Endoscopic gastroenterostomy: techniques and review

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Surgical Oncology

Background:

• Gastric outlet obstruction (GOO) presents significant challenges, historically managed with surgery or luminal stents.
• Luminal stents for malignant GOO have limitations, including high rates of tumor ingrowth/overgrowth leading to recurrent obstruction.
• Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a novel, minimally invasive therapeutic option.

Purpose of the Study:

• To describe five distinct techniques for performing EUS-GE using lumen-apposing metal stents.
• To compare the benefits and risks associated with each EUS-GE approach.
• To evaluate EUS-GE as an alternative to surgical gastrojejunostomy and luminal stents for GOO.

Main Methods:

• Utilizing endoscopic ultrasound (EUS) to guide the placement of a biflanged, lumen-apposing metal stent.
• Describing five techniques: antegrade EUS-GE (traditional/downstream and rendezvous), retrograde EUS-GE (EPASS), and antegrade EUS-GE (direct).
• Preprocedural computed tomography (CT) to assess patient anatomy and rule out contraindications like significant ascites.

Main Results:

• Technical success rates for EUS-GE approximate 90%, irrespective of the technique employed.
• Clinical success rates are high, with only a small proportion of patients experiencing persistent symptoms.
• Overall morbidity is low, with rare occurrences of adverse events such as pain, bleeding, pneumoperitoneum, and peritonitis. One procedure-related death reported.

Conclusions:

• EUS-GE, utilizing various techniques, demonstrates excellent efficacy in managing GOO.
• Stent misdeployment or displacement is the most common significant adverse event.
• Further prospective, randomized trials comparing EUS-GE to endoluminal stents and surgical gastrojejunostomy are warranted.