EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction

[Treatment Strategies for Gastric Cancer Patients with Gastric Outlet Obstruction]

Gastric cancer frequently leads to gastric outlet obstruction (GOO), causing significant symptoms and complications. Surgical bypass and stenting are two representative palliative treatments for GOO by gastric cancer. This study reviews clinical guidelines for malignant GOO treatment, highlighting differences in recommendations based on patient survival expectations and systemic health. A meta-analysis of surgical bypass and stenting in gastric cancer patients revealed no significant difference in technical and clinical success rates between the two treatments. However, stenting allowed faster resumption of oral intake and shorter hospital stays but had higher rates of major complications and reobstruction. Despite these differences, overall survival did not significantly differ between the two groups. Emerging techniques like EUS-guided gastrojejunostomy show promise but require further research and experienced practitioners. Ultimately, treatment should be tailored to patient preferences and the specific benefits and drawbacks of each method to improve quality of life and outcomes.

Endoscopic ultrasound-guided gastrojejunostomy for benign gastric outlet obstruction (GOO): a retrospective analysis of patients and outcomes

BACKGROUND AND STUDY AIMS

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) has been well utilized in treating malignant gastric outlet obstructions (GOO) given its efficacy and lower risk profile compared to surgery. However, its efficacy and potential for use in patients with benign GOO who are poor surgical candidates is not well documented. The aim of this study was to examine the role of EUS-GJ in treatment of benign GOO in select patients.

PATIENTS AND METHODS

This is a single-center, open-label, retrospective descriptive study that included all consecutive patients undergoing EUS-GJ to treat benign causes of GOO. Direct antegrade and direct retrograde methods were utilized.

RESULTS

A total of 18 patients were included, 38.9% female with an average age of 63.3 years. Extrinsic GOO was present in (10 of 18) 55.5% of patients and intrinsic etiology was present in (8 of 18) 45.5% of patients. Technical success was achieved in 100% (18 of 18) patients and clinical success was achieved in 94% (17 of 18) patients. In total, 13 patients had follow-up endoscopy, 2 patients were treated relatively recently in time, 1 patient was lost to follow-up, and 2 patients died of other chronic illnesses. Stents remained in place for a median of 286 days (range 88-1444 days). In patients whose stents were removed, 75% (3 of 4) had extrinsic etiologies of GOO.

CONCLUSIONS

This study reports a favorable long-term patency with excellent technical and clinical success of EUS-GJ in patients with benign GOO. Despite the limitations of sample size and retrospective nature, it adds to the extremely limited literature of EUS-GJ in management of patients with benign GOO.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Endoscopic Treatment of Gastric Outlet Obstruction

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.

EUS-guided gastroenterostomy for gastric outlet obstruction: a comprehensive meta-analysis

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.

Managing complications of chronic pancreatitis: a guide for the gastroenterologist

INTRODUCTION

Chronic pancreatitis is a heterogeneous and complex syndrome that, in most cases, causes pain as a cardinal symptom and affects both the morphology and function of the pancreas, leading to several serious complications.

AREAS COVERED

The present review, based on a non-systematic PubMed search updated to June 2023, aims to present the current available evidence on the role of gastroenterologists in the diagnosis and treatment of both local and systemic complications by either endoscopic or medical treatments.

EXPERT OPINION

At diagnosis and during chronic pancreatitis follow-up, particular care is needed to consider not only the clinically manifest signs and symptoms of the disease, such as pain, jaundice, gastrointestinal obstruction, and pseudocysts, which require multidisciplinary discussion to establish the best treatment option (endoscopic or surgical), but also less evident systemic complications. Pancreatic exocrine and endocrine insufficiency, together with chronic inflammation, addiction, and dysbiosis, contribute to malnutrition, sarcopenia, and osteopathy. These complications, in turn, increase the risk of infection, thromboembolic events, and death. Patients with chronic pancreatitis also have an increased risk of psychiatric disorders and pancreatic cancer onset. Overall, patients with chronic pancreatitis should receive a holistic evaluation, considering all these aspects, possibly through multidisciplinary care in dedicated expert centers.

The Role of Luminal Apposing Metal Stents on the Treatment of Malignant and Benign Gastric Outlet Obstruction

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.

Outcomes of endoscopic ultrasound-guided gastro-enterostomy for gastric outlet obstruction in a two-centre Australian Cohort (with video)

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.

The Role of Endoscopic Management in Afferent Loop Syndrome

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.

Endoscopic ultrasound-guided gastrointestinal anastomosis: Current status and future perspectives

OBJECTIVES

Both clinical experience and supporting data have improved drastically in the context of endoscopic ultrasound-guided gastrointestinal anastomosis (EUS-GIA). Where outcomes used to be questioned, focus has now moved towards performing comparative studies, optimizing technical approaches, improving patient selection, and developing well-defined treatment algorithms.

METHODS

The purpose of this review is to provide an overview of technical developments within EUS-GIA and to discuss the current status of EUS-GIA and future directions.

RESULTS

EUS-GIA techniques such as EUS-guided gastroenterostomy (EUS-GE), EUS-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) (EDGE) and EUS-guided treatment afferent loop syndrome have undergone further development, refining technical approaches, improving patient selection and subsequent outcomes. Retrospective evaluations of EUS-GE have shown similar safety when compared to enteral stenting, whilst attaining surgical range efficacy. Whereas, in patients with gastric bypass anatomy, EDGE seems less cumbersome and time consuming than enteroscopy-assisted ERCP, while preventing surgical morbidity associated with laparoscopy-assisted ERCP. Although less evidence is available on EUS-guided treatment of afferent loop syndrome, this technique has been associated with higher clinical success and fewer reinterventions and adverse events when compared to enteral stenting and percutaneous drainage, respectively. Several randomized studies are currently underway evaluating EUS-GE in malignant gastric outlet obstruction (GOO), whereas more prospective data are still required on EDGE and long-term fistula management.

CONCLUSION

EUS-GIA has become a crucial alternative to established techniques, overcoming technical limitations and subsequently improving patient outcomes. Although we should focus on prospective confirmation of these results in the context of GOO and EDGE, the current evidence already allows for a prominent role for EUS-GIA in our everyday practice.

Clinical and technical outcomes of patients undergoing endoscopic ultrasound-guided gastroenterostomy using 20-mm vs. 15-mm lumen-apposing metal stents

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.

Perceived Feasibility of Endoscopic Ultrasound-Guided Gastroenteric Anastomosis: An Italian Survey

Background and Objectives: Endoscopic ultrasound-guided gastroenteric anastomosis (EUS-GEA) using lumen-apposing metal stents (LAMS) is emerging as a minimally invasive alternative to surgery across several indications. The aim of this survey is to investigate the perceived feasibility of this technique nationwide, within a working group skilled in interventional endosonography. Materials and Methods: Endoscopists were asked to answer to 49 items on a web-based questionnaire about expertise, peri- and intra-procedural aspects in the three main settings of EUS-GEA performance, budget/refund, and future perspectives. Statistical analysis was performed through SPSS^® (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). Results: Sixty endosonographers belonging to forty Italian centers were I-EUS app users and were all invited to participate. In total, 29 participants from 24 Italian centers completed the survey. All the participants were endosonographers with a broad range of experience both in the field of EUS (only 10.3% with more than 20 years of experience) and duodenal stenting (only 6.9% placed more than 10 stents in 2020), whereas 86.2% also performed ERCP. A total of 27.6% of participants performed EUS-GEA (3.4% more than 20 during their career); on the other hand, 79.3% of participants routinely performed drainage of peri-pancreatic fluid collections, 62.1% performed biliary drainage, and 62.1% performed gallbladder drainage with LAMS. A total of 89.7% of participants thought that EUS-GEA could be useful in their daily clinical practice, with 100% concluding that this procedure will need to be performed in referral centers in the near future; however, in 55.2% of cases, organizational obstacles may occur and affect the diffusion of the procedure. With regard to indications: 44.8% of participants performed the procedure with palliative intent for malignant indication (96.6% pancreatic adenocarcinoma), and 13.6% also for benign indication. A total of 20.7% of participants experienced adverse events (none severe or fatal, 66.6% moderate). A total of 62.1% of participants considered the procedure technically challenging, although 82.8% considered the risk of adverse events acceptable when considering the benefit. Conclusions: To our knowledge, this is the first survey assessing the perceived feasibility of EUS-guided anastomoses after its advent. There are currently wide variations in practice nationwide, which demonstrate a need to define technical, qualitative, and peri-procedural requirements to carry out this procedure. Therefore, a standardization of these requirements is needed in order to overcome the technical, economical, and organizational obstacles relative to its diffusion.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

1:  ESGE recommends a prolonged course of a prophylactic broad-spectrum antibiotic in patients with ascites who are undergoing therapeutic endoscopic ultrasound (EUS) procedures.Strong recommendation, low quality evidence. 2:  ESGE recommends placement of partially or fully covered self-expandable metal stents during EUS-guided hepaticogastrostomy for biliary drainage in malignant disease.Strong recommendation, moderate quality evidence. 3:  ESGE recommends EUS-guided pancreatic duct (PD) drainage should only be performed in high volume expert centers, owing to the complexity of this technique and the high risk of adverse events.Strong recommendation, low quality evidence. 4:  ESGE recommends a stepwise approach to EUS-guided PD drainage in patients with favorable anatomy, starting with rendezvous-assisted endoscopic retrograde pancreatography (RV-ERP), followed by antegrade or transmural drainage only when RV-ERP fails or is not feasible.Strong recommendation, low quality evidence. 5:  ESGE suggests performing transduodenal EUS-guided gallbladder drainage with a lumen-apposing metal stent (LAMS), rather than using the transgastric route, as this may reduce the risk of stent dysfunction.Weak recommendation, low quality evidence. 6:  ESGE recommends using saline instillation for small-bowel distension during EUS-guided gastroenterostomy.Strong recommendation, low quality evidence. 7:  ESGE recommends the use of saline instillation with a 19G needle and an electrocautery-enhanced LAMS for EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) procedures.Strong recommendation, low quality evidence. 8:  ESGE recommends the use of either 15- or 20-mm LAMSs for EDGE, with a preference for 20-mm LAMSs when considering a same-session ERCP.Strong recommendation, low quality evidence.

Wilkie’s syndrome as a cause of anxiety-depressive disorder: A case report and review of literature

BACKGROUND

Superior mesenteric artery syndrome is a disease with a complex diagnosis, and it is associated with complications that make it even harder to identify. Currently, a frequent association with psychiatric disorders has been noted. Despite numerous case reports and case series, the variability of the disease has not allowed the development of protocols regarding diagnosis and management.

CASE SUMMARY

A 33-year-old woman presented with abdominal pain, nausea, and bile vomiting over the last 15 mo, associated with a 15-kg weight loss over the last three months. After the onset of the symptoms, the patient was diagnosed with anxiety-depressive disorder and treated appropriately. Standard examinations excluded an organic cause, and the cause of the symptoms was considered psychogenic. The persistence of symptoms, even under treatment, prompted a computer tomography angiography examination of the abdomen and pelvis. The examination identified emergence at a sharp angle of 13.7° of the superior mesenteric artery, with a reduced distance between the artery and the anterior wall of the aorta up to a maximum of 8 mm. A diagnosis of aortomesenteric clamp was established. Surgical treatment by laparoscopic duodenojejunostomy was performed. Postoperative evolution was marked by a patent anastomosis at 1 mo, with a 10-kg weight gain and improvement of the associated anxiety.

CONCLUSION

This case report underlines two major aspects. One aspect refers to the predisposition of patients with superior mesenteric artery syndrome to develop psychiatric disorders, with an excellent outcome when proper treatment is administered. The second aspect underlines the key role of a multidisciplinary approach and follow-up.

Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

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.

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

Background

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

Main body

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

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

Conclusion

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

Supplementary Information

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

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

Background and Objectives:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

Lumen-apposing metal stents (with videos)

BACKGROUND AND AIMS

Lumen-apposing metal stents (LAMSs) are a novel class of devices that have expanded the spectrum of endoscopic GI interventions. LAMSs with their dumbbell configuration, short saddle length, and large inner luminal diameter provide favorable stent characteristics to facilitate anastomosis formation between the gut lumen and adjacent structures.

METHODS

The MEDLINE database was searched through April 2021 for articles related to LAMSs by using additional relevant keywords such as "walled-off pancreatic necrosis," "pseudocysts," "pancreatic fluid collection," "cholecystitis," "gastroenterostomy," in addition to "endoscopic treatment" and "endoscopic management," among others.

RESULTS

This technology review describes the full spectrum of LAMS designs and delivery systems, techniques for deployment, procedural outcomes, safety, training issues, and financial considerations.

CONCLUSIONS

Although LAMSs were initially introduced for drainage of pancreatic pseudocysts and walled-off necrosis, the versatility of these devices has led to a variety of off-label uses including gallbladder drainage, enteric bypass with the creation of gastroenterostomies, and treatment of luminal GI strictures.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Endoscopic ultrasound-guided gastroenterostomy using large-diameter (20 mm) lumen apposing metal stent (LLAMS)

Background and study aims  Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a 15-mm lumen apposing metal stent (LAMS) has emerged as a viable alternative to surgical gastrojejunostomy for management of gastric outlet obstruction (GOO). However, given the size of the anastomosis created with a 15-mm LAMS, long-term luminal patency and clinical outcomes may be suboptimal. The aim of this study was to evaluate the technical feasibility, efficacy, and safety of EUS-GE with a large-diameter (20 mm) LAMS (LLAMS). Patients and methods  A retrospective analysis of a prospectively maintained database of all patients undergoing EUS-GE with LLAMS between December 1, 2018 and September 30, 2020 was performed. All EUS-GEs were performed using a cautery-enhanced LLAMS. Results  Thirty-three patients were referred for endoscopic management of GOO. Two patients were excluded due to a lack of an adequate window for EUS-GE. The remaining 31 patients (93.94 %) (mean age: 61.35 ± 16.52 years; 54.84 % males) underwent EUS-GE using LLAMS for malignant (n = 23) and benign (n = 8) GOO. Technical success was achieved in all patients (100 %) with attempted EUS-GE. Complete clinical success (tolerance of regular diet) was achieved in 93.55 % of patients (n = 29). Two patients (6.45 %) had partial clinical success and died of unrelated causes prior to advancing diet beyond full liquids. Overall mean follow-up was 140.84 ± 160.41 days (median 70, range 4-590). All stents remained patent with no evidence of recurrent GOO symptoms. One patient (3.23 %) developed an asymptomatic clean-based jejunal ulcer on 3-month follow-up endoscopy. Conclusions  EUS-GE with LLAMS is a technically feasible, effective and safe option for patients with GOO allowing for tolerability of regular diet. Future prospective, ideally randomized studies comparing long-term outcomes of EUS-GE with 20- and 15-mm LAMS are required.

Feasibility and patency of echoendoscopic anastomoses with lumen apposing metal stents depending on the gastrointestinal segment involved

EUS-guided anastomoses with LAMS have emerged as a therapeutic option for patients with obstruction of the digestive tract. However, the long-term permeability of these anastomoses remains unknown. Most of the published cases involve the gastric wall and experience in distal obstruction is limited to few case reports. We review our series of patients treated with LAMS for gastrointestinal obstruction and describe the technical success according to the anastomotic site and the long-term follow-up in those cases in which the stent migrated spontaneously or was removed. Out of 30 cases treated with LAMS, EUS-guided anastomosis did not involve the gastric wall in 6 patients. These procedures were technically more challenging as two failures were recorded (2/6, 33%) while technical success was achieved in 100% of the cases in which the stent was placed through the gastric wall. In two of the patients, one with entero-enteric and another with recto-colic anastomosis, stent removal after spontaneous displacement was followed by long term permeability of the EUS-guided anastomosis (172 and 234 days respectively). In a EUS-guided gastroenterostomy the stent was removed at 118 days, but closure of the fistula was confirmed 26 days later. Our experience suggests that LAMS placement between bowel loops is feasible and might allow the creation of an anastomosis with long-term patency. As compared to LAMS placement between bowel loops, when LAMS are placed through the gastric wall, removal of the LAMS seems to lead to closure of the fistula.

Endoscopic Ultrasonography-Guided Gastroenterostomy Techniques for Treatment of Malignant Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) can be caused by periampullary malignancies and often leads to a reduction in a patient’s quality of life. Recently, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) using a lumen-apposing self-expandable metal stent (LAMS) has been developed as a minimally invasive and durable endoscopic treatment for GOO. There are three types of EUS-GE technique: (1) the direct technique; (2) device-assisted techniques, such as a balloon catheter, nasobiliary drainage tube, and ultraslim endoscopy; and (3) EUS-guided double balloon-occluded gastrojejunostomy bypass. Previous reports of EUS-GE with LAMS have shown technical and clinical success rates (regardless of technique and etiology) of 87%–100% and 84%–100%, respectively. Studies comparing EUS-GE and surgical gastrojejunostomy have shown similar success rates, reintervention rates, and cost benefits, with a lower rate of early adverse events in EUS-GE. A comparison of EUS-GE and endoscopic enteral stent placement revealed similar technical success rates, but initial clinical success rate was higher and the rate of stent failure requiring reintervention was lower with EUS-GE.

Endoscopic ultrasound-guided anastomosis: Is it ready for prime time?

Significant advancements in endoscopic ultrasound (EUS)-guided drainage procedures and EUS-guided anastomosis have recently been described. The described procedures include EUS-guided drainage of pancreatic fluid collections, biliary drainage, pancreatic duct drainage, gallbladder drainage, and gastroenterostomy. These procedures have been made possible with novel devices that can reduce the difficulties of the procedures and potentially reducing the risk of adverse events. The procedures are also becoming standardized, which is essential for dissemination of the techniques. Furthermore, results from randomized studies are becoming available showing definite benefits associated with these procedures. In this paper, we will provide a review on EUS-guided anastomotic procedures.

Management of gastric outlet obstruction: Focusing on endoscopic approach

Gastric outlet obstruction (GOO) is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction. The obstructions typically involved in GOO can be benign or malignant. Peptic ulcer disease is the most common cause of benign GOO, and malignant causes include gastric cancer, lymphoma, and gastrointestinal stromal tumor. With the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors, the predominant causes have changed from benign to malignant diseases. Treatment of GOO depends on the underlying cause: Proton pump inhibitors, H. pylori eradication, endoscopic treatments including balloon dilatation or the placement of self-expandable stents, or surgery.