Patency of endoscopic ultrasound-guided gastroenterostomy in the treatment of malignant gastric outlet obstruction

Kastelijn, Janine B; Moons, Leon M.G.; Garcia-Alonso, Francisco J.; Pérez-Miranda, Manuel; Masaryk, Viliam; Will, Uwe; Tarantino, Ilaria; van Dullemen, Hendrik M; Bijlsma, Rina A; Poley, Jan-Werner; Schwartz, Matthijs P; Vleggaar, Frank P.

doi:10.1055/a-1214-5659

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Patency of endoscopic ultrasound-guided gastroenterostomy in the treatment of malignant gastric outlet obstruction

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Author(s): Janine B. Kastelijn ¹ , Leon M.G. Moons ¹ , Francisco J. Garcia-Alonso ² , Manuel Pérez-Miranda ² , Viliam Masaryk ³ , Uwe Will ³ , Ilaria Tarantino ⁴ , Hendrik M. van Dullemen ⁵ , Rina Bijlsma ⁶ , Jan-Werner Poley ⁷ , Matthijs P. Schwartz ⁸ , Frank P. Vleggaar ¹

Publication date (Electronic): 31 August 2020

Journal: Endoscopy International Open

Publisher: © Georg Thieme Verlag KG

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Abstract

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) is a novel, minimally invasive technique in the palliative treatment of malignant gastric outlet obstruction (GOO). Several studies have demonstrated feasibility and safety of EUS-GE, but evidence on long-term durability is limited. The aim of this study was to evaluate patency of EUS-GE in treatment of malignant GOO.

Patients and Methods An international multicenter study was performed in seven centers in four European countries. Patients who underwent EUS-GE with a LAMS between March 2015 and March 2019 for palliative treatment of symptomatic malignant GOO were included retrospectively. Our main outcome was recurrent obstruction due to LAMS dysfunction; other outcomes of interest were technical success, clinical success, adverse events (AEs), and survival.

Results A total of 45 patients (mean age 69.9 ± 12.3 years and 48.9 % male) were included. Median duration of follow-up was 59 days (interquartile range [IQR] 41–128). Recurrent obstruction occurred in two patients (6.1 %), after 33 and 283 days of follow-up. Technical success was achieved in 39 patients (86.7 %). Clinical success was achieved in 33 patients (73.3 %). AEs occurred in 12 patients (26.7 %), of which five were fatal. Median overall survival was 57 days (IQR 32–114).

Conclusions EUS-GE showed a low rate of recurrent obstruction. The relatively high number of fatal AEs underscores the importance of careful implementation of EUS-GE in clinical practice.

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Most cited references 16

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Endoscopic palliation of malignant gastric outlet obstruction using self-expanding metal stents: experience in 36 patients.

Todd Baron, Sharon G. Adler (2001)

Malignant gastric outlet obstruction is seen in the setting of a variety of cancers, most commonly pancreatic. Self-expanding metal stents can be used to palliate these patients and restore the ability to eat. We reviewed the Mayo Clinic experience in the endoscopic treatment of malignant gastric outlet obstruction. Thirty-six patients (26 male, 10 female) were treated between October, 1998 and January, 2001. Data were collected from charts, endoscopy reports, x-rays, and telephone calls. A scoring system was created to grade the ability to eat. All procedures were successful. Thirty-one of 36 patients (86%) required one stent at initial endoscopy, and 5/36 patients (14%) required two or more stents. Pretreatment, 19/36 patients (53%) were nil per os, 15/36 (42%) drank liquids, and 2/36 were able to eat soft solids. After stent placement, only 1/36 (3%) was still nil per os, 13/36 (36%) drank liquids, 13/36 (36%) ate soft solids, and 9/36 (25%) ate a full diet. The improvement in ability to eat using the scoring system was statistically significant (p < 0.0001). Nine of 36 patients (25%) required reintervention for recurrent symptoms. Sixteen of 36 patients (44%) had concomitant or subsequent development of biliary obstruction, of which 15 were successfully decompressed. Self-expanding metal stents are a safe and efficacious method for palliating malignant gastric outlet obstruction. The majority of patients do not require reintervention, and those that do can usually be managed nonoperatively.

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EUS-Guided Gastroenterostomy versus Enteral Stent Placement for Palliation of Malignant Gastric Outlet Obstruction

Phillip S Ge, Joyce Young, William Dong … (2019)

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 is limited. We aimed to compare clinical outcomes between EUS-GE and enteral stent placement in the palliation of malignant GOO. Retrospective analysis of a prospectively collected database on patients who underwent EUS-GE or enteral stent placement for palliation of malignant GOO from 2014–2017. 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. 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). 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.

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Endoscopy or surgery for malignant GI outlet obstruction?

Mario Del Piano, Marco Ballarè, Franco Montino … (2005)

The treatment of gastroduodenal outflow obstruction (GOO) caused by malignant diseases represents a significant challenge. Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. More recently, endoscopic placement of self-expanding metallic stents (SEMS) has been proposed and the results of small, preliminary studies are encouraging. This study compared technical and clinical success, morbidity, mortality, and hospital stay in patients undergoing endoscopic and surgical treatment of GOO. Medical records of 60 consecutive patients with GOO seen between April 1997 and November 2002 were retrospectively reviewed. Because of extremely short life expectancy, 13 patients were treated by insertion of a double-lumen nasogastric-jejunal tube. The remaining 47 patients (28 men, 19 women; mean age 73.5 years, range 48-92 years) with unresectable pancreatic (33), gastric (7), metastatic lymph nodal (4), papillary (2), and biliary (1) tumors were treated by placement of a SEMS (24) or open surgical GJ (23). The technical success rates were similar, but clinical success was lower in the GJ group (92% vs. 56%, p = 0.0067). The SEMS group had a shorter length of hospital stay (3.0 [1.4] days vs. 24.1 [10.3], p < 0.001). Thirty-day mortality was 30% in the GJ group, and 0% in the SEMS group ( p = 0.004). Morbidity was higher in the GJ compared with the SEMS group (61% vs. 17%, p = 0.0021). Mean survival was longer in the SEMS group (96.1 [9.6] days vs. 70.2 [36.2] days, p = 0.0165 for a single test of hypothesis; Bonferroni correction for a multiple testing removes this significance), consequently, out-of-hospital survival was longer for the SEMS group (93.2 [9.3] days vs. 46.0 [31.5] days, p < 0.001). None of the endoscopic procedures required the assistance of an anesthesiologist or the use of an operating room. The results of this retrospective study suggest that SEMS insertion is better than surgical GJ for palliation of patients with GOO in terms of clinical success, morbidity, and mortality. Technical success rates were similar. SEMS placement should be proposed as the first-line treatment for relief of GOO. However, a randomized, comparative, prospective study of SEMS vs. laparoscopic GJ is needed.

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Author and article information

Journal

Journal ID (nlm-ta): Endosc Int Open

Journal ID (iso-abbrev): Endosc Int Open

Journal ID (doi): 10.1055/s-00025476

Title: Endoscopy International Open

Publisher: © Georg Thieme Verlag KG (Stuttgart · New York )

ISSN (Print): 2364-3722

ISSN (Electronic): 2196-9736

Publication date (Print): September 2020

Publication date (Electronic): 31 August 2020

Volume: 8

Issue: 9

Pages: E1194-E1201

Affiliations

[1 ]Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands

[2 ]Department of Gastroenterology and Hepatology, Hospital Universitario Rio Hortega, Valladolid, Spain

[3 ]Department of Gastroenterology and General Internal Medicine, SRH Wald-Klinikum, Gera, Germany

[4 ]Gastroenterology and Endoscopy Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (IsMeTT), Palermo, Italy

[5 ]Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands

[6 ]Department of Gastroenterology and Hepatology, Martini Hospital Groningen, Groningen, The Netherlands

[7 ]Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands

[8 ]Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, The Netherlands

Author notes

Corresponding author Prof. Dr. F.P. Vleggaar Department of Gastroenterology and Hepatology University Medical Center Utrecht P.O. Box 85500, 3508 GAUtrechtThe Netherlands.+0031887550724 f.vleggaar@ 123456umcutrecht.nl

Article

DOI: 10.1055/a-1214-5659

PMC ID: 7458745

PubMed ID: 32904815

SO-VID: 3057a885-30ec-4d95-b2dd-fad5287842d3

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

History

Date received : 25 February 2020

Date accepted : 28 May 2020

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