68 EUS-GUIDED GASTROJEJUNOSTOMY WITH LUMEN APPOSING METAL STENT VERSUS ENTERAL STENT PLACEMENT FOR PALLIATION OF MALIGNANT GASTRIC OUTLET OBSTRUCTION

Abstract

Enteral stent placement is commonly performed for palliation of obstructive symptoms caused by malignant gastric outlet obstruction (GOO). EUS-guided gastrojejunostomy (EUS-GJ) with placement of a lumen-apposing metal stent (LAMS) is a novel procedure that may offer long lasting patency with fewer incidence of stent failure, however there is limited data comparing EUS-GJ to enteral stent placement. To compare clinical outcomes and adverse events between EUS-GJ and enteral stent placement in the endoscopic palliation of malignant GOO. A prospectively collected university health care system registry was queried for LAMS, enteral stents, and GOO, and a retrospective analysis was performed. Patients who underwent EUS-GJ and enteral stent placement for the palliation of malignant GOO from 2014-2017 were included. Patients with benign GOO, gastroparesis, or surgically altered anatomy were excluded. Demographics, procedural and technical characteristics, and relevant clinical outcomes were recorded. Adverse events were assessed. Characteristics and clinical outcomes were compared using Fisher’s exact test and Student’s t test when appropriate. A total of 100 consecutive patients who underwent endoscopic palliation of malignant GOO during the study period were analyzed, of which 78 patients underwent enteral stent placement, and and 22 patients underwent EUS-GJ. Mean age was 65.9 ± 11.9 years, and 44.0% of patients were female. A total of 121 stents were placed, including 24 LAMS in the EUS-GJ group and 97 uncovered self expanding metal stents in the enteral stent group. When comparing EUS-GJ and enteral stent cases, technical success was achieved in 100% in both groups, however higher clinical success was attained in the EUS-GJ group compared to enteral stent group (91.7% vs 69.1%, p = 0.036). Mean length of hospital stay following stent placement was similar between the two groups (p = 0.821). The rate of stent failure requiring repeat intervention was significantly higher in the enteral stent group (31.6% vs 8.0%, p = 0.021). The enteral stent group had greater number of adverse events (40.2% vs 20.8%, p = 0.098) and incidence of stent ingrowth (16.5% vs 4.2%, p = 0.189), however this did not reach statistical significance. Misdeployment resulting in perforation occurred in two cases of EUS-GJ, however both cases were managed endoscopically with subsequent successful LAMS deployment in the same session, and neither case required surgery. When compared to enteral stent placement, EUS-GJ has higher rate of initial clinical success and lower rate of stent failure requiring repeat intervention. EUS-GJ should be offered as a minimally invasive alternative for selected patients with malignant GOO in centers with extensive experience.Tabled 1Table 1. Clinical OutcomesEUS-GJ (n, %)Enteral Stent (n, %)p valuePatients22 (22.0)78 (78.0)---Stents Placed24 (19.8)97 (80.2)---Technical Success24 (100.0)97 (100.0)1.000Clinical Success22 (91.7)67 (69.1)0.036Length of Hospital Stay Following Stent Placement (± SD, days)7.4 (9.1)7.9 (8.2)0.821Stent Failure Requiring Re-Intervention2 (8.0)31 (31.6)0.021Time to Re-Intervention (± SD, days)128 (157.0)99.2 (166.5)0.812Total Adverse Events5 (20.8)39 (40.2)0.098Stent Ingrowth1 (4.2)16 (16.5)0.189Stent Obstruction (not including ingrowth)0 (0.0)7 (7.2)0.342Stent Migration0 (0.0)2 (2.1)1.000Inadequate Stent Length0 (0.0)2 (2.1)1.000Bleeding0 (0.0)1 (1.0)1.000Biliary Obstruction0 (0.0)2 (2.1)1.000PEG Placement1 (4.2)5 (5.2)1.000Conversion to EUS-GJ (enteral stent only)---1 (1.0)---LAMS Mesh Erosion (EUS-GJ only)1 (4.2)------LAMS Misdeployment (EUS-GJ only)2 (8.3)------Death Within 30 Days0 (0.0)3 (3.1)1.000Abbreviations: EUS = endoscopic ultrasound GJ = gastrojejunostomy LAMS = lumen apposing metal stent SD = standard deviation Open table in a new tab