Comparative Study of NOTES Versus Endoscopic Ultrasound Gastrojejunostomy in Pigs: A Prospective Study

Surgical gastrojejunal anastomosis (GJJ) is considered the standard palliative option for gastric outlet obstruction. The use of endoscopic GJJ has generated a lot of attention and has enlarged the horizon for patients with open surgery contraindications. Our study aimed to assess and compare 2 purely endoscopic GJJ approaches using a lumen-apposing hot tip double-flanged metal stent, with focus on technical and clinical success rates on experimental animals.

Two endoscopic GJJ techniques using a double-flanged self-expandable metal stent were compared on 8 pigs. Natural orifice transluminal endoscopic surgery (NOTES) was used on 4 pigs, while the other group was subjected to an endoscopic ultrasound (EUS) balloon-guided approach.

On a 21-day follow-up, both EUS and NOTES-GJJ were technically successful in all experimental animals, and necropsy confirmed full integrity of the anastomosis. Adhesions were confirmed only on 2 pigs after NOTES procedure. The mean time for GJJ-NOTES completion was 31.375 ± 2.03, whereas EUS-GJJ was completed with a median time of 20.275 ± 0.65. The stent distance from the stomach varied; in NOTES-GJJ it was 47.8 ± 11.13 cm away from the pylorus, whereas in EUS-GJJ was at 37 ± 1.85 cm.

No major complications were encountered during both procedures. EUS-GJJ balloon-guided approach might be a more attractive technique by using sonographic guidance, because of less endoscopic instrument changing as well as in achieving the desired anastomotic distance.