EUS-Guided Gastroenterostomy in Malignant Gastric Outlet Obstruction: A Comparative Study between First- and Second-Line Approaches after Enteral Stent Placement

Abstract

Introduction: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used in the setting of malignant gastric outlet obstruction (GOO). However, little is known about the role of primary EUS-GE. The aim of the present study is to compare the outcomes of EUS-GE by using the freehand technique as a first- and second-line approach after enteral stenting (ES). Methods: This is an observational single-center study using a prospectively collected database. All consecutive patients who underwent an EUS-GE using the freehand technique due to malignant GOO were included. Patients with previous gastric surgery, a wire-guided EUS-GE technique, or those presenting without GOO were excluded. The primary outcome was the clinical success, defined as a solid oral intake at 1 week after the procedure (GOO Score, GOOSS ≥ 2). The secondary outcomes were technical success and adverse event (AE) rates. The impact on nutritional parameters was also assessed. Results: Forty-five patients underwent an EUS-GE for all indications. Finally, 28 patients (mean age: 63 ± 17.2 years, 57.1% male) with (n = 13, 46.4%) and without (n = 15, 53.6%) a previous ES were included. The technical success was achieved in 25 cases (89.3%), with no differences between the two groups (92.3% vs. 86.7%, p = 1). The median limb diameter and procedure time were 27 mm (range:15–48) and 37 min. Overall, clinical success was achieved in 22 cases (88%), with three failures due to AEs (n = 2) or peritoneal carcinomatosis (n = 1). The diet progression was quicker in patients with a previous ES (GOOSS at 48 h, 2 vs. 1, p = 0.023), but the GOOSS at 1 week (p = 0.299), albumin gain (p = 0.366), and BMI gain (0.257) were comparable in the two groups. The AE rate was 7.1%. Conclusions: EUS-GE achieves a high technical and clinical success in patients with GOO regardless of the presence of a previous ES. Patients with previous ES may have a quicker progression of their diet, but the GOOSS and nutritional status in the long term at 1 week or 1 month are comparable. Primary EUS-GE might require fewer procedures and less discontinuation of chemotherapy to achieve a comparable result.

Delayed ipsilateral intestinal perforation after endoscopic gastrojejunostomy: A perspective on underlying mechanisms

“…From the operative standpoint, it's noteworthy to mention the distance between the stomach and small bowel was <10 mm and there was no evidence of intervening ascites – both factors associated with EUS‐GJ technical success 5 . Additionally, delayed perforation is not associated with stent size, as prior reports have occurred with both 15 and 20‐mm diameter LAMS 3,6,7,10 . While factors of mucosal barrier integrity should be acknowledged, they do not entirely explain the prevalence of perforated peptic ulcer disease or, accordingly, perforation after stent implantation within the gastrointestinal tract.…”

“… 5 Additionally, delayed perforation is not associated with stent size, as prior reports have occurred with both 15 and 20‐mm diameter LAMS. 3 , 6 , 7 , 10 While factors of mucosal barrier integrity should be acknowledged, they do not entirely explain the prevalence of perforated peptic ulcer disease or, accordingly, perforation after stent implantation within the gastrointestinal tract. Other factors pertinent to long‐term safety may be unrecognized due to the low incidence of delayed EUS‐GJ perforations.…”

Endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stents: a retrospective multicentric comparison of wireless and over-the-wire techniques

“…The reported technical success rate of EUS-GE is around 90 %-95 % [7,8]. Compared with enteral stenting, EUS-GE has shown higher clinical success rates and lower stent dysfunction rates, with similar levels of safety [9][10][11]. Indeed, the longer patency of an EUS-GE compared with enteral stenting allows enteral feeding to be maintained for longer periods without reintervention.…”