Endoscopy – surgery: the sliding doors

The advent of therapeutic endoscopic ultrasound (EUS) has marked a significant shift in the approach to gastrointestinal diseases, particularly those affecting the pancreas and biliary tract. With linear echoendoscopes, the possibility of accessing target sites under precise real-time endosonographic guidance has been a tremendous revolution. Furthermore, the advent of the lumen-apposing metal stent (LAMS) has permitted the easy creation of a stable connection between two lumens, which has been proven advantageous for EUS-guided drainage of peripancreatic fluid collections, the biliary tract, the gallbladder, and even for connecting two different gastrointestinal tracts with the advent of EUS-guided anastomoses [1].

Initially confined to the management of malignancies – both for primary palliation and for treating post-surgical complications – therapeutic EUS has progressively expanded its scope. Today, a large chapter of preclinical and clinical research encompasses benign conditions and complex clinical scenarios where conventional therapeutic options are limited or associated with high morbidity.

“Potential indications for reversible endoscopic gastroduodenal bypass may extend beyond refractory ulcers to include symptomatic neoplastic invasions, complex gastrointestinal fistulas, and beyond.”

A paradigm shift in this evolution is exemplified by the use of EUS in the treatment of pancreaticobiliary diseases in patients with post-surgical anatomical alterations, where EUS can help by creating connections between the pancreaticobiliary limb and the proximal gastrointestinal tract, to allow the so-called EUS-directed endoscopic retrograde cholangiopancreatography (ERCP) [2], or even by transgastric EUS-guided access to the intrahepatic biliary tract or the pancreatic duct to perform antegrade interventions such as dilation or stenting of anastomoses or stone extraction [3].

In this issue of Endoscopy and following their former preclinical study [4], Kadkhodayan et al. have clinically explored an additional possibility of therapeutic EUS by introducing the concept of reversible endoscopic gastroduodenal bypass (REGB) [5]. This concept merges EUS-guided gastroenterostomy with pylorus endosuturing, creating an endoscopic alternative to the standard surgical procedure of duodenal exclusion, and overcoming some limitations of the surgical intervention.

The authors have explored this possibility in the scenario of perforated duodenal ulcers that are refractory to surgical treatment. The standard surgical procedure of omental patch repair (omentopexy) still presents a non-negligible rate of postoperative leak persistence. Surgical reintervention in these patients poses a significant technical challenge, exacerbated by dense adhesions and poor nutritional status, making conventional approaches highly morbid. REGB emerges as a minimally invasive alternative that avoids the need for repeat laparotomy, is organ-sparing, and, most importantly, is completely reversible, allowing for the restoration of normal anatomy and physiology once the complication is resolved.

The experience reported by Kadkhodayan et al. demonstrates that the procedure can be performed in a single session with relative technical ease, yielding high clinical success rates. Moreover, other possible therapeutic scenarios might be speculated, such as the treatment of iatrogenic perforation during hepatic surgery or cholecystectomy, or endoscopic interventions, such as ERCP or duodenal resections. In this scenario, REGB provides a new perspective in a field where traditional surgery is often burdened with a risk of failure and morbidity.

However, certain challenges must be considered. The first limitation is the requirement for advanced training in therapeutic EUS and endoscopic suturing, skills that are not yet widely available among endoscopists. In particular, a crucial moment in the procedure is the creation of the EUS-guided gastroenterostomy, which can be burdened by risks such as misdeployment. Performing it in a complex surgical scenario, such as a frozen abdomen, can significantly hamper the potential surgical backup, and create an additional complication to be managed. Therefore, it is essential to have proficiency with the technique and adhere to a standardized method, such as the wireless EUS-guided gastroenterostomy simplified technique used by the authors [6] [7].

The second concern relates to nutritional implications. Patients undergoing REGB experienced significant weight loss between the first and second procedure, likely due to metabolic stress, a catabolic state, and exclusion of an absorptive segment of the intestine. Encouragingly, most patients regained lost weight within 3 months after stent removal.

Further questions pertain to the optimal duration of the procedure. While short-term outcomes are promising, and compatible with the resolution of short-term diseases such as fistulas or leaks, long-term data on the effects of prolonged stent placement remain scarce. Reaction to the LAMS itself in the long term has not yet been elucidated, whereas the removal of LAMS often results in spontaneous fistula closure, as also observed in this series. Therefore, the application of REGB to other clinical scenarios remains completely experimental.

Thus, the study by Kadkhodayan et al. raises critical questions and opens new avenues for REGB application. Its potential indications may extend beyond refractory ulcers to include symptomatic neoplastic invasions, complex gastrointestinal fistulas, and beyond. However, to solidify its role in clinical practice, multicenter studies with extended follow-up and, ideally, randomized controlled trials assessing its safety, efficacy, and cost-effectiveness relative to surgery would be essential.

Therapeutic endoscopy is undergoing a radical transformation, blurring the traditional boundaries between medical disciplines. Advanced techniques such as REGB demonstrate that it is now possible to replicate complex surgical procedures in a less invasive manner, significantly reducing operative risks and improving patient quality of life. The sliding doors between surgery and endoscopy are opening, revealing an increasingly integrated future where endoscopy is a well-established and evolving therapeutic alternative.

Publication History

Article published online:
14 May 2025

• References

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