EUS-guided gastroenterostomy in management of benign gastric outlet obstruction

Abstract

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in malignant gastric outlet obstruction (GOO) appears to be promising; however, its role in benign GOO is unclear. The aim of this study was to ascertain the clinical efficacy and safety of EUS-GE in benign GOO.

Patients and methods This was an international retrospective series involving 5 tertiary centers. Consecutive patients who underwent EUS-GE between 1/2013 – 10/2016 for benign GOO were included. The primary endpoint was the rate of clinical success defined as ability to tolerate oral intake without vomiting. Secondary endpoints included technical success and rate of adverse events (AE).

Results Overall, 26 patients (46.2 % female; mean age 57.7 ± 13.9 years) underwent EUS-GE for benign GOO due to strictures from chronic pancreatitis (n = 11), surgical anastomosis (n = 6), peptic ulcer disease (n = 5), acute pancreatitis (n = 1), superior mesentery artery syndrome (n = 1), caustic injury (n = 1), and hematoma (n = 1). Technical success was achieved in 96.2 %. Dilation of the lumen apposing metal stent was performed in 13/25 (52 %) with a mean maximum diameter of 14.6 ± 1.0 mm. Mean procedure time was 44.6 ± 26.1 min. Clinical success was observed in 84.0 % with a mean time to oral intake of 1.4 ± 1.9 days and a median follow-up of 176.5 (IQR: 47 – 445.75) days. Rate of unplanned re-intervention was 4.8 %. 3 AE were noted including 2 misdeployed stents and 1 gastric leak needing surgical intervention following elective GE stent removal.

Conclusions EUS-GE is a promising treatment for benign GOO. Larger and prospective data are needed to further validate this novel endoscopic technique in treating benign GOO of various etiologies.

• References

• 1 Committee ASoP. Banerjee S, Cash BD. et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc 2010; 71: 663-668
• 2 Paimela H, Tuompo PK, Perakyl T. et al. Peptic ulcer surgery during the H2-receptor antagonist era: a population-based epidemiological study of ulcer surgery in Helsinki from 1972 to 1987. Br J Surg 1991; 78: 28-31
• 3 Johnson CD, Ellis H. Gastric outlet obstruction now predicts malignancy. Br J Surg 1990; 77: 1023-1024
• 4 Khullar SK, DiSario JA. Gastric outlet obstruction. Gastrointest Endosc Clin N Am 1996; 6: 585-603
• 5 Kochhar R, Kochhar S. Endoscopic balloon dilation for benign gastric outlet obstruction in adults. World J Gastrointest Endosc 2010; 2: 29-35
• 6 Boylan JJ, Gradzka MI. Long-term results of endoscopic balloon dilatation for gastric outlet obstruction. Dig Dis Sci 1999; 44: 1883-1886
• 7 DiSario JA, Fennerty MB, Tietze CC. et al. Endoscopic balloon dilation for ulcer-induced gastric outlet obstruction. Am J Gastroenterol 1994; 89: 868-871
• 8 Kozarek RA, Botoman VA, Patterson DJ. Long-term follow-up in patients who have undergone balloon dilation for gastric outlet obstruction. Gastrointest Endosc 1990; 36: 558-561
• 9 Lam YH, Lau JY, Fung TM. et al. Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection. Gastrointest Endosc 2004; 60: 229-233
• 10 Solt J, Bajor J, Szabo M. et al. Long-term results of balloon catheter dilation for benign gastric outlet stenosis. Endoscopy 2003; 35: 490-495
• 11 Chiu YC, Liang CM, Tam W. et al. The effects of endoscopic-guided balloon dilations in esophageal and gastric strictures caused by corrosive injuries. BMC Gastroenterol 2013; 13: 99
• 12 Kochhar R, Dutta U, Sethy PK. et al. Endoscopic balloon dilation in caustic-induced chronic gastric outlet obstruction. Gastrointest Endosc 2009; 69: 800-805
• 13 Binkert CA, Jost R, Steiner A. et al. Benign and malignant stenoses of the stomach and duodenum: treatment with self-expanding metallic endoprostheses. Radiology 1996; 199: 335-338
• 14 Choi WJ, Park JJ, Park J. et al. Effects of the temporary placement of a self-expandable metallic stent in benign pyloric stenosis. Gut Liver 2013; 7: 417-422
• 15 Dormann AJ, Deppe H, Wigginghaus B. Self-expanding metallic stents for continuous dilatation of benign stenoses in gastrointestinal tract - first results of long-term follow-up in interim stent application in pyloric and colonic obstructions. Z Gastroenterol 2001; 39: 957-960
• 16 Heo J, Jung MK. Safety and efficacy of a partially covered self-expandable metal stent in benign pyloric obstruction. World J Gastroenterol 2014; 20: 16721-16725
• 17 Binmoeller KF, Shah JN. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503
• 18 Khashab MA, Kumbhari V, Grimm IS. et al. EUS-guided gastroenterostomy: the first U.S. clinical experience (with video). Gastrointest Endosc 2015; 82: 932-938
• 19 Chen YI, Khashab MA. Endoscopic approach to gastrointestinal bypass in malignant gastric outlet obstruction. Curr Opin Gastroenterol 2016; DOI: 10.1097/MOG.0000000000000292.
• 20 Chen YI, Itoi T, Baron T. et al. EUS-guided gastroenterostomy is comparable to enteral stenting in terms of technical feasibility and clinical success with lower rates of re-intervention: An international multicenter comparative study [abstract]. Digestive Disease week 2016. Gastrointest Endosc 2016; 83: AB168
• 21 Itoi T, Ishii K, Ikuchi N. et al. Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut 2016; 65: 193-195
• 22 Tyberg A, Perez-Miranda M, Sanchez-Ocana R. et al. Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open 2016; 4: E276-E281
• 23 Chen YI, Kunda R, Storm AC. et al. EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc 2017; DOI: 10.1016/j.gie.2017.07.030.
• 24 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 25 Khashab M, Alawad AS, Shin EJ. et al. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc 2013; 27: 2068-2075
• 26 Itoi T, Tsuchiya T, Tonozuka R. et al. Novel EUS-guided double-balloon-occluded gastrojejunostomy bypass. Gastrointest Endosc 2016; 83: 461-462
• 27 Kochhar R, Sethy PK, Nagi B. et al. Endoscopic balloon dilatation of benign gastric outlet obstruction. J Gastroenterol Hepatol 2004; 19: 418-422
• 28 Rana SS, Bhasin DK, Chandail VS. et al. Endoscopic balloon dilatation without fluoroscopy for treating gastric outlet obstruction because of benign etiologies. Surg Endosc 2011; 25: 1579-1584