Introduction
Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical GastroEnterostomy (S-GE) or Endoscopic Stenting (ES). More recently, EUS GastroEnterostomy (EUS-GE) has emerged as a low-invasive alternative with surgical-range efficacy, supported by guidelines. Nevertheless, its worldwide diffusion is heterogeneous and advantages/disadvantages debated. The aim of this survey is to assess clinical decision-making of international specialists regarding mGOO and to explore current opinion regarding EUS-GE use.
Aims & Methods
An online survey was created exploring centers’ experiences and physicians’ opinions regarding indications, contraindications, benefits and risks of available treatments; 2 case vignettes explored clinical decision-making in different scenarios. The survey was spread through social networks and the EPC newsletter.
Results
Overall, 290 pancreatologists from 44 countries (5 continents) responded, of whom 35% surgeons and 65% gastroenterologists, 44% from centers managing > 20 mGOO/year. The most frequently available treatment for mGOO was ES (91%), followed by S-GE, while EUS-GE was only available to 59% of responders, and only 10% declared proficiency in this technique.
68% referred an established gold-standard in their centers, but this differed by specialty, with ES, EUS-GE and S-GE being advised by 45%, 20% and 10% of gastroenterologists and 24%, 8% and 25% of surgeons.
For 51% of responders, EUS-GE will become the primary treatment for mGOO. This percentage increases among gastroenterologists and high-volume centers. For 14%, EUS-GE spread will be limited in the future, or used only when ES fails (19%), with higher rates among surgeons.
When choosing between alternatives, the main decision driver is life expectancy, followed by disease stage and patient’s frailty, whereas potential future surgical resectability does not contraindicate any treatment for 3/4 of responders. The main perceived advantages of EUS-GE were minimally invasiveness and high clinical efficacy, while the learning curve remains its main disadvantage.
Conclusion
This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms.
Despite great enthusiasm around EUS-GE, its availability remains suboptimal, with learning curve as the main barrier. Life expectancy and patients’ frailty are likely to remain the main decision factors.
