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Wang J, Hu JL, Sun SY. Endoscopic ultrasound guided gastroenterostomy: Technical details updates, clinical outcomes, and adverse events. World J Gastrointest Endosc 2023; 15:634-640. [DOI: 10.4253/wjge.v15.i11.634] [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: 08/09/2023] [Revised: 09/12/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023] Open
Abstract
Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has been transformed from an innovative technique, into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction. Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed, giving patients more less invasive options. However, EUS-GE is still a technically challenging procedure. In order to improve EUS-GE, several techniques have been reported to improve the technical details. With EUS-GE widely performed, more data about EUS-GE’s clinical outcomes have been reported. The aim of the current review is to describe technical details updates, clinical outcomes, and adverse events of EUS-GE.
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Affiliation(s)
- Jian Wang
- Department of Gastroenterology, People's Hospital of Shenyang Economic and Technological Development Zone, Shenyang 110001, Liaoning Province, China
| | - Jin-Long Hu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Si-Yu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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Hu J, Wang G, Gao H, Sheng S, Sun S. The formation process and mechanism of gastrointestinal anastomosis after retrieval anchor-assisted endoscopic ultrasound-guided gastroenterostomy: a preclinical study. Surg Endosc 2023; 37:2043-2049. [PMID: 36289084 DOI: 10.1007/s00464-022-09565-4] [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: 11/21/2021] [Accepted: 08/14/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a promising method of treating gastric outlet obstruction. However, no study has investigated gastrointestinal anastomosis formation after EUS-GE. We aimed to evaluate the formation of gastrointestinal anastomosis after EUS-GE in a porcine model. METHODS Retrieval anchor-assisted EUS-GE was performed on 15 Bama mini pigs. Five pigs each were randomly euthanized 3, 7, and 14 days postoperatively to evaluate the formation of gastrointestinal anastomosis and measure the anastomotic distance. The expression of transforming growth factor-β1(TGF-β1) and Smad3 in the anastomosis site were examined by immunohistochemistry. RESULTS EUS-GE was successfully performed in all 15 pigs. The mean procedure time was 29.2 ± 6.0 (range 18-40) minutes. The anastomotic distance was 34.0 ± 3.6 cm in 14 pigs. The site of gastroenterostomy of one pig was at the ileum. For pigs euthanized 3 days postoperatively, the structure was mechanically maintained by a stent. For pigs euthanized 7 or 14 days postoperatively, the stomach and small intestine were anastomosed to form a stable structure. The level of TGF-β1 and Smad3 in the anastomosis site gradually increased from 3 to 14 days after EUS-GE. TGF-β1 and Smad3 expression had a significant difference between 3 days, 7 days, and 14 days after EUS-GE (P < 0.05). CONCLUSIONS For EUS-GE, the stomach and small intestine were initially linked together mechanically and spontaneously anastomosed to form a stable structure 7 days postoperatively. TGF-β1 and Smad3 play an important role in the formation of a stable structure of gastrointestinal anastomosis.
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Affiliation(s)
- Jinlong Hu
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Guoxin Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Haixin Gao
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Shiyun Sheng
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China
| | - Siyu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang, 110004, China.
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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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van Wanrooij RLJ, Bronswijk M, Kunda R, Everett SM, Lakhtakia S, Rimbas M, Hucl T, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M, Pérez-Miranda M, van Hooft JE, van der Merwe SW. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54:310-332. [PMID: 35114696 DOI: 10.1055/a-1738-6780] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- 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, Imelda General Hospital, Bonheiden, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Rastislav Kunda
- Department of Surgery, Department of Gastroenterology and Hepatology, and Department of Advanced Interventional Endoscopy, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Simon M 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
| | - 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 Giorgio 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, 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 Pérez-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
| | - Schalk W van der Merwe
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
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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: 181] [Impact Index Per Article: 90.5] [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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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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