Introduction

EUS-guided Gastroenterostomy (EUS-GE) represents a recent breakthrough in therapeutic endosonography, with most existing data derived from retrospective studies focused on short-term technical outcomes. Limited information is available on long-term outcomes, the need for reinterventions and modifications of Lumen Apposing Metal Stents (LAMS) over time.

Aims & Methods

All consecutive EUS-GE performed in a single institution with the Wireless Simplified Technique (WEST) between 2020 and 2024 were enrolled in a prospective registry (PROTECT, ClinicalTrials.gov NCT04813055), with efficacy and safety outcomes assessed every 60 days. The primary outcomes were symptom recurrence after initial clinical success (rate, proportion) and dysfunction-free survival (DyFS) estimated using Kaplan Meier curves. Endoscopic LAMS reassessments were used to calculate the time to first modification of the stent and surrounding tissues, whilst Radiologic imaging was used to estimate the change in stent calibre (linear regression).

Results

164 EUS-GEs (median age 66 [60-74], male 52.4%, malignant indication 99.4% [pancreatic cancer 73.2%, metastatic 58.3%]) were included. A 20 mm LAMS was used in 98.8%, dilated up to 18 mm in 98.8% of cases. Technical and Clinical success rates were 98.8% and 96.3%, respectively. Adverse events (AEs) were registered in 15.2% (procedure-related 6.1%, severe/fatal 3.7%).
Over a median follow-up of 112 [40-190] days, symptom recurrence occurred in 9.1%, but was related to stent dysfunctions in 10/154 (6.5%) cases. Stent dysfunctions happened after a median of 231 [67-321] days from the procedure, all of which (100%) were successfully managed endoscopically. Estimated DyFS at 6 and 12 months was 97.5% and 82.6%, respectively.
Among 38 patients undergoing endoscopic LAMS re-evaluation for different reasons, tissue reactions on the gastric or jejunal side were observed in 34.2% after a median of 190 [33-351] days, and LAMS ingrowth was seen in 13.2% after a median of 421 [250-560] days. A total of 132 CT scans from 75 patients were analysed, with regression analysis revealing a reduction in LAMS diameter of ≈ 0.25 mm + 0.03 every 2 months (F-test p<.0001).

Conclusion

In the natural history of EUS-GE, subclinical LAMS changes and tissue reactions can be frequently detected during follow-up along with a progressive narrowing of LAMS diameter. However, most of these modifications are asymptomatic, with a 6.5% rate of endoscopic reinterventions, all performed successfully. Analysis of these curves may be helpful to plan scheduled reinterventions, especially in cases with benign indication or in long-term survivors.

Introduction

The Percutaneous Endoscopic Gastrostomy (PEG) tube is used to provide enteral nutrition when oral intake is not adequate.
Regular follow-up of PEG patients is essential to detect complications and clarify doubts. A partnership protocol was developed with ACES Lisboa Central (ACESLC) and Loures/Odivelas (ACESLO) to improve continuity of care.

Results & Findings

We analyzed data from PEG patients followed between 2023 and 2024. Inclusion criteria for referral to ACES included:
• Clinical stabilization;
• Absence of PEG-related complications requiring hospital admission;
• Willingness and ability of the patient/caregiver to participate actively in care.
Monitoring of the protocol was based on quarterly evaluation of five performance indicators:
1st: Percentage of patients referred to ACES, out of the total seen in PEG review consultations;
2nd: Percentage of referred patients who returned to hospital before the expected date due to complications;
3rd: Percentage of cases in which complete referral documentation, as per protocol, was sent to ACES;
4th: Percentage of cases with confirmation that ACES sent back all required clinical data;
5th: Percentage of compliance with scheduled PEG follow-up appointments at ACESLO.

Summary & Discussion

The 1st indicator shows low referral rates in both years, mainly due to out-of-area institutionalization, clinical worsening, or death.
The 2nd indicator indicates fewer unplanned hospital readmissions among referred patients; when they occurred, complications were the cause.
Results show fewer complications and emergency visits, reflecting the benefit of close ACES collaboration.
The 3rd indicator reflects 100% compliance in sending referral documentation.
The 4th indicator showed gaps in home visit records in 2023, improved in 2024 through better coordination.
One challenge was the mismatch between designated ACES nurses and those conducting home visits, which required articulation with family health teams (USF).
The 5th indicator confirms overall adherence to scheduled PEG reviews.

Conclusion

The protocol streamlined follow-up for PEG patients.
In 2024, a previous limitation was overcome, allowing referrals of institutionalized patients within the protocol’s coverage.
As a pioneering project, we aim to share these findings to support protocol expansion to other units.

References

Kurion, M., Andrews, R., Tattersall, R., McAlindon, M., Wong, E., Johnston, A., Hoeroldt, B., Dear, K. & Sanders, D. (2017). Gastrostomies preserve but do not increase quality of life for patients and caregivers. Clinical Gastroenterology and Hepatology. 15, 1047-1054.
Lee, C.,Kang, H., Lim, Y., Lee, J., Koh, M., Lee, J., Yang, C. & Kim, J. (2013). Comparison of complications between endoscopic and percutaneous replacement of percutaneous endoscopic gastrostomy tubes. JKoren Medical Sciences. 28, 1781-1787.
Lucendo, A. J. & Friginal-Ruiz, A. B. (2014). Percutaneous endoscopic gastrostomy: An update on its indications, management, complications, and care. Revista Española de Enfermedades Digestivas. 106(8), 529-539.