Clinical Review of EUS-guided Gastroenterostomy (EUS-GE)

Lumen-apposing metal stents for anastomosis creation throughout the gastrointestinal tract: A large single-center experience

Objectives

The introduction of lumen-apposing metal stents (LAMSs) has revolutionized the field of therapeutic endoscopic ultrasound. This study aims to evaluate the efficacy and safety of LAMS in creating an endoscopic ultrasound-guided anastomosis between two segments of the gastrointestinal (GI) tract.

Methods

Data from all consecutive LAMS procedures for anastomosis creation between two segments of the GI, conducted between October 2019 and February 2024, were retrospectively analyzed for technical success (defined as correct deployment of the LAMS in the target), clinical success (defined as achievement of the intended clinical goal), and adverse events.

Results

A total of 145 LAMS procedures were performed in 136 patients. Indications for LAMS procedures included the need for endoscopic access to or reversal of surgically excluded segments of the GI tract (n = 73, 50.3%), and the alleviation of any GI outflow obstruction (n = 72, 49.7%). The overall technical and clinical success rates were very high (97.2% and 95.2%, respectively). Adverse events were observed in 20/145 (13.8%) cases, including 11 (7.6%) minor events (AGREE <3) and nine (6.2%) major events (AGREE ≥3). Major events included stent migration (n = 1), persisting fistula (n = 3), and bleeding (n = 4). All adverse events were successfully managed, and there were no procedure-related deaths. Loss of LAMS patency occurred in 4/145 (2.8%) cases and could be endoscopically managed in all cases.

Conclusions

The creation of anastomoses with LAMS between two segments of the GI tract appears to be effective and safe, with a low reintervention rate due to loss of LAMS patency.

Therapeutic Endoscopic Ultrasound and Endoscopic Ultrasound-Endoscopic Retrograde Cholangiopancreatography Interventions

Therapeutic endoscopic ultrasound (EUS) encompasses an array of procedures to manage pancreaticobiliary and luminal gastrointestinal disorders. Therapeutic EUS procedures include EUS-guided rendezvous of the pancreatic and biliary ducts, as well as direct drainage of the bile duct, pancreatic duct, and gallbladder, drainage of pancreatic fluid collections, and luminal anastomosis creation. These procedures have a range of required equipment, approaches, clinical outcomes, and adverse events dependent on both procedure-related and patient-related factors. In expert hands, these procedures provide patients with less invasive options and can achieve excellent clinical outcomes.

Treatment of choice for malignant gastric outlet obstruction: More than clearing the road

In this editorial, we comment on the in-press article in the World Journal of Gastrointestinal Endoscopy concerning the treatment of malignant gastric outlet obstruction (mGOO). The original theory of treatment involves bypassing the obstruction or reenabling the patency of the passage. Conventional surgical gastroenterostomy provides long-term relief of symptoms in selected patients, with substantial morbidity and a considerable rate of delayed gastric emptying. Endoscopic stenting was introduced as an alternative minimally invasive procedure with less procedural morbidity and rapid clinical improvement; however, it presented a high rate of long-term recurrence. Therefore, challenges remain in the treatment of mGOO patients to improve clinical outcomes. Endoscopic ultrasound-guided gastroenterostomy has recently emerged as a promising method because of the combined effects of surgery and endoscopy, whereas stomach-partitioning gastrojejunostomy has been reported as a modified surgical procedure to reduce the rate of delayed gastric emptying. In decision-making regarding the treatment of choice, it should be taken into account that mGOO might be accompanied by a variety of pathological conditions, including cancer cachexia, anorexia, malabsorption, and etc., all of which can also lead to the characteristic symptoms and poor nutritional status of mGOO. The treatment plan should consider comprehensive aspects of patients to achieve practical improvements in prognosis and the quality of life.

Endoscopic ultrasound-guided gastrojejunostomy with wire endoscopic simplified technique: Move towards benign indications (with video)

OBJECTIVES

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an alternative to duodenal stenting and surgical GJ (SGGJ) in malignant gastric outlet obstruction (MGOO). European Society of Gastrointestinal Endoscopy guidelines restricted EUS-GJ for MGOO only, because of misdeployment. The aim was to evaluate its outcomes focusing on benign indications.

METHODS

This was a retrospective study conducted from 2016 to 2023 in a tertiary center. Patients included had malignant or benign GOO indicated for EUS-GJ. Techniques were the direct approach until August 2021, and the wire endoscopic simplified technique (WEST) afterwards. The main objective was to compare outcomes in benign vs. MGOO. Secondary end-points were technical success, adverse events rates, and describing the evolution of techniques and indications.

RESULTS

In all, 87 patients were included, 46 men, mean age 66 ± 16.2 years. Indications were malignant in 60.1% and benign in 39.1%. The EUS-GJ technique was direct in 33 patients (37.9%) and WEST in 54 (62.1%). No difference was found in terms of technical, clinical, or adverse events rates. The initial technical success rate was 88.5%. The final technical and clinical success rates were 96.6% and 94.25%, respectively. In the last year, benign exceeded malignant indications (70.4% vs. 29.6%, P < 0.05). Seven misdeployments occurred, six being addressed with the rescue technique. The misdeployment rate was significantly decreased using the WEST approach compared to the direct one: 3.7% vs. 18% (P < 0.05). The severe postoperative adverse events rate was 2.3%.

CONCLUSION

This study demonstrated similar outcomes of EUS-GJ between benign and MGOO, with a decreasing misdeployment rate (<4%) applying WEST. This represents an additional step towards recommending EUS-GJ in benign indications.

EUS-guided Gastroenterostomy: A Multicenter International Study Comparing Benign and Malignant Diseases

BACKGROUND

Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is a minimally invasive therapy for patients with gastric outlet obstruction without the risks of surgical bypass and the limited long-term efficacy of enteral self-expanding metal stent placement. However, due to its novelty, there is a lack of significant data comparing long-term outcomes of patients with EUS-GE, based on the underlying disease. In this study, we compare outcomes of EUS-GE on benign versus malignant indications.

METHODS

Consecutive patients from 12 international, tertiary care centers who underwent EUS-GE over 3 years were extracted in a retrospective registry. Demographic characteristics, procedure-related information and follow-up data was collected. Primary outcome was the rate of adverse events associated with EUS-GE and the comparison of the rate of adverse events in benign versus malignant diseases. Secondary outcomes included technical and clinical success as well as hospitalization admission.

RESULTS

A total of 103 patients were included: 72 malignant and 31 benign. The characteristics of the patients undergoing EUS-GE is shown in Table 1. The mean age of the cohort was 68 years and 58 years for malignant and benign etiology. Gender distribution was 57% and 39% being females in malignant and benign etiology group, respectively. Clinical success, technical success, average procedure time, and hospital length of stay were similar in both groups. Patients with benign underlying etiology had significantly higher number of surgically altered midgut anatomy ( P =0.0379).

CONCLUSION

EUS-GE is equally efficient regardless of the underlying etiology (malignant vs. benign), and the adverse events both groups were comparable.

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.

Endoscopic ultrasound-guided gastroenterostomy versus enteral stenting for gastric outlet obstruction: a systematic review and meta-analysis

Background

The symptoms of gastric outlet obstruction have traditionally been managed surgically or endoscopically. Enteral stenting (ES) is a less invasive endoscopic treatment strategy for this condition. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently become a potential alternative technique.

Objectives

We conducted a systematic review and meta-analysis of the effectiveness and safety profile of EUS-GE compared with ES.

Design

Meta-analysis and systematic review.

Data sources and methods

We searched multiple databases from inception to August 2023 to identify studies that reported the effectiveness and safety of EUS-GE compared with ES. The outcomes of technical success, clinical success, and adverse events (AEs) were evaluated. Pooled proportions were calculated using both fixed and random effects models.

Results

We included 13 studies with 1762 patients in our final analysis. The pooled rates of technical success for EUS-GE were 95.59% [95% confidence interval (CI), 94.01-97.44, I 2 = 32] and 97.96% (95% CI, 96.06-99.25, I 2 = 63) for ES. The pooled rate of clinical success for EUS-GE was 93.62% (95% CI, 90.76-95.98, I 2 = 54) while for ES it was lower at 85.57% (95% CI, 79.63-90.63, I 2 = 81). The pooled odds ratio (OR) of clinical success was higher for EUS-GE compared to ES at 2.71 (95% CI, 1.87-3.93). The pooled OR of clinical success for EUS-GE was higher compared to ES at 2.72 (95% CI, 1.86-3.97, I 2 = 0). The pooled rates of re-intervention for EUS-GE were lower at 3.77% (95% CI, 1.77-6.46, I 2 = 44) compared with ES, which was 25.13% (95% CI, 18.96-31.85, I 2 = 69). The pooled OR of the rate of re-intervention in the ES group was higher at 7.96 (95% CI, 4.41-14.38, I 2 = 13). Overall, the pooled rate for AEs for EUS-GE was 8.97% (95% CI, 6.88-11.30, I 2 = 15), whereas that for ES was 19.63% (95% CI, 11.75-28.94, I 2 = 89).

Conclusion

EUS-GE and ES are comparable in terms of their technical effectiveness. However, EUS-GE has demonstrated improved clinical effectiveness, a lower need for re-intervention, and a better safety profile compared to ES for palliation of gastric outlet obstruction.

Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy

Gastric outlet obstruction (GOO) poses a common and challenging clinical scenario, characterized by mechanical blockage in the pylorus, distal stomach, or duodenum, resulting in symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its diverse etiology encompasses both benign and malignant disorders. The spectrum of current treatment modalities extends from conservative approaches to more invasive interventions, incorporating procedures like surgical gastroenterostomy (SGE), self-expandable metallic stents (SEMSs) placement, and the advanced technique of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). While surgery is favored for longer life expectancy, stents are preferred in malignant gastric outlet stenosis. The novel EUS-GE technique, employing a lumen-apposing self-expandable metal stent (LAMS), combines the immediate efficacy of stents with the enduring benefits of gastroenterostomy. Despite its promising outcomes, EUS-GE is a technically demanding procedure requiring specialized expertise and facilities.

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.

[Complicated gastric cancer and modern treatment approaches]

Among all patients with gastric cancer, 40% admit to the hospitals due to cancer-related complications. The most common complications of gastric cancer are bleeding (22-80%), malignant gastric outlet obstruction (26-60%), and perforation (less than 5%). The main treatment methods for gastric cancer complicated by bleeding are various forms of endoscopic hemostasis, transarterial embolization and external beam radiotherapy. Surgical treatment is possible in case of ineffective management. However, surgical algorithm is not standardized. Malignant gastric outlet stenosis requires decompression: endoscopic stenting, palliative gastroenterostomy. Surgical treatment is also possible (gastrectomy, proximal or distal resection of the stomach). The main problem for patients with complicated gastric cancer is the lack of standardized algorithms and abundance of potential surgical techniques. The aim of our review is to systematize available data on the treatment of complicated gastric cancer and to standardize existing methods.

Preferred techniques for endoscopic ultrasound-guided gastroenterostomy: a survey of expert endosonographers

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an emerging procedure that lacks technical standardization with limited adoption beyond expert centers. We surveyed high-volume endosonographers about the technical aspects of EUS-GE to describe how the procedure is currently performed at expert centers and identify targets for standardization. Methods Invitations to complete an electronic survey were distributed to 21 expert EUS practitioners at 19 U.S. centers. Respondents were surveyed about technical aspects of EUS-GE, indications, efficacy, safety, and attitudes toward the procedure. Results All 21 (100%) invited expert endoscopists completed the survey. Nine (42.9%) reported performing >10 EUS-GEs in the last 12 months. About half (47.6%, 10/21) puncture the target loop prior to lumen-apposing metal stent (LAMS) introduction, most often to confirm the loop is jejunum. No respondents reported guidewire placement prior to LAMS introduction. Most (71.4%, 15/21) do not use a guidewire at any time, while 28.6% (6/21) reported wire placement after distal flange deployment to secure the tract during apposition. Eight (38.1%, 8/21) reported at least one major adverse event, most commonly intraperitoneal LAMS deployment (87.5%, 7/8). Factors most often reported as advantageous for EUS-GE over enteral stenting included lack of papilla interference (33.3%, 7/21) and decreased occlusion risk (23.8%, 5/21). Conclusions Significant variation in performance technique for EUS-GE exists among expert US endoscopists, which may hinder widespread adoption and contribute to inconsistencies in reported patient outcomes. The granularity provided by these survey results may identify areas to focus standardization efforts and guide future studies on developing an ideal EUS-GE protocol.

Therapeutic Endoscopic Ultrasound: Current Indications and Future Perspectives

The transcendence of endoscopic ultrasound (EUS) from diagnostic to therapeutic tool has revolutionized management options in the field of gastroenterology. Through EUS-guided methods, pancreaticobiliary obstruction can now be utilized as an alternative to surgical and percutaneous approaches. This modality also allows for gallbladder drainage in patients who are not ideal operative candidates. By utilizing its unique imaging capabilities, EUS also allows for drainage access points in cases of gastric outlet obstruction as well as windows to ablate pancreatic cystic lesions. As technical progress continues to evolve, interventional gastroenterology continues to push the envelope of minimally invasive therapeutic procedures in a multidisciplinary setting. In this comprehensive review, we set out to describe current indications and innovations through EUS.

Benefits of EUS-guided gastroenterostomy over surgical gastrojejunostomy in the palliation of malignant gastric outlet obstruction: a large multicenter experience

BACKGROUND AND AIMS

Palliation of malignant gastric outlet obstruction (mGOO) allows resumption of peroral intake. Although surgical gastrojejunostomy (SGJ) provides durable relief, it may be associated with a higher morbidity, interfere with chemotherapy, and require an optimum nutritional status. EUS-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative. We aimed to conduct the largest comparative series to date between EUS-GE and SGJ for mGOO.

METHODS

This multicenter retrospective study included consecutive patients undergoing SGJ or EUS-GE at 6 centers. Primary outcomes included time to resumption of oral intake, length of stay (LOS), and mortality. Secondary outcomes included technical and clinical success, reintervention rates, adverse events (AEs), and resumption of chemotherapy.

RESULTS

A total of 310 patients were included (EUS-GE, n = 187; SGJ, n = 123). EUS-GE exhibited significantly lower time to resumption of oral intake (1.40 vs 4.06 days, P < .001), at lower albumin levels (2.95 vs 3.33 g/dL, P < .001), and a shorter LOS (5.31 vs 8.54 days, P < .001) compared with SGJ; there was no difference in mortality (48.1% vs 50.4%, P = .78). Technical (97.9% and 100%) and clinical (94.1% vs 94.3%) success was similar in the EUS-GE and SGJ groups, respectively. EUS-GE had lower rates of AEs (13.4% vs 33.3%, P < .001) but higher reintervention rates (15.5% vs 1.63%, P < .001). EUS-GE patients exhibited significantly lower interval time to resumption of chemotherapy (16.6 vs 37.8 days, P < .001). Outcomes between the EUS-GE and laparoscopic (n = 46) surgical approach showed that EUS-GE had shorter interval time to initiation/resumption of oral intake (3.49 vs 1.46 days, P < .001), decreased LOS (9 vs 5.31 days, P < .001), and a lower rate of AEs (11.9% vs 17.9%, P = .003).

CONCLUSIONS

This is the largest study to date showing that EUS-GE can be performed among nutritionally deficient patients without affecting the technical and clinical success compared with SGJ. EUS-GE is associated with fewer AEs while allowing earlier resumption of diet and chemotherapy.

Analysis of prognostic factors in patients with self-expandable metallic stents for treatment of malignant gastric outlet obstruction

BACKGROUND AND AIM

Self-expandable metallic stents (SEMSs) are widely accepted as a less-invasive treatment for malignant gastric outlet obstruction (GOO). However, the factors related to prognosis and stent dysfunction after SEMS placement are not well known, and we aimed to investigate them.

METHODS

This was a single-center retrospective cohort study of 212 malignant strictures in 207 patients. Factors related to prolonged overall survival (OS) and time to recurrent GOO (TRGOO) after SEMS placement were evaluated.

RESULTS

Improvement of oral intake was confirmed in 179 patients (86%). The median OS was 65 days. A Cox proportional hazards model revealed that lower cancer stage, lower performance status score at the time of SEMS placement, and administration of chemotherapy after SEMS placement were significant predictive factors for prolonged OS. The median OS was 182 days in the group of SEMS followed by chemotherapy (group A) and 43 days in the group of SEMS alone (group B) (p< .0001). Chemotherapy after SEMS implantation contributed to the prolongation of survival in gastric cancer (hazard ratio (HR), 0.12) and pancreatic cancer (HR, 0.41). Furthermore, the cumulative incidence rates of stent dysfunction on day 120 after SEMS placement were 30% in group A and 61% in group B (p=.03). Notably, the preventive effect of chemotherapy on stent dysfunction was significant in pancreatic cancer.

CONCLUSIONS

SEMS is a treatment with high technical and clinical success rate for malignant GOO. Furthermore, subsequent chemotherapy prolongs OS especially in gastric cancer, and TRGOO in pancreatic cancer.

EUS-guided gastroenterostomy versus duodenal self-expandable metal stent for malignant gastric outlet obstruction: results from a nationwide multicenter retrospective study (with video)

BACKGROUND AND AIMS

Traditionally, palliative treatment of malignant gastric outlet obstruction (GOO) has been surgical, but surgical treatment carries significant morbidity and mortality rates. Endoscopic placement of a duodenal self-expandable metal stent (D-SEMS) has been proven to be successful for this indication in the short term. However, D-SEMSs are likely to malfunction over time. EUS-guided gastroenterostomy (EUS-GE) may help overcome these limitations. We aimed to evaluate stent failure-free survival at 3 months.

METHODS

A nationwide multicenter, observational study of D-SEMS and EUS-GE procedures for patients with malignant GOO was conducted at 7 academic centers from January 2015 to June 2020. Stent failure-free survival at 1, 3, and 6 months; technical and clinical success; adverse events (AEs); and patient survival were evaluated in both groups and compared.

RESULTS

Ninety-seven patients were included in the D-SEMS group and 79 in the EUS-GE group. Pancreatic cancer was the main underlying malignancy in 53.4%. No statistically significant differences regarding technical (92.8% vs 93.7%) or clinical success (83.5% vs 92.4%) were found. AE rates did not differ between groups (10.3% vs 10.1%), although 2 events in the EUS-GE group required surgical management. Patients in the EUS-GE group had improved stent patency when compared with those patients in the D-SEMS group at 3 months (92.23% vs 80.6%; adjusted hazard ratio, .37; P = .033).

CONCLUSIONS

EUS-GE seems to have improved patency outcomes when compared with D-SEMS placement for palliative treatment of malignant GOO. Prospective trials are needed to fully compare their efficacy and AE profile.

Endoscopic ultrasound guided access procedures following surgery

EUS-guided therapeutic procedures have emerged in the recent years as a minimally invasive option for the management of complex hepatobiliary disorders. Gastrointestinal surgeries, e.g., pancreaticoduodenectomy, Roux-en-Y Gastric Bypass, Roux-en-Y hepaticojejunostomy, and partial gastrectomy with different reconstructions are commonly performed for a wide range of indications that include tumour resections and weight loss. Conventional endoscopic procedures are challenging in those patients due to inaccessible or unreachable ampulla. Patients with surgically altered anatomy are good candidates for EUS-guided access procedures that have shown good technical and clinical success rates. This category of procedures includes EUS-guided biliary drainage, EUS-guided pancreatic drainage, EUS-directed transgastric ERCP (EDGE) and EUS-guided Gastroenterostomy. Studies have shown that these procedures have comparable or better results than traditional endoscopic, interventional radiology-guided and surgical procedures. This article discusses the indications, technique and outcome of the different EUS-guided access procedures in patients with surgically altered anatomy.

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.

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy in treatment of malignant gastric outlet obstruction: Systematic review and meta-analysis

Background and study aims  Palliative treatment of malignant gastric outlet obstruction (GOO) has conventionally been with surgical gastrojejunostomy (SGJ). Advent of devices like lumen apposing metal stents has made endoscopic ultrasound-guided gastroenterostomy (EUS-GE) a potential alternative to SGJ for these patients. We performed a systematic review and meta-analysis of studies that compared outcomes of EUS-GE versus SGJ. Methods  We performed a comprehensive systematic search of multiple electronic databases and conference proceedings through January 2021 and identified six studies that compared outcomes of EUS-GE versus SGJ in the management of malignant GOO. The rates of technical success, clinical success, and AEs were analyzed, and pooled odds ratios were calculated using random effects model. Results  Six studies were included in our analysis with a total of 484 patients, of which 291 underwent EUS-GE and 193 underwent SGJ. The technical success rate of SGJ was superior to EUS-GE (OR = 0.195; 95 %CI:0.054-0.702; P  = 0.012; I ²  = 0). The clinical success of EUS-GE was statistically similar to SGJ (OR = 1.566; 95 %CI:0.585-4.197; P  = 0.372; I ²  = 46.68 %). EUS-GE had significantly fewer AEs compared to SGJ (OR = 0.295; 95 %CI:0.172-0.506; P  < 0.005; I ²  = 0). Among studies which reported reintervention rates, EUS-GE was statistically similar to SGJ (OR = 0.587; 95 %CI:0.174-1.979; P  = 0.390, I ²  = 54.91). Minimal to moderate heterogeneity was noted in the analyses. Conclusions  EUS-GE has equivalent clinical success and reintervention rates, but significantly lower adverse events compared to SGJ. When feasible, EUS-GE appears to be an effective and safe alternative to SGJ for palliative management of malignant GOO.

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.

EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis

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.

Gastric Outlet Obstruction: Current Status and Future Directions

Gastric outlet obstruction (GOO) is a relatively common condition in which mechanical obstruction of the pylorus, distal stomach, or duodenum causes severe symptoms such as nausea, vomiting, abdominal pain, and early satiety. Its etiology includes both benign and malignant disorders. Currently, GOO has many treatment options, including initial conservative therapeutic protocols and more invasive procedures, such as surgical gastroenterostomy, stent placement and, the most recently implemented procedure, endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Each procedure has its merits, with surgery often prevailing in patients with longer life expectancy and stents being used most often in patients with malignant gastric outlet stenosis. The newly developed EUS-GE combines the immediate effect of stents and the long-term efficacy of gastroenterostomy. However, this novel method is a technically demanding process that requires expert experience and special facilities. Thus, the true clinical effectiveness, as well as the duration of the effects of EUS-GE, still need to be determined.

Interventional Endoscopy for Palliation of Luminal Gastrointestinal Obstructions in Management of Cancer: Practical Guide for Oncologists

Self-expanding metal stents placed during endoscopy are increasingly the first-line treatment for luminal obstruction caused by esophageal, gastroduodenal, and colorectal malignancies in patients who are not candidates for definitive surgical resection. In this review, we provide a practical guide for clinicians to optimise patient and procedure selection for endoscopic stenting in malignant gastrointestinal obstructions. The role of endoscopic stenting in each of the major anatomical systems (esophageal, gastroduodenal, and colorectal) is presented with regard to pre-procedural patient evaluation, procedural techniques, clinical outcomes, and potential complications, as well as post-procedure aftercare.

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.

Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy

BACKGROUND AND AIMS

Stent misdeployment (SM) has hindered the dissemination of EUS-guided gastroenterostomy (EUS-GE) for gastric outlet obstruction (GOO) management. We aimed to provide a classification system for SM during EUS-GE and study clinical outcomes and management accordingly.

METHODS

This is a retrospective study involving 16 tertiary care centers (8 in the United States, 8 in Europe) from March 2015 to December 2020. Patients who developed SM during EUS-GE for GOO were included. We propose classifying SM into 4 types. The primary outcome was rate and severity of SM (per American Society for Gastrointestinal Endoscopy lexicon), whereas secondary outcomes were clinical outcomes and management of dislodgement according to the SM classification type, in addition to salvage management of GOO after SM.

RESULTS

From 467 EUS-GEs performed for GOO during the study period, SM occurred in 46 patients (9.85%). Most SMs (73.2%) occurred during the first 13 EUS-GE cases by the performing operators. SM was graded as mild (n = 28, 60.9%), moderate (n = 11, 23.9%), severe (n = 6, 13.0%), or fatal (n = 1, 2.2%), with 5 patients (10.9%) requiring surgical intervention. Type I SM was the most common (n = 29, 63.1%), followed by type II (n = 14, 30.4%), type IV (n = 2, 4.3%), and type III (n = 1, 2.2%). Type I SM was more frequently rated as mild compared with type II SM (75.9% vs 42.9%, P = .04) despite an equivalent rate of surgical repair (10.3% vs 7.1%, P = .7). Overall, 4 patients (8.7%) required an intensive care unit stay (median, 2.5 days). The median length of stay was 4 days after SM.

CONCLUSIONS

Although SM is not infrequent during EUS-GE, most are type I, mild/moderate in severity, and can be managed endoscopically with a surgical intervention rate of approximately 11%.

Assessment of the learning curve for EUS-guided gastroenterostomy for a single operator

BACKGROUND AND AIMS

EUS-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative to surgery and enteral stent placement to manage gastric outlet obstruction (GOO). However, no data are available on the learning curve (LC) for EUS-GE. Defining the LC is necessary to create adequate subspecialty training programs and quality assurance.

METHODS

This study is a retrospective analysis of a prospectively maintained dataset of patients who underwent EUS-GE at 1 tertiary referral center. Primary outcome was the LC for EUS-GE defined by the number of cases needed to achieve proficiency and mastery using cumulative sum (CUSUM) analysis. Moving average graphs and sequential time-block analysis were also performed to assess procedural time. Secondary outcomes included efficacy and safety of EUS-GE.

RESULTS

Eighty-seven consecutive patients underwent EUS-GE, mostly for malignant GOO. For consistency, 14 patients were excluded from analysis (noncautery-assisted EUS-GE, 11; surgical anatomy, 3). The same endoscopist performed all procedures using the same freehand technique. Technical success was achieved in 68 of 73 patients (93%). Immediate adverse events occurred in 4 patients (5.5%), whereas late adverse events occurred only in 1 patient (1%), all managed conservatively or endoscopically. All immediate adverse events occurred during the first 39 cases. Clinical success (defined as resuming at least an oral liquid diet within a week) was achieved in 97% of patients. The mean procedural time was 36 minutes (standard deviation, 24). Evaluation of the CUSUM curve revealed that 25 cases were needed to achieve proficiency and 40 cases to achieve mastery. These results were confirmed with the average moving curve and sequential time-block analysis.

CONCLUSIONS

We report, for the first time, data on the LC for EUS-GE. About 25 procedures can be considered as the threshold to achieve proficiency and about 40 cases are needed to reach mastery of the technique.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients' survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.

Endoscopic ultrasound-guided gastroenterostomy versus open surgical gastrojejunostomy: clinical outcomes and cost effectiveness analysis

BACKGROUND

Early data suggests that endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a safe and efficacious option for gastric outlet obstruction (GOO). However, there is a scarcity of data comparing outcomes with open gastrojejunostomy (OGJ).

METHODS

Single-center retrospective cohort study of adult patients hospitalized with GOO who underwent EUS-GE or OGJ between January 1, 2014 and February 28, 2020. Primary outcomes were technical and clinical success.

RESULTS

Sixty-six patients were included of which 40 (60.0%) underwent EUS-GE and 26 (40.0%) underwent OGJ. Baseline characteristics were similar with respect to age (70.5 vs 69.7, p = 0.81), sex (42.5% vs 42.3% female, p = 0.99), median length of follow-up (98.0 vs 166.5 days, p = 0.8), prior failed intervention for GOO (22.5% vs 26.9%, p = 0.68), and the presence of altered anatomy (12.5% vs 30.8%, p = 0.07) between EUS-GE and OGJ, respectively. Technical success was achieved in 37 (92.5%) of EUS-GE and 26 (100%) of OGJ patients (p = 0.15). EUS-GE was associated with faster resumption of oral intake (1.3 vs 4.7 days, p < 0.001) and shorter length of stay (5 vs 14.5 days, p < 0.001). There were no significant differences in symptom recurrence (17.5% vs 19.2%, HR 1.85, CI 0.52-6.65, p = 0.34), reintervention (20% vs 11.5%, HR 0.82, CI 0.22-3.15, p = 0.78), death within 30 days (12.5% vs 3.8%, HR 0.80, CI 0.09-6.85, p = 0.84), or 30-day readmission (17.5% vs 24.1%, HR 1.69, CI 0.53-5.41, p = 0.37) between EUS-GE and OGJ, respectively. EUS-GE patients initiated chemotherapy sooner (17.7 vs 31.3 days, p = 0.033) and had lower overall costs as compared to OGJ ($49,387 vs $124,192, p < 0.001).

CONCLUSION

There were no significant differences in technical or clinical success, symptom recurrence, reintervention, 30-day readmission, or 30-day mortality between EUS-GE and OGJ. EUS-GE patients experienced shorter delays to resumption of oral intake and chemotherapy, had shorter lengths of stay, and reduced hospital costs. Further prospective comparative studies are warranted to verify our results.

Lumen-apposing metal stents for approved and off-label indications: a single-centre experience

BACKGROUND AND STUDY AIMS

Lumen-apposing stents (LAMS) are approved to treat peripancreatic collections and for gallbladder and bile duct drainage. Over the last years, LAMS have also been used for off-label indications including gastrojejunostomy, gastro-gastrostomy and drainage of postsurgical collections. We aimed to analyze indications, technical/clinical success rates and complications of all LAMS placed over the last 2 years.

PATIENTS AND METHODS

Data from 61 consecutive LAMS (Hot Axios, Boston Scientific) in 57 patients were analyzed. Technical success was defined as successful deployment of the LAMS in the desired position. Clinical success was defined as follows: for pancreatic collections: resolution without the need for non-endoscopic interventions; for choledochoduodenostomy: ≥ 50% drop in baseline serum bilirubin within 2 weeks AND patient can receive chemotherapy if indicated; for gastrojejunostomy: resolution of gastric outlet obstruction and successful re-initiation of oral intake; for gastro-gastrostomy: successful endoscopic access to the excluded stomach; for gallbladder or postsurgical collection drainage: resolution of sepsis.

RESULTS

Indications were drainage of peripancreatic collections in 24 cases (39.3%), choledochoduodenostomy in 13 (21.3%), gastrojejunostomy in 6 (9.8%), gastro-gastrostomy in 13 (21.3%), gallbladder drainage in 1 (1.6%) and postsurgical collection drainage in 4 (6.6%). Overall technical and clinical success rates were high (57/61; 93.4% and 54/61; 88.5%, respectively). Clinical success rate for non-approved indications was 95.6% (22/23 cases). Complications occurred in 13 patients (21.3%, 4 serious).

CONCLUSIONS

LAMS are increasingly used in interventional endoscopy. In our cohort, more than one third of LAMS are placed for off-label indications, with a high success rate and acceptable complication rate.

Retrieval anchor-assisted endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction

OBJECTIVES

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an emerging procedure for gastric outlet obstruction (GOO) as an alternative to endoscopic stent placement in the duodenum or surgery; however, it is technically challenging. This study aimed to evaluate the safety, success rate, and adverse events rate associated with retrieval anchor-assisted EUS-GE.

METHODS

Data from patients who underwent retrieval anchor-assisted EUS-GE for malignant and benign GOO were retrospectively analyzed. Patients' clinical and demographic characteristics, procedure time, and success and adverse event rates were recorded.

RESULTS

A total of 10 patients (6 females; mean age 63.2 ± 5.8 years) were included in our study. Nine cases were malignant and one case was benign GOO. Nine patients received retrievable anchor-assisted EUS-GE for GOO. One patient received retrievable anchor-assisted EUS-GE and concurrent EUS-guided hepatogastrostomy due to the biliary obstruction. There were no complications during any of the procedures. The rate of technical and clinical success was 100%.

CONCLUSIONS

EUS-GE is a safe and effective procedure for GOO. The retrieval anchor can make EUS-GE easier to perform successfully.

Malignant gastric outlet obstruction: Which is the best therapeutic option?

Malignant gastric outlet obstruction (MGOO) is a clinical condition characterized by the mechanical obstruction of the pylorus or the duodenum due to tumor compression/infiltration, with consequent reduction or impossibility of an adequate oral intake. MGOO is mainly secondary to advanced pancreatic or gastric cancers, and significantly impacts on patients’ survival and quality of life. Patients suffering from this condition often present with intractable vomiting and severe malnutrition, which further compromise therapeutic chances. Currently, palliative strategies are based primarily on surgical gastrojejunostomy and endoscopic enteral stenting with self-expanding metal stents. Several studies have shown that surgical approach has the advantage of a more durable relief of symptoms and the need of fewer re-interventions, at the cost of higher procedure-related risks and longer hospital stay. On the other hand, enteral stenting provides rapid clinical improvement, but have the limit of higher stent dysfunction rate due to tumor ingrowth and a subsequent need of frequent re-interventions. Recently, a third way has come from interventional endoscopic ultrasound, through the development of endoscopic ultrasound-guided gastroenterostomy technique with lumen-apposing metal stent. This new technique may ideally encompass the minimal invasiveness of an endoscopic procedure and the long-lasting effect of the surgical gastrojejunostomy, and brought encouraging results so far, even if prospective comparative trial are still lacking. In this Review, we described technical aspects and clinical outcomes of the above-cited therapeutic approaches, and discussed the open questions about the current management of MGOO.