EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction

Abstract

Background

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 are limited. We aimed to compare clinical outcomes between EUS-GE and enteral stent placement in the palliation of malignant GOO.

Methods

Retrospective analysis of a prospectively collected database on patients who underwent EUS-GE or enteral stent placement for palliation of malignant GOO from 2014 to 2017 was conducted. 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.

Results

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).

Conclusion

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.

This is a preview of subscription content, log in to check access.

Fig. 1

References

  1. 1.

    van Hooft JE, Uitdehaag MJ, Bruno MJ et al (2009) Efficacy and safety of the new WallFlex enteral stent in palliative treatment of malignant gastric outlet obstruction (DUOFLEX study): a prospective multicenter study. Gastrointest Endosc 69:1059–1066

    Article  PubMed  Google Scholar 

  2. 2.

    Warshaw AL, Fernandez-del Castillo C (1992) Pancreatic carcinoma. N Engl J Med 326:455–465

    Article  CAS  PubMed  Google Scholar 

  3. 3.

    Chekan EG, Clark L, Wu J et al (1999) Laparoscopic biliary and enteric bypass. Semin Surg Oncol 16:313–320

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Jeurnink SM, Steyerberg EW, van Hooft JE et al (2010) Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 71:490–499

    Article  PubMed  Google Scholar 

  5. 5.

    Zheng B, Wang X, Ma B et al (2012) Endoscopic stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Dig Endosc 24:71–78

    Article  PubMed  Google Scholar 

  6. 6.

    Binmoeller KF, Shah JN (2012) Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 44:499–503

    Article  CAS  PubMed  Google Scholar 

  7. 7.

    Khashab MA, Kumbhari V, Grimm IS et al (2015) EUS-guided gastroenterostomy: the first U.S. clinical experience (with video). Gastrointest Endosc 82:932–938

    Article  PubMed  Google Scholar 

  8. 8.

    Soetikno RM, Carr-Locke DL (1999) Expandable metal stents for gastric-outlet, duodenal, and small intestinal obstruction. Gastrointest Endosc Clin N Am 9:447–458

    Article  CAS  PubMed  Google Scholar 

  9. 9.

    Wong YT, Brams DM, Munson L et al (2002) Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation. Surg Endosc 16:310–312

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Yim HB, Jacobson BC, Saltzman JR et al (2001) Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction. Gastrointest Endosc 53:329–332

    Article  CAS  PubMed  Google Scholar 

  11. 11.

    Del Piano M, Ballare M, Montino F et al (2005) Endoscopy or surgery for malignant GI outlet obstruction? Gastrointest Endosc 61:421–426

    Article  PubMed  Google Scholar 

  12. 12.

    Topazian M, Ring E, Grendell J (1992) Palliation of obstructing gastric cancer with steel mesh, self-expanding endoprostheses. Gastrointest Endosc 38:58–60

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Gaidos JK, Draganov PV (2009) Treatment of malignant gastric outlet obstruction with endoscopically placed self-expandable metal stents. World J Gastroenterol 15:4365–4371

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Teoh AYB, Dhir V, Kida M et al (2018) Consensus guidelines on the optimal management in interventional EUS procedures: results from the Asian EUS group RAND/UCLA expert panel. Gut 67(7):1209–1228

    Article  Google Scholar 

  15. 15.

    Abidi WM, Thompson CC (2016) Endoscopic choledochoduodenostomy and gastrojejunostomy in the treatment of biliary and duodenal obstruction. Gastrointest Endosc 83:1287–1288

    Article  PubMed  Google Scholar 

  16. 16.

    Brewer Gutierrez OI, Nieto J, Irani S et al (2017) Double endoscopic bypass for gastric outlet obstruction and biliary obstruction. Endosc Int Open 5:E893–E899

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Itoi T, Ishii K, Ikeuchi N et al (2016) Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut 65:193–195

    Article  PubMed  Google Scholar 

  18. 18.

    Tyberg A, Perez-Miranda M, Sanchez-Ocana R et al (2016) Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open 4:E276–E281

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Khashab MA, Bukhari M, Baron TH et al (2017) International multicenter comparative trial of endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction. Endosc Int Open 5:E275–E281

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Perez-Miranda M, Tyberg A, Poletto D et al (2017) EUS-guided gastrojejunostomy versus laparoscopic gastrojejunostomy: an international collaborative study. J Clin Gastroenterol 51:896–899

    Article  PubMed  Google Scholar 

  21. 21.

    Chen YI, Itoi T, Baron TH et al (2017) EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surg Endosc 31:2946–2952

    Article  PubMed  Google Scholar 

  22. 22.

    Chen YI, Kunda R, Storm AC et al (2018) EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc 87:1215–1221

    Article  PubMed  Google Scholar 

  23. 23.

    Itoi T, Itokawa F, Uraoka T et al (2013) Novel EUS-guided gastrojejunostomy technique using a new double-balloon enteric tube and lumen-apposing metal stent (with videos). Gastrointest Endosc 78:934–939

    Article  PubMed  Google Scholar 

  24. 24.

    Itoi T, Tsuchiya T, Tonozuka R et al (2016) Novel EUS-guided double-balloon-occluded gastrojejunostomy bypass. Gastrointest Endosc 83:461–462

    Article  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Christopher C. Thompson.

Ethics declarations

Disclosures

Phillip S. Ge: Boston Scientific (Consultant). Christopher C. Thompson: Boston Scientific (Consultant), Medtronic (Consultant), USGI Medical (Consultant, Advisory Board Member, Research Support), Olympus (Consultant, Research Support), Apollo Endosurgery (Consultant, Research Support), GI Windows (Ownership Interest), Aspire Bariatrics (Research Support), Fractyl (Consultant, Advisory Board Member), Spatz (Research Support), EndoTAGSS (Ownership Interest), GI Dynamics (Consultant). Joyce Y. Young and William Dong have no conflicts of interest or financial ties to disclose.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ge, P.S., Young, J.Y., Dong, W. et al. EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction. Surg Endosc 33, 3404–3411 (2019). https://doi.org/10.1007/s00464-018-06636-3

Download citation

Keywords

  • Gastroenterostomy
  • Gastric outlet obstruction
  • GOO
  • MGOO
  • Lumen-apposing metal stent
  • LAMS
  • Enteral stent
  • SEMS
  • Therapeutic endoscopic ultrasound
  • Pancreatic cancer