of Surgical Treatment for Morbid Obesity, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Nico Pagano
- Gastroenterology Unit, Sant'Orsola Hospital, Bologna, Italy
| | - Matteo Rottoli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy.
- Department of Medical and Surgical Sciences, Center for the Study and Research of Surgical Treatment for Morbid Obesity, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy.
| | - Massimo P Di Simone
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Sciannamea
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Center for the Study and Research of Surgical Treatment for Morbid Obesity, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| | - Gilberto Poggioli
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Paolo Bernante
- Surgery of the Alimentary Tract, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Center for the Study and Research of Surgical Treatment for Morbid Obesity, Alma Mater Studiorum University of Bologna, Via Massarenti 9, 40138, Bologna, Italy
| |
Collapse
|
13
|
Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success. Surg Endosc 2020; 35:1997-2004. [PMID: 32358692 DOI: 10.1007/s00464-020-07594-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 04/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Lumen-apposing metal stents (LAMS) may be inserted to create gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This new technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO), especially of malignant origin. Technical success was high in the few and small available studies. Aim of this study was to report our experience with this technique and to identify predictors of success in the setting of a large teaching hospital in Germany. METHODS All subsequent patients who underwent EUS-guided gastrointestinal anastomosis with LAMS from 02/2016 to 08/2019 were included. We performed a retrospective chart analysis including technical procedural details, basic demographic, and health characteristics. Technical success was defined as successful insertion of LAMS. In patients with GOO, the GOO Scoring System was used; an improvement ≥ 1 point was defined as clinical success. RESULTS Thirty-five patients (22 female, median age: 79 years) were included. Indication for the anastomosis was malignant GOO in 33 patients. In ten patients LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of LAMS was performed, and other techniques were used in two patients. Technical success rate was 80.0%. Adverse events occurred in 14.3%. Clinical success rate was 74.3%. Technical success increased and procedure time decreased significantly during the study period. Distance between the two lumina connected with LAMS was significantly shorter (median: 9 mm) in patients with technical success compared to those without (median: 20 mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis. CONCLUSIONS EUS-guided gastrointestinal anastomosis with LAMS is an emerging technique. Its success mainly depends on the distance between the two lumina that are going to be connected by the LAMS and is influenced by the endoscopist's experience.
Collapse
|
14
|
Iqbal U, Khara HS, Hu Y, Kumar V, Tufail K, Confer B, Diehl DL. EUS-guided gastroenterostomy for the management of gastric outlet obstruction: A systematic review and meta-analysis. Endosc Ultrasound 2020; 9:16-23. [PMID: 31898587 PMCID: PMC7038736 DOI: 10.4103/eus.eus_70_19] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Gastric outlet obstruction (GOO) is characterized by epigastric pain and postprandial vomiting secondary to mechanical obstruction. Management of GOO is usually focused on alleviating the symptoms of obstruction and can be achieved by surgical gastrojejunostomy or enteral stenting. Recent studies have shown success with EUS-guided gastroenterostomy (EUS-GE) in the management of GOO but data is limited. We, therefore, conducted a meta-analysis to evaluate the safety and efficacy of EUS-GE in the management of GOO. A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to January 2019 to identify all studies that evaluate the efficacy and safety of EUS-GE in GOO. Our primary outcome was to evaluate technical success and clinical success. Secondary outcomes were to evaluate the need for reintervention and adverse events of the procedure. Twelve studies including 285 patients were included in the meta-analysis. Technical success was achieved in 266 patients with a pooled technical success of 92% (95% confidence interval [CI]: 88%-95%). Clinical success was achieved in 90% of the patients (95% CI: 85%-94%). Recurrence of symptoms or unplanned reintervention was needed in 9% of the patients (95% CI: 6%-13%) and adverse events were reported in 12% of the patients (95% CI: 8%-16%). The heterogeneity tests among studies were nonsignificant with I2 = 0. EUS-GE is a safe and efficacious treatment modality for the management of benign and malignant GOO. Larger prospective studies are needed to further evaluate its utility in GOO.
Collapse
Affiliation(s)
- Umair Iqbal
- Department of Internal Medicine, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Harshit S Khara
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - Yirui Hu
- Geisinger Medical Center, Biomedical and Translational Informatics Institute, Danville, PA, USA
| | - Vikas Kumar
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - Kashif Tufail
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - Bradley Confer
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| | - David L Diehl
- Department of Gastroenterology and Hepatology, Geisinger Medical Center, Danville, PA, USA
| |
Collapse
|
15
|
Pérez-Cuadrado Robles E, Prat F, Deprez PH. Endoscopic ultrasound-guided drainage with lumen-apposing metal stents: a good safety profile also in the long term? REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:416-418. [PMID: 31081671 DOI: 10.17235/reed.2019.6348/2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Lumen-apposing metal stents (LAMSs) have been specifically designed for the endoscopic drainage of pancreatic fluid collections and walled-off necrosis. Lately, LAMS indications have expandedto other anastomoses, and these stents have proven to be effective in multiple situations. Safety data for this device are still limited, most studies to date being focused on intraoperative complications and not long-term issues. There are little data regarding the best timing for removal and the risks associated in leaving them in place for long duration. In addition, not all the procedure-related complications have the same clinical impact, and the settings in which LAMS have been used are heterogeneous, leading to different safety profiles and outcomes. A wide consensus on the definition of complications and a list of key performance measures for LAMS placement seems mandatory to allow for a robust assessment of their long-term outcomes.
Collapse
Affiliation(s)
| | | | - Pierre H Deprez
- Gastroenterology, Cliniques universitaires Saint-Luc, Belgium
| |
Collapse
|
16
|
Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018. Gastrointest Endosc 2019; 90:35-43. [PMID: 30928425 DOI: 10.1016/j.gie.2019.03.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 12/11/2022]
Abstract
The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.
Collapse
|
17
|
Adler DG. Should Patients With Malignant Gastric Outlet Obstruction Receive Stents or Surgery? Clin Gastroenterol Hepatol 2019; 17:1242-1244. [PMID: 30503965 DOI: 10.1016/j.cgh.2018.11.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Douglas G Adler
- Gastroenterology and Hepatology Division, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, Utah
| |
Collapse
|
18
|
Abstract
Linear echoendoscopes with large instrument channels enable EUS-guided interventions in organs and anatomical spaces in proximity to the gastrointestinal tract. Novel devices and tools designed for EUS-guided transluminal interventions allow various new applications and improve the efficacy and safety of these procedures. New-generation biopsy needles provide higher histology rates and require less passes. Specially designed stents and stent insertion devices enable intra- and extra-hepatic bile and pancreatic duct stenting as well as gallbladder drainage. Currently, EUS-guided biliary drainage in obstructive jaundice due to malignant distal bile duct obstruction is feasible and safe when ERCP has failed. It might replace ERCP as first choice intervention in future. EUS-guided transmural stenting is regarded as the preferred intervention in the management of symptomatic peripancreatic fluid collections. Creating a new anastomosis between different organs such as gastrojejunostomy has also become possible with lumen-apposing stents. EUS-guided creation of a gastrogastrostomy is a promising novel technique to access the excluded stomach to facilitate conventional ERCP in patients with Roux-en-Y gastric bypass anatomy. The role of EUS in tumor ablation and targeted angiotherapy is also constantly expanding. In this review, we report on the newest developments of therapeutic EUS within the past 4 years.
Collapse
Affiliation(s)
- Barbara Braden
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Vipin Gupta
- Translational Gastroenterology Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | |
Collapse
|