Introduction

Gastroparesis is a motility disorder of the stomach characterized by a delayed emptying of food into the small bowel in the absence of mechanical obstruction. Medical treatment is difficult and symptoms such as epigastric pain, nausea and vomiting can lead to a significantly reduced quality of life. As endosonographic-guided gastroenterostomy facilitates gastric emptying and has been used successfully in patients with gastric outlet obstruction over years, it might be a viable option to treat refractory gastroparesis. The aim of the study was to report the first experience with that approach and to evaluate its feasibility and efficacy.

Aims & Methods

The data of 7 patients with refractory gastroparesis undergoing EUS-GE between march 2021 and August 2023 were retrospectively collected and analyzed. Primary endpoint was to assess the clinical and technical success of the intervention. Secondary endpoints were to assess the stent patency, adverse events and the rate of reinterventions.

Results

Technical and clinical success rate was 100% with a mean reduction in gastroparesis cardinal symptom index of 71%. During the ongoing surveillance, 2 stents had to be replaced after 12 months due to ingrowth, the other 5 stents remained patent after up to 36 months. We observed 2 stent obstructions in one patient due to food which had to be removed gastroscopically.

Conclusion

EUS-GE can effectively reduce the symptom burden in patients with gastroparesis refractory to medical treatment.

Introduction

EUS-guided gastroenterostomy(EUS-GE) with lumen-apposing metal stent(LAMS) has emerged as a mini-invasive, effective and safe alternative to surgical gastrojejunostomy and endoluminal stenting to treat malignant gastric outlet obstruction(MGOO).Currently, intra-abdominal carcinomatosis represents a relative contraindication to this procedure, due to a possible higher risk of clinical failure.

Aims & Methods

The primary aim was to compare clinical success of EUS-GE in patients (pts) with MGOO with vs without concomitant intra-abdominal carcinomatosis.Secondary aims was to compare between the same subgroups of pts the clinical and procedural characteristics, the technical success rate and long-term outcomes.All pts undergoing EUS-GE for MGOO at our institution from Jun.2018 to Dec.2024 were retrospectively enrolled.Technical success was defined as successfully establishing EUS-GE and clinical success as oral diet tolerance without re-intervention for 14 days after the procedure. Inclusion criteria: 1)age>18 years; 2)MGOO; 3)complete clinical records. Exclusion criterium:missing data. Intra-abdominal carcinomatosis was defined according to CT/MRI imaging. Adverse events (AEs) recorded and classified (AGREE). Obstructive symptoms graded according to the GOOSS score. Data expressed as median [range], comparisons by the Student-t-test, Mann-Whitney-u test and X² test as appropriate.

Results

EUS-GE for MGOO was performed in 74 pts (36 [48.6%] males, age 71 [30-92]), with ECOG performance status ≥2 in 29(39.2%). Obstructive symptoms were reported by 72(97.3%) pts (GOOSS: 1 [0-3]). Intra-abdominal carcinomatosis was present in 29(39.2%) pts. Ascites was more frequent in pts with vs without carcinomatosis (19[65.5%] vs 12[26.7%], p=0.02). Other clinical characteristics were comparable between groups.All EUS-GE were performed in deep sedation. LAMS included Axios and Spaxus (Axios: 37[82.2%] vs 25[86.2%],p=0.89). 20mm LAMS were used in a comparable proportion of pts with vs without carcinomatosis (25[86.2%] vs 37[83.2%], p=0.89). Technical success rates and procedural time did not differ between groups (28[96.6%] vs 43[95.6%],p=0.69; 33[16-85] vs 40[20-106],p=0.52). Overall, 9 misdeployments were observed (carcinomatosis: 3[10.3%] vs no-carcinomatosis: 6[13.3%], p=0.98). AEs were 4 (19.8%) and 9 (20%) in pts with vs without carcinomatosis (p=0.71), all grade III. Time to refeeding (days) was comparable between groups (1[1-5] vs 1[1-5], p=0.96), while hospital stay (days) was longer in patients with carcinomatosis (8[2-18] vs 4[2-15],p=0.0009). Clinical success rate did not differ in pts with vs without carcinomatosis (25[86.2%] vs 43[95.6%],p=0.31). All 6 failures were due to malignancy progression. Median follow-up duration was 51[21-622] days. During follow-up, 27(93.1%) pts with and 38(84.4%) without carcinomatosis died(p=0.45). Median survival (days) and oral diet toleration until last follow-up/death were comparable between pts with vs without carcinomatosis (42[21-398] vs 66[26-622],p=0.07; 26[89.6%] vs 42[93.3%],p=0.89). Oncological treatments were resumed in 11(37.9%) pts with and 23(51.1%)without carcinomatosis (p=0.38). Rehospitalization rate for any cause was comparable in both groups (14[48.3%] vs 26[57.7%],p=0.57), requiring reintervention in 1case.

Conclusion

In our study population high technical and clinical success rates of EUS-GE were comparable in pts with and without intra-abdominal carcinomatosis. The major outcomes were comparable between these 2 subgroups of pts, suggesting the long-term efficacy of this procedure also in those with more advanced malignancy.

Clinical Case Summary

A 56-year-old male presented with postprandial vomiting and weight loss beginning three weeks after laparoscopic ulcerorraphy of a perforated pyloric ulcer. An abdominal CT showed marked gastric distension and upper GI endoscopy revealed gastric stasis and a fibrotic stenosis in the duodenal bulb in close relation with a suture stitch, only transposable with an ultra-slim gastroscope. Two sessions of balloon dilation (BD) until 20mm were performed one month apart with poor clinical/endoscopic improvement. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) was proposed to avoid surgical reintervention.
Using a standard gastroscope a 0.035´´guidewire was passed into the proximal jejunum allowing insertion of a 7-french nasobiliary drain. Jejunal distension was achieved through saline, iodate contrast and methylene blue infusion. The linear echoendoscope was used to identify a distended loop adjacent to the gastric wall and EUS-guided puncture with a 19G needle was accomplished. A 20x10mm lumen-apposing metal stent (LAMS) was deployed in distal gastric body. The flow of blue mixture to the lumen confirmed successful gastroenterostomy creation. The patient was hospitalized overnight and resumed oral feeding the day after the procedure. No symptom recurrence was observed and the gastroenterostomy remained patent during the 6 months of follow-up.
Gastric outlet obstruction (GOO) may result from several malignant and benign causes. Surgical gastroenterostomy, self-expandable metal stents (SEMS) and BD are standard therapeutic options. EUS-GE is emerging as an effective and minimally invasive alternative. EUS-GE presents high technical and clinical success with lower rates of adverse events and reduced need of reintervention when compared to surgery and other endoscopic therapies. In benign GOO, SEMS seems less adequate and BD often results in suboptimal outcomes. The authors exemplify the effectiveness of EUS-GE in a case of GOO associated with a benign condition.

References

Illustrative material:
- Endoscopic and fluoroscopic images of guidewire and nasobiliary drain passed into the proximal jejunum
- EUS image of jejunal distension previous to LAMS placement
- EUS image of LAMS placement
- Endoscopic and fluoroscopic images of LAMS in situ
- Endoscopic image of 6 months follow-up

Introduction

Malignant gastric outlet obstruction (GOO) can arise from a spectrum of malignancies, including gastroduodenal, pancreaticobiliary, colorectal, breast, and lung cancers. Typically, GOO heralds a grim prognosis and manifests with symptoms such as nausea, bloating, vomiting, and abdominal pain. Presently, laparoscopic gastroenterostomy (L-GE) stands as the preferred therapeutic modality; however, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) employing lumen apposing metal stents has emerged as a promising minimally invasive alternative. Comparative studies directly assessing the efficacy of EUS-GE versus L-GE remain scarce.

Aims & Methods

We aimed to compare EUS-GE with L-GE for the treatment of GOO using a propensity score-matched analysis.
In a retrospective, multicenter analysis, consecutive patients were enrolled between April 2019 and April 2024 from two academic centers and one primary care facility. To mitigate selection bias, propensity score matching was employed, taking into account factors such as underlying malignancy, tumor stage, and clinical performance status. Clinical success, defined as a reduction of gastric outlet obstruction (GOO) symptom scores by ≥1, served as the primary outcome measure. Secondary endpoints included technical success, time to oral intake, occurrence of adverse events (AEs), length of hospital stay, and 30-day mortality.

Results

A total of 94 patients underwent EUS-GE, while 78 patients underwent L-GE, as per initial screening. Propensity score matching resulted in 72 patients allocated to each group in a 1:1 ratio. The mean age of the study cohort was 68.2±12.3 years, with 59.7% being female. Clinical success rates were 90.2% for EUS-GE and 82.2% for L-GE (p=0.25). Technical success rates were 95.2% for EUS-GE and 100% for L-GE (p=0.06). The mean duration of hospital stay was significantly shorter for EUS-GE compared to L-GE (10.1±13.4 days vs. 15.5±10.5 days; p<0.001). Less AE were observed in the EUS-GE group compared to the L-GE group, both in total (4.8% vs. 22%; p=0.01) and in serious AE (1.6% vs. 6.7%; p=0.3). The 30-day mortality rate was 11.3% in the EUS-GE group and 17.8% in the L-GE group.

Conclusion

In patients presenting with malignant GOO, EUS-GE showed a tendency towards enhanced clinical success, although not statistically significant, while maintaining comparable technical success rates to L-GE. Notably, clinical recovery post-intervention and hospital stay duration were notably shorter in the EUS-GE cohort, accompanied by a significantly lower incidence of adverse events. Consequently, EUS-GE stands poised to emerge as a preferred therapeutic option for GOO. Nevertheless, further prospective, randomized trials are imperative to validate these retrospective findings.

Disclosure

ME, CG, TB, HN received consultation fees and study support from Boston Scientific, USA. The other authors have nothing to declare.

Introduction

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent (LAMS) is a novel endoscopic technique used to treat gastric outlet obstruction mostly caused by malignant disease such as pancreatic, gastric or biliary cancer. It is a technically challenging procedure with a high-risk of complications especially when performed by an endoscopist with limited experience.

Aims & Methods

We retrospectively analyzed our prospectively collected data of all EUS-GE performed in our center from 2021. Clinical success was defined by the gastric outlet obstruction scoring system (GOOSS). All procedures were done by one endoscopist with no previous experience with the technique.

Results

In total 30 patients were included in the study (16 men, 14 women, mean age 69 years (range 44-90). The indication for EUS-GE was malignant disease (pancreatic cancer, cholangiocellular carcinoma, gastric cancer, gallbladder cancer, breast cancer, renal cancer, small bowel and liver cancer) in 28 cases and benign disease (chronic pancreatitis, aortic aneurysm) in 2 patients. The procedure was technically feasible in all but one patient (29/30, 96,7%). Clinical success when evaluated as restoration of solid oral intake was 86,2%
(25/29 patients) and 100% (29/29) when evaluated as restoration of at least liquid oral intake. The overall mean GOOSS achieved was 2,5 (1-3). Severe complications occurred in two patients (2/29, 6,9%). In one patient we experienced an unusual complication 6 months after the procedure when a gastrojejunocolic fistula developed, causing weight loss and fecal content vomiting. The fistula was successfully closed endoscopically. Another patient with a metastatic gastric cancer died one day after the intervention of a cardiac cause. Mean procedure time was 46 minutes (20-91) with no difference in mean time of the first and last five procedures. Mean survival post intervention was 135 days (1-560). No intervention for symptom recurrence was needed during a mean follow-up of 90 days.

Conclusion

EUS-GE is an efficient and safe technique in the treatment of gastric outlet obstruction even when performed by an endoscopist with no prior experience.

References

1. Itoi T, Ishii K, Ikeuchi N, Sofuni A, Gotoda T, Moriyasu F, Dhir V, Teoh AY, Binmoeller KF. Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut. 2016 Feb;65(2):193-5. doi: 10.1136/gutjnl-2015-310348. Epub 2015 Aug 17. PMID: 26282674
2. Antonelli G, Kovacevic B, Karstensen JG, Kalaitzakis E, Vanella G, Hassan C, Vilmann P. Endoscopic ultrasound-guided gastro-enteric anastomosis: A systematic review and meta-analysis. Dig Liver Dis. 2020 Nov;52(11):1294-1301. doi: 10.1016/j.dld.2020.04.021. Epub 2020 Jun 3. PMID: 32505567
3. Hujova A, Stirand P, Turza P, Spicak J, Hucl T. Endoscopic management of gastrojejunocolic fistula as an unusual complication of endoscopic ultrasound-guided gastroenterostomy. Endoscopy. 2023 Dec;55(S 01):E151-E152. doi: 10.1055/a-1937-9558. Epub 2022 Oct 28. PMID: 36307072; PMCID: PMC9829763.

Introduction

Gastric outlet obstruction (GOO) is a debilitating condition commonly caused by malignant or benign diseases, impairing gastric emptying and nutritional status. While surgical gastrojejunostomy (SGJ) has traditionally been the standard palliative approach, endoscopic ultrasound-guided gastrojejunostomy (EUSGJ) has recently emerged as a minimally invasive alternative. This systematic review and meta-analysis aimed to compare the efficacy and safety of EUSGJ versus SGJ for the management of GOO.

Aims & Methods

A systematic search of PubMed, Embase, Medline, and Cochrane Library was conducted to identify studies directly comparing EUSGJ and SGJ in adult patients with GOO. Nine retrospective studies comprising 1,086 patients (654 EUSGJ; 432 SGJ) were included. Primary outcomes included technical and clinical success, length of hospital stay (LOS), operative time, and overall complication rates. Secondary outcomes included infection, ileus, hemorrhage, perforation, and re-intervention. Meta-analyses were performed using fixed or random effects models depending on data heterogeneity.

Results

EUSGJ was significantly superior to SGJ in terms of technical success (OR = 0.16; 95% CI: 0.05–0.45; p = 0.0006), shorter operative time (MD = –96.89 minutes; 95% CI: –146.16 to –47.61; p < 0.00001), reduced postoperative LOS (MD = –4.79 days; 95% CI: –6.52 to –3.06; p < 0.0001), lower overall complication rates (OR = 0.24; 95% CI: 0.17–0.33; p < 0.00001), reduced postoperative ileus (OR = 0.07; 95% CI: 0.02–0.17; p < 0.00001), and fewer infections (OR = 0.17; 95% CI: 0.08–0.37; p < 0.00001). No statistically significant differences were found regarding clinical success, re-intervention, hemorrhage, or perforation.

Conclusion

EUSGJ demonstrates superior procedural outcomes and safety profiles compared to SGJ in the management of GOO and represents a valuable tool in expert hands. However, further prospective studies and randomized trials are necessary to validate these findings, assess long-term outcomes, and define its role within individualized patient care and clinical guidelines.

Disclosure

No conflict of interest