Introduction
Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is emerging as a new and minimally invasive endoscopic treatment method for gastric outlet obstruction (GOO). In EUS-GE, it is important that stents can be safely and reliably deployed and that there is no stent migration. As the optimal method, we have developed the EUS-guided balloon-occluded gastrojejunostomy bypass (EPASS) and have performed it as a clinical study.
Aims & Methods
We retrospectively evaluated the results of EPASS including long-term outcomes. The EPASS procedure was performed under conscious sedation. The endoscope was used to reach the site of obstruction. The stricture was cannulated with a 0.025-inch guidewire and the guidewire was used to negotiate beyond the site of obstruction under endoscopic and fluoroscopic guidance. The double balloon tube was then inserted on the guidewire beyond the duodenal–jejunal flexure using an overtube. The two balloons of the occluder were inflated with 30–40 mL normal saline and constrast. 200–300 mL of methyleneblue-stained saline was then injected to distend the occluded segment of duodenum. A linear echoendoscope was then inserted into the stomach. A site in the posterior wall of the body of the stomach was punctured directly by the delivery system of the lumen apposing metal stent. A 20 x 10 or 15 x 10 mm stent was used. The distal flange of the stent was deployed under EUS guidance, followed by deployment of the proximal flange under endoscopic or EUS guidance. Stent position was confirmed with the drainage of methylene-blue-stained saline, the endoscopic view of the proximal flange and also the fluoroscopic image. Thirty-six consecutive patients with symptomatic GOO who were not refractory to surgical gastrojejunostomy were enrolled in the study. The primary endpoint was technical success rate. Secondary endpoints included procedure time, GOO scoring system (GOOSS) scores at 7 days and 1 month after EPASS, clinical success rate (improvement in GOOSS scores at 7 days after EPASS), procedure-related adverse events (AEs) rate, overall survival (OS) after EPASS in the 23 patients with long-term follow-up, and stent patency rate.
Results
The mean age was 70.6 years (range 47-91), 16 (44%) were female, and the underlying diseases were 18 pancreatic cancer, 9 gastric cancer, 3 duodenal cancer, 4 gallbladder cancer, 1 breast cancer, and 1 chondrosarcoma. The technical success rate was 94.4% (34/36), mean procedure time was 26.9 minutes (range 14-40), mean time to double-balloon tube insertion was 9.8 minutes (range 6-28), mean pre-GOOSS score was 0.42, mean GOOSS score was 2.08 and 2.21 at 7 days and 1 month after EPASS, and the clinical success rate was 88.9% (32/36). The incidence of procedure-related AE was 16.7% (6/36), including 2 cases of fever, 2 cases of abdominal pain, and 2 cases of worsening ascites. The mean overall survival after EPASS was 183.8 days, all patients died of primary disease, and there were no events such as stent occlusion or stent deviation (stent patency was 100%).
Conclusion
EPASS is a safe and reliable EUS-GE method and may be a useful treatment for symptomatic malignant GOO.
References
(1) Tsuchiya T, et al. Tech Innov Gastrointest Endosc. 2020;22:27-32.
(2) Itoi T, et al. J Hepatobiliary Pancreat Sci. 2020;27:791-792.
(3) Itoi T, et al. Gut 2016;65:193-5
Disclosure
Lecture fee : Boston Scientific Japan, Olympus Japan