Technical feasibility and clinical success of direct “free hand” EUS-guided gastroenterostomy in patients with gastric outlet obstruction

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Abstract

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with lumen-apposing metal stents (LAMS) appears to be a promising intervention in management of gastroduodenal out obstruction (GOO), particularly for patients for whom surgery is high risk or in a palliative setting. This study aimed to evaluate the technical feasibility, procedure-associated adverse events (AEs), and clinical outcome of direct “free hand” EUS-GE.

Patients and methods This retrospective two-center study included patients who underwent direct “free hand” EUS-GE (April 2017 to March 2021) investigating technical success (correctly placed LAMS), clinical outcome (successful oral nutrition), and management of procedure-associated AEs. “Free hand” was defined as the use of the electrocautery enhanced stent delivery system alone without additional guidewire-assistance for EUS-GE creation.

Results Forty-five patients (58 % women/42 % men; mean age 65 years) with malignant (n = 39), benign (n = 4) or unclear (n = 2) GOO underwent direct “free hand” EUS-GE. The technical success rate was 98 % (44/45). Of the patients, 95% (42/44) had less vomiting and increased ability to tolerate oral food intake after the intervention. In one patient, a second EUS-GE was necessary to achieve sufficient clinical improvement. Procedure-associated AEs were observed in 24 % (11/45) of cases including stent misplacement (n = 7), leakage (n = 1), development of a gastrojejunocolic fistula (n = 1), and bleeding (n = 2), which could be all managed endoscopically.

Conclusions Direct EUS-GE has a favorable risk-benefit profile for patients with GOO, showing high technical success rates, manageable AEs, and rapid symptom relief.

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Most cited references 16

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A lexicon for endoscopic adverse events: report of an ASGE workshop.

Peter Cotton, Glenn M Eisen, Lars Aabakken … (2010)

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Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients.

Todd Baron, Sharon G. Adler (2001)

Malignant gastric outlet obstruction is seen in the setting of a variety of cancers, most commonly pancreatic. Self-expanding metal stents can be used to palliate these patients and restore the ability to eat. We reviewed the Mayo Clinic experience in the endoscopic treatment of malignant gastric outlet obstruction. Thirty-six patients (26 male, 10 female) were treated between October, 1998 and January, 2001. Data were collected from charts, endoscopy reports, x-rays, and telephone calls. A scoring system was created to grade the ability to eat. All procedures were successful. Thirty-one of 36 patients (86%) required one stent at initial endoscopy, and 5/36 patients (14%) required two or more stents. Pretreatment, 19/36 patients (53%) were nil per os, 15/36 (42%) drank liquids, and 2/36 were able to eat soft solids. After stent placement, only 1/36 (3%) was still nil per os, 13/36 (36%) drank liquids, 13/36 (36%) ate soft solids, and 9/36 (25%) ate a full diet. The improvement in ability to eat using the scoring system was statistically significant (p < 0.0001). Nine of 36 patients (25%) required reintervention for recurrent symptoms. Sixteen of 36 patients (44%) had concomitant or subsequent development of biliary obstruction, of which 15 were successfully decompressed. Self-expanding metal stents are a safe and efficacious method for palliating malignant gastric outlet obstruction. The majority of patients do not require reintervention, and those that do can usually be managed nonoperatively.

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EUS-Guided Gastroenterostomy versus Enteral Stent Placement for Palliation of Malignant Gastric Outlet Obstruction

Phillip S Ge, Joyce Young, William Dong … (2019)

EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO), however data comparing EUS-GE to enteral stent placement is limited. We aimed to compare clinical outcomes between EUS-GE and enteral stent placement in the palliation of malignant GOO. Retrospective analysis of a prospectively collected database on patients who underwent EUS-GE or enteral stent placement for palliation of malignant GOO from 2014–2017. Primary outcome was the rate of stent failure requiring repeat intervention. Secondary outcomes included technical and clinical success, time to repeat intervention, length of hospital stay, and adverse events. A total of 100 consecutive patients (mean age 65.9±11.9 years, 44.0% female) were identified, of which 78 underwent enteral stent placement, and 22 underwent EUS-GE. Rate of stent failure requiring repeat intervention was higher in the enteral stent group than the EUS-GE group (32.0% vs 8.3%, p =0.021). Technical success was achieved in 100% in both groups. Higher initial clinical success was attained in the EUS-GE group than the enteral stent group (95.8% vs 76.3%, p =0.042). Mean length of hospital stay following stent placement was similar between groups ( p =0.821). The enteral stent group trended towards increased adverse events (40.2% vs 20.8%, p =0.098). Kaplan-Meier analysis showed decreased stent function in the enteral stent group ( p =0.013). Compared to enteral stent placement, EUS-GE has a higher rate of initial clinical success and lower rate of stent failure requiring repeat intervention. EUS-GE may be offered for selected patients with malignant GOO in centers with extensive experience.

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Author and article information

Journal

Journal ID (nlm-ta): Endosc Int Open

Journal ID (iso-abbrev): Endosc Int Open

Journal ID (doi): 10.1055/s-00025476

Title: Endoscopy International Open

Publisher: Georg Thieme Verlag KG (Rüdigerstraße 14, 70469 Stuttgart, Germany )

ISSN (Print): 2364-3722

ISSN (Electronic): 2196-9736

Publication date (Electronic): 17 October 2022

Publication date Collection: October 2022

Publication date PMC-release: 1 October 2022

Volume: 10

Issue: 10

Pages: E1358-E1363

Affiliations

[1 ]Klinik für Gastroenterologie und Hepatologie, München Klinik Neuperlach, Munich, Germany

[2 ]II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität, Munich, Germany

[3 ]UniversitätsSpital Zürich, Klinik für Gastroenterologie und Hepatologie, Raemistrasse 100, Zurich 8091, Switzerland

Author notes

Corresponding author Christoph Schlag UniversitätsSpital Zürich Klinik fur Gastroenterologie und Hepatologie Raemisstrasse 100Zurich 8091Switzerland+41432531370 Christoph.Schlag@ 123456usz.ch

Article

DOI: 10.1055/a-1907-5393

PMC ID: 9576332

PubMed ID: 36262515

SO-VID: 58224848-876f-4b68-b0ee-6d09aa0a0b1e

Copyright © The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

History

Date received : 26 March 2022

Date accepted : 08 July 2022

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