Should Patients With Malignant Gastric Outlet Obstruction Receive Stents or Surgery?

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emer-ged as an alternative treatment for gastric outlet obstruction (GOO) in selected patients.

AIM

To report the initial experience of EUS-GE in patients with GOO.

METHODS

This study was a retrospective, observational, multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected. We analyzed technical success, clinical success, adverse events, and survival. Technical success was defined as adequate position-ing and deployment of the stent. Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure. Post-procedural adverse events were recorded.

RESULTS

Eleven procedures in 10 patients with GOO were included. The mean age of the patients was 67.5 years (range: 56-77 years). Malignant GOO was present in 9 patients. Technical success was achieved in 9/11 procedures (82%). Among them, clinical success was achieved in 9 patients (100%). Adverse events occurred in 1 patient (9%). The median survival was 3 months (n = 7; range: 1-8 months).

CONCLUSION

EUS-GE is a feasible therapeutic option in the treatment of GOO.

Utility of interventional endoscopic ultrasound in pancreatic cancer

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.

No difference in outcomes with 15 mm vs. 20 mm lumen-apposing metal stents for endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a meta-analysis

BACKGROUND/AIMS

We compared outcomes between use of 15 vs. 20 mm lumen-apposing metal stents (LAMSs) in endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction.

METHODS

Databases were queried for studies that used LAMS for EUS-GE to relieve gastric outlet obstruction, and a proportional meta-analysis was performed.

RESULTS

Thirteen studies were included. The 15 mm and 20 mm LAMS had pooled technical success rates of 93.2% (95% confidence interval [CI], 90.5%-95.2%) and 92.1% (95% CI, 68.4%-98.4%), clinical success rates of 88.6% (95% CI, 85.4%-91.1%) and 89.6% (95% CI, 79.0%-95.1%), adverse event rates of 11.4% (95% CI, 8.1%-15.9%) and 14.7% (95% CI, 4.4%-39.1%), and reintervention rates of 10.3% (95% CI, 6.7%-15.4%) and 3.5% (95% CI, 1.6%-7.6%), respectively. Subgroup analysis revealed no significant differences in technical success, clinical success, or adverse event rates. An increased need for reintervention was noted in the 15 mm stent group (pooled odds ratio, 3.59; 95% CI, 1.40-9.18; p=0.008).

CONCLUSION

No differences were observed in the technical, clinical, or adverse event rates between 15 and 20 mm LAMS use in EUS-GE. An increased need for reintervention is possible when using a 15 mm stent compared to when using a 20 mm stent.

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy for the palliation of gastric outlet obstruction in patients with peritoneal carcinomatosis

BACKGROUND : Gastric outlet obstruction (GOO) with peritoneal carcinomatosis presents a technical challenge. Surgical gastrojejunostomy (SGJ) or enteral stenting have been the standard of care; however, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a favorable alternative. Few data exist that compare these techniques in the setting of peritoneal carcinomatosis. METHODS : This single-center retrospective cohort study included 25 EUS-GE and 27 SGJ consecutive patients. Baseline demographics, cancer diagnosis and stage, clinical and technical success, adverse events, and obstruction recurrence data were collected. The primary outcome was the technical success comparison; secondary outcome was the adverse event rate comparison. Rates were compared with standard statistical tests. RESULTS : Mean age, obstruction location, and symptoms were similar between the groups. The EUS-GE group had more advanced disease (clinical stage 4, 100 % vs. 67 %; P = 0.006) and higher American Society of Anesthesiologists classification (class 3-4, 92 % vs. 50 %; P = 0.004). The technical success rate was 100 % in both groups (P > 0.99) and the adverse event rate was lower for EUS-GE (8 % vs. 41 %; P = 0.01). Clinical success was 88 % for EUS-GE and 85 % for SGJ (P > 0.99) and recurrent obstruction was lower with EUS-GE (28 % vs. 41 %; P = 0.13). The EUS-GE group had shorter procedure duration, length of stay, and time to chemotherapy resumption than the SGJ group. CONCLUSIONS : Although the EUS-GE group was older, with more comorbidity and advanced stages, the technical success rate was similar to SGJ and it had significantly fewer adverse events. EUS-GE is a safe and effective option for the management of malignant GOO with peritoneal carcinomatosis.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction (GOO) is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum. GOO can be caused by either benign or malignant etiologies, often resulting in early satiety, nausea, vomiting and poor oral intake. GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies. Traditional treatment options for GOO can be broadly divided into surgical [surgical gastrojejunostomy (GJ)] and endoscopic interventions (dilation and/or placement of luminal self-expanding metal stents). While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting, it has also been associated with a higher rate of adverse events. Furthermore, many patients with advanced metastatic disease are not good surgical candidates. More recently, endoscopic ultrasound (EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches. This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Staged laparoscopic management of locally advanced gastric cancer with outlet obstruction

BACKGROUND

The prognosis of patients with locally advanced gastric cancer with outlet obstruction is poor. Gastrectomy with curative intent is often initially impossible or difficult.

OBJECTIVE

We report our experience of curative distal gastrectomy after laparoscopic gastrojejunostomy and fluorouracil, leucovorin, oxaliplatin, and docetaxel (FLOT) chemotherapy to examine the feasibility and safety of this modified strategy for locally advanced gastric cancer with outlet obstruction, initially deemed unresectable.

METHODS

Between October 2017 and June 2019, 15 patients diagnosed with locally advanced gastric cancer with outlet obstruction sequentially underwent gastrojejunostomy, received four cycles of FLOT chemotherapy, and underwent laparoscopic distal gastrectomy with curative intent (R0 resection + D2 lymphadenectomy). Clinical data were retrospectively collected and analyzed.

RESULTS

R0 resection was possible in 12/15 patients, laparoscopically in 11, and one conversion to laparotomy was necessary. There was no perioperative mortality in the 12 patients. Pathologic evaluation of the resected specimens revealed that complete tumor grade regression 1a (TRG1a), TRG1b, TRG2, and TRG3 occurred in 3, 2, 4, and 3 patients, respectively.

CONCLUSION

This case series showed that curative surgical resection was feasible as a staged approach for patients with locally advanced gastric cancer with outlet obstruction, after initial staged gastrojejunostomy and chemotherapy.