Treatment Of Gastric Outlet Obstruction Research Articles

Laparoscopic Gastrojejunostomy Versus Endoscopic Stenting as a Palliative Treatment for Gastric Outlet Obstruction.

Introduction: Gastric outlet obstruction (GOO) is a common complication in advanced stage upper gastrointestinal malignancies. The symptoms of severe nausea and protracted vomiting can lead to a decline in quality of life and cachexia. Symptoms of GOO can be effectively managed with either operative or nonoperative palliative interventions. In our article, we aim to compare laparoscopic gastrojejunostomy (GJ) to endoscopic stenting as palliative interventions for GOO. Methods: We retrospectively evaluated the charts of patients who underwent palliative procedure for gastric outlet obstruction. Group I included patients who underwent endoscopic stenting, and group II patients underwent Laparoscopic GJ. The groups' demographics (age, gender), length of procedure, length of stay, days to oral intake, overall survival, complications rate, and 30-day mortality rates were compared. Results: Overall, 38 patients were included in the study. Nineteen patients underwent endoscopic stenting and 19 underwent laparoscopic GJ. Comparing the groups, no significant differences were noted. Surgical time was significantly longer than the endoscopic procedures (83 minutes versus 25 minutes, P = .001). No significant differences were noted in days of oral intake initiation, overall survival and 30-day mortality rates. Five patients in the stenting group had complications (26.3%) versus none in the surgical group (P = .046). No postoperative complications were noted. Conclusion: Laparoscopic GJ is a safe and feasible treatment for GOO, demonstrating early resumption of oral intake. The relative short hospital stay, combined with an encouraging postoperative complications profile and low reintervention rate, should be kept in mind especially among patients with longer life expectancy.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emer-ged as an alternative treatment for gastric outlet obstruction (GOO) in selected patients. AIM To report the initial experience of EUS-GE in patients with GOO. METHODS This study was a retrospective, observational, multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected. We analyzed technical success, clinical success, adverse events, and survival. Technical success was defined as adequate position-ing and deployment of the stent. Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure. Post-procedural adverse events were recorded. RESULTS Eleven procedures in 10 patients with GOO were included. The mean age of the patients was 67.5 years (range: 56-77 years). Malignant GOO was present in 9 patients. Technical success was achieved in 9/11 procedures (82%). Among them, clinical success was achieved in 9 patients (100%). Adverse events occurred in 1 patient (9%). The median survival was 3 months (n = 7; range: 1-8 months). CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.

EUS-Guided Gastroenterostomy in the Treatment of Gastric Outlet Obstruction

EUS-Guided Gastroenterostomy in the Treatment of Gastric Outlet Obstruction

Palliative treatment for gastric outlet obstruction: A network meta-analysis.

36 Background: The optimal palliative treatment for gastric outlet obstruction (GOO) remains inconclusive between gastrojejunostomy (G), endoscopic ultrasound-guided gastroenterostomy (E), stomach partitioning gastrojejunostomy (P), endoscopic stenting (S). This study was part of a comprehensive systematic review investigating the outcomes of the aforementioned treatments for malignant GOO. Methods: We conducted a systematic screening randomized controlled trials (RCTs) and cohort studies that compared at least two palliative procedures for GOO from Pubmed, Embase, Cochrane, Web of Science, Scopus, Clinicaltrial, WHO International Clinical Trials Registry Platform. We included full-text studies that reported at least clinical outcomes (clinical success rate, complication rate, 30-day mortality rate, and reintervention rate). We conducted this network meta-analysis using the frequentist approach, inverse variance model with a naïve combination of the treatment effects from RCTs and non-RCTs. We used P-score for treatment ranking. Certainty of evidence was evaluated following CINeMA approach. Results: This study included four RCTs and four prospective and 32 retrospective cohorts with 3417 patients. The pooled overall rates of clinical success, complication, 30-day mortality, and reintervention were 88.9% (95%CI 85.6-91.6), 20.7% (95%CI 17.2-24.7), 5.4% (95%CI 3.2-8.9), and 13.9% (95%CI 10.7-17.9), respectively. P was ranked the safest for reintervention rate (P-score: 0.90) due to obstruction and complication post-procedure (P-score: 0.88 and 0.81, respectively). E was ranked the safest for the 30-day mortality rate (P-score: 0.82). Cluster rank combined the P-score for 30-day mortality and reintervention or reintervention rate due to obstruction showed the benefit of P and E versus G and S (cophenetic correlation coefficient - c: 0.94 and 0.94, respectively). Cluster rank combined with the P-score for 30-day mortality and reintervention due to complication showed the benefit of P (c:0.99). The overall certainty of evidence was low to very low. Conclusions: P and E are recommended for malignant GOO, and P should be the first choice in centers with limited resources or cases of unfeasible or unsuccessful E.

EUS-guided gastroenterostomy using a novel electrocautery lumen apposing metal stent for treatment of gastric outlet obstruction (with video).

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) for the treatment of gastric outlet obstruction (GOO) has been actually performed only with one type of electrocautery lumen-apposing metal stents (EC-LAMS). We aimed to evaluate the safety, technical and clinical effectiveness of EUS-GE using a newly available EC-LAMS in patients with malignant and benign GOO. Consecutive patients who underwent EUS-GE for GOO using the new EC-LAMS at five endoscopic referral centers were retrospectively evaluated. Clinical efficacy was determined utilizing the Gastric Outlet Obstruction Scoring System (GOOSS). Twenty-five patients (64% male, mean age 68.7±9.3 years) met the inclusion criteria; 21 (84%) had malignant etiology. Technically, EUS-GE was successful in all patients, with a mean procedural time of 35±5min. Clinical success was 68% at 7 days and 100% at 30 days. The mean time to resume oral diet was 11.4±5.8h, with an improvement of at least one point of GOOSS score observed in all patients. The median hospital stay was 4 days. No procedure-related adverse events occurred. After a mean follow-up of 7.6 months (95% CI 4.6-9.2), no stent dysfunctions were observed. This study suggests EUS-GE can be performed safely and successfully using the new EC-LAMS. Future large multicenter prospective studies are needed to confirm our preliminary data.

Innovations in the Treatment of Gastric Outlet Obstruction: Is This the Era of Endoscopic Ultrasonography-Guided Gastroenterostomy?

Abstract Purpose of review Gastric outlet obstruction is a syndrome that is caused by several benign and malignant diseases. Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel treatment that seems to combine the advantages of the two traditional treatments: enteral stent placement (ES) and surgical gastrojejunostomy (SGJ). This review aims to determine the current position of EUS-GE amidst the two traditional treatment options. Recent findings Different approaches can be adopted to facilitate EUS-GE. Direct gastroenterostomy seems to have the shortest procedure time. All methods possess high technical success rates. Several retrospective analyses have compared EUS-GE to ES and SGJ. EUS-GE seems to have better stent patency compared to ES and a lower adverse event rate compared to SGJ. Recently, randomized trials have been initiated which compare EUS-GE with ES or SGJ. Summary Although the currently published literature unequivocally shows the great promises of EUS-GE, properly powered and controlled studies are warranted to ascertain the definitive position of EUS-GE within the treatment repertoire of GOO. Until reliable data has been collected, EUS-GE can be considered a safe and effective alternative to ES and SGJ.

Current landscape of therapeutic EUS: Changing paradigms in gastroenterology practice.

Therapeutic EUS has witnessed exponential growth in the last decade, but it has been considered investigational until recently. An increasing body of good-quality evidence is now demonstrating clear advantages over established alternatives, adding therapeutic EUS to management algorithms of complex hepato-pancreato-biliary (HPB) and gastrointestinal (GI) conditions. In this review, the available evidence and clinical role of therapeutic EUS in established and evolving applications will be discussed. A Graphical Summary for each scenario will provide (1) technical steps, (2) anatomical sketch, (3) best-supporting evidence, and (4) role in changing current and future GI practice. Therapeutic EUS has accepted well-established applications such as drainage of symptomatic peripancreatic fluid collections, biliary drainage in failed endoscopic retrograde cholangiopancreatography, and treatment of acute cholecystitis in unfit-for-surgery patients. In addition, good-quality evidence on several emerging indications (e.g., treatment of gastric outlet obstruction, local ablation of pancreatic solid lesions, etc.) is promising. Specific emphasis will be given to how these technical innovations have changed management paradigms and algorithms and expanded the possibilities of gastroenterologists to provide therapeutic solutions to old and emerging clinical needs. Therapeutic EUS is cementing its role in everyday practice, radically changing the treatment of different HPB diseases and other conditions (e.g., GI obstruction). The development of dedicated accessories and increased training opportunities will expand the ability of gastroenterologists to deliver highly effective yet minimally invasive therapies, potentially translating into a better quality of life, especially for oncological and fragile patients.

Endoscopic ultrasound guided gastrojejunostomy in the treatment of gastric outlet obstruction: multi-centre experience from the United Kingdom

BackgroundEndoscopic ultrasound guided gastrojejunostomy (EUS-GJ) with lumen apposing metal stents has recently emerged as a viable option, as an alternative to surgical gastrojejunostomy and endoscopic enteral stenting, for managing gastric outlet obstruction (GOO). We aim to perform a retrospective analysis of the efficacy, safety and outcomes of EUS-GJ performed at three tertiary institutions in the United Kingdom.MethodsConsecutive patients who underwent EUS-GJ between August 2018 and March 2021 were identified from a prospectively maintained database. Data were obtained from interrogation of electronic health records.ResultsTwenty five patients (15 males) with a median age of 63 years old (range 29–80) were included for analysis. 88% (22/25) of patients had GOO due to underlying malignant disease. All patients were deemed surgically inoperable or at high surgical risk. Both technical and clinical success were achieved in 92% (23/25) of patients. There was an improvement in the mean Gastric Outlet Obstruction Scoring System scores following a technically successful EUS-GJ (2.52 vs 0.68, p < 0.01). Adverse events occurred in 2/25 patients (8%), both due to stent maldeployment necessitating endoscopic closure of the gastric defect with clips. Long-term follow-up data were available for 21 of 23 patients and the re-intervention rate was 4.8% (1/21) over a median follow-up period of 162 (range 5–474) days.ConclusionEUS-GJ in carefully selected patients is an effective and safe procedure when performed by experienced endoscopists.

Prepyloric Stricture in a 5-Year Old Infant Caused by Corrosive Injury: A Case Report

Background: The incidence of corrosive ingestion is high and largely unreported in developing countries due to lack of parental supervision and careless storing of these chemicals at home.&#x0D; Case presentation: A 5 years, 1-month-old boy came to the outpatient clinic department of pediatric Dr. M. Djamil General Hospital with a chief complaint of recurrent vomit since 6 weeks before admission. There was a history of ingested accumulator water 1,5 months before admission. The patient vomits every day, especially after eating and drinking.&#x0D; Conclusion: The most common symptoms are vomiting, feeding problems in oral intake, and rapid weight loss. The clinical diagnosis of prepyloric stricture is based on the history of the disease, physical examination, and supporting the investigation. Treatment of gastric outlet obstruction caused by corrosive ingestion should be treated surgically.

Safety and efficacy of endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in different sites: A single-center retrospective study.

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently been employed as a novel treatment for gastric outlet obstruction (GOO). The aim of this study was to evaluate the safety and efficacy of EUS-GE for GOO at different sites. Consecutive hospitalized patients who underwent EUS-GE for GOO at the Department of Gastroenterology, Nanjing Drum Tower Hospital from March 2017 to April 2020 were recruited in this retrospective study. Patients were divided into three groups depending on the obstruction site. The primary outcomes included technical success and clinical success. The secondary outcomes were operation time, post-procedure length of stay (LOS), hospitalization cost, and complications such as peritonitis, bleeding, pneumoperitoneum, abdominal pain, and infection. A total of 51 patients were included. Technical success achieved in 100% patients with proximal GOO and in 88.9% with distal GOO (P=0.176). Clinical success declined from the oral side to the anal side (P=0.510). Operation time, hospitalization costs, and post-procedural LOS were similar among groups (P=0.532, 0.520, and 0.144, respectively). Complications were observed in 28 (54.9%) patients. In approaching the mature phase of the endosopist, clinical success improved, while the secondary outcomes showed no statistically significant difference compared with the initial phase. EUS-GE may be challenging for distal GOO; however, it is safe and effective when carried out by experienced endoscopists. A complete preoperative evaluation to assess the difficulty of the procedure is necessary. Prospective studies with large sample size are needed to further validate our findings.

Endoscopic duodenal stenting is efficient, but has higher rate of reoperations than gastrojejunostomy in palliative treatment for gastric outlet obstruction

BackgroundSurgical gastrojejunostomy has traditionally been the palliative treatment of choice for patients with advanced malignancies and gastric outlet obstruction syndrome. Recently, palliative endoscopic duodenal stenting has increased in popularity. We report outcomes after gastrojejunostomy and duodenal stenting when used for palliative indications.MethodsConsecutive patients undergoing palliative gastrojejunostomy or palliative endoscopic duodenal stenting in a Finnish tertiary referral center between January 2015 and December 2020 were included. The postoperative outcomes of these two palliative interventions were compared. The main outcome measures were mortality and morbidity, rate of reoperations, postoperative oral intake ability, and length of hospital stay.ResultsA total of 88 patients, 46 (52%) patients underwent palliative gastrojejunostomy and 42 (48%) duodenal stenting. All patients had malignant disease, most typically hepatopancreatic cancer. Nineteen (44%) patients in duodenal stenting group and 4 (8.7%) patients in gastrojejunostomy group required subsequent interventions due to persisting or progressing symptoms (p < 0.001). Median delay until first oral intake was 2 days (1–24) after gastrojejunostomy and 0 days (0–3) after stenting (p < 0.001). Postoperative morbidity was 30% after gastrojejunostomy and 45% after stenting (p < 0.001). Median length of hospital stay was 7 days (1–27) after surgery and 5 days (0–20) after endoscopy (p < 0.001).ConclusionsPatients undergoing endoscopic duodenal stenting are more able to initiate rapid oral intake and have shorter hospital stay. On the other hand, there are significantly more reoperations in stenting group. If the patient’s life expectancy is short, we recommend stenting, but for patients whose life expectancy is longer, gastrojejunostomy could be a better procedure, for the reasons mentioned above.

EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis.

Background and study aims Surgical gastroenterostomy (SGE) has been the mainstay treatment for gastric outlet obstruction (GOO). The emergence of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) presents a less invasive alternative for palliation of GOO. We conducted a comprehensive review and meta-analysis to compare the effectiveness and safety of EUS-GE compared to SGE. Methods Multiple electronic databases and conference proceedings up to April 2021 were searched to identify studies that reported on safety and effectiveness of EUS-GE in comparison to SGE. Pooled odds ratios (ORs) of technical success, clinical success, adverse events (AE) and recurrence, and pooled standardized mean difference (SMD) of procedure time and post-procedure length of stay (LOS) were calculated. Study heterogeneity was assessed using I 2 and Cochran Q statistics. Results Seven studies including 625 patients (372 EUS-GE and 253 SGE) were included. EUS-GE had lower pooled odds of technical success compared with SGE (OR 0.19, 95 % confidence interval [CI] 0.06–0.60, I 2 0 %). Among the technically successful cases, EUS-GE was superior in terms of clinical success (OR 4.73, 95 % CI 1.83–12.25, I 2 18 %), lower overall AE (OR 0.20, 95 % CI 0.10–0.37, I 2 39 %), and shorter procedure time (SMD –2.4, 95 % CI –4.1, –0.75, I 2 95 %) and post-procedure LOS (SMD –0.49, 95 % CI –0.94, –0.03, I 2 78%). Rates of severe AE (0.89, 95 % CI 0.11–7.36, I 2 67 %) and recurrence (OR 0.49, 95 % CI 0.18–1.38, I 2 49 %) were comparable. Conclusions Our results suggest EUS-GE is a promising alternative to SGE due to its superior clinical success, overall safety, and efficiency. With further evolution EUS-GE could become the intervention of choice in GOO.

S3584 Endoscopic Evaluation in a Patient with Post-Bulbar Duodenal Ulcer and Stricture

Introduction: Gastric outlet obstruction (GOO) is the least frequent complication of peptic ulcer disease (PUD) in the US after bleeding and perforation. Ulcers located in the pyloric region and duodenum are most causative of GOO. PUD has decreased since the advent of PPI and eradication of Helicobacter pylori. Although most patients have typical ulcer symptoms prior to the development of complications, asymptomatic ulcers necessitate the need for endoscopic evaluation. Early suspicion and endoscopic evaluation can assist with the prompt management of this complication. Case Description/Methods: 71 year-old white male evaluated for a 5 week history of abdominal pain, nausea, post-prandial vomiting, 35 pound weight loss. Denied the use of non-steroidal anti-inflammatory drugs. Medical history is significant for type 2 diabetes mellitus current tobacco use and hypertension. No prior history of PUD. Physical exam was notable for epigastric tenderness and muscle wasting. Contrasted Abdominopelvic CT showed questionable diverticulum in the second portion of the duodenum and no evidence of pancreatic mass. Endoscopic evaluation showed severe erosive esophagitis, a pinhole stricture in the duodenal bulb with the appearance of a benign peptic stricture. The duodenal stricture was unable to be traversed with a standard gastroscope. With fluoroscopic guidance, the stricture was dilated progressively with a balloon to 6mm, 8mm and 10mm. Biopsies were obtained and the stricture was then traversed with a pediatric scope. After endoscopic evaluation, it was determined that the duodenal stricture was not amenable to durable endoscopic intervention. Pathology, negative for Helicobacter pylori and malignancy. Patient subsequently underwent an exploratory laparotomy and gastrojejunostomy with gastro-jejunal tube placement. Patient continued to improve and was discharged to continue tube feeding at home, outpatient follow up with gastroenterology and surgery. Discussion: Endoscopy plays a critical role in the evaluation and management of patients with symptoms concerning for post bulbar duodenal ulcer, stricture and gastric outlet obstruction. Silent ulcers and complications are more prevalent in older patients. Early detection, evaluation and treatment of GOO could improve disease related morbidity and mortality. Risk modification which consists of tobacco cessation, treating post bulbar ulcers, duodenal ulcers and Helicobacter pylori infection could improve the GOO trends.Figure 1.: Severe Duodenal Stenosis.

ID: 3526552 FEASIBILITY AND SAFETY OF ENDOSCOPIC ULTRASOUND GUIDED GASTROJEJUNOSTOMY (EUS-GJ) IN SYMPTOMATIC GASTRIC OUTLET OBSTRUCTION (GOO) PATIENS WITH ASCITES

Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) is a novel endoscopic procedure for the treatment of gastric outlet obstruction (GOO). Currently, limited data exists regarding the safety and efficacy of EUS-GJ. We aimed to study the outcomes and safety of EUS-GJ in GOO patients with ascites versus those without ascites.

Gastric peroral myotomy (G-POEM) in patients with delayed emptying function of the stomach

Introduction. Disorders in the gastric evacuation function are met in patients with gastroesophageal reflux. In most cases, simultaneous laparoscopic pyloroplasty can solve the problem. As an alternative to surgical pyloroplasty to treat gastroparesis, a new technique has been proposed – peroral submucosal pyloromyotomy or gastric peroral endoscopic myotomy (G-POEM). Recently, this endoscopic surgery has been implemented in adults and in newborns with congenital hypertrophic pyloric stenosis to treat gastric paresis. In the present work, the authors describe this technique and short-term results after G-POEM in a child who had previously been operated on for gastroesophageal reflux.Material and methods. Peroral submucosal pyloromyotomy was performed in a girl of 5 y.o. with impaired motor-evacuation function of the stomach after surgical treatment of gastroesophageal reflux disease at the age of two . For 3 years, the child had therapy which included antiemetics and H2-receptor blockers. However, clinical symptoms constantly recurred, and it was decided to make a thorough examination of the patient. At the contrast examination of upper gastrointestinal tract, stomach enlargement and slow transit of the contrast preparation into the duodenum were seen. Fibrogastroduodenoscopy confirmed the normal function of the fundoplication cuff and found a cause of impaired gastric emptying. A contracted gastric outlet as a spasmodic pylorus was found to be an obstacle for normal stomach evacuation function. A narrow hole in the pylorus was found. A 5.4 mm gastroscope could pass through it. The patient had a complete peroral endoscopic submucosal pyloromyotomy. The technique of this surgery consisted in creating a submucosal tunnel at 4 cm before the pylorus and in dissecting the hypertrophied muscle layer by Ramstedt incision using an electrocoagulation knife. After the end of surgery, the incision on the mucous layer was closed with special clamps.Results. Surgical time lasted for 45 minutes. There were no intraoperative complications: bleedings and mucosal perforation . The patient began to eat in 6 hours after the surgery. The transition to full enteral feeding lasted for 24 hours. The child was discharged from the hospital next day in good condition. At the follow-up examination 6 months after surgery, the girl had weight and height typical for her age. There were no signs of dysphagia, abdominal distension, nausea and vomiting any more . There were no post-operative scarring on the child’s abdominal wall.Conclusion. Peroral submucosal pyloromyotomy is technically implementable, safe and effective for treating disorders of stomach evacuation function in children. Further research is needed to find the place of this technique in the treatment of gastric outlet obstruction.

Retrievable puncture anchor traction method for endoscopic ultrasound-guided gastroenterostomy: A porcine study.

BACKGROUNDEndoscopic ultrasound-guided gastroenterostomy (EUS-GE) is an alternative method for the surgical treatment of gastric outlet obstruction, but it is regarded as a challenging technique for endoscopists as the bowel is highly mobile and can tent away. Thus, the technique requires superb skill. In order to improve EUS-GE, we have developed a retrievable puncture anchor traction (RPAT) device for EUS-GE to address the issue of bowel tenting.AIMTo evaluate the feasibility of RPAT-assisted EUS-GE using an animal model.METHODSSix Bama mini pigs each weighing between 15 and 20 kg underwent the RPAT-assisted EUS-GE procedure. Care was taken to ensure that the animals experienced minimal pain and discomfort. Two days prior to the procedure the animals were limited to a liquid diet. No oral intake was allowed on the day before the procedure. A fully covered metal stent was placed between the stomach and the intestine using the RPAT-assisted EUS-GE method. Infection in the animals was determined. Four weeks after the procedure, a standard gastroscope was inserted into the pig’s intestine through a previously created fistula in order to check the status of the stents under anesthesia. The pig was euthanized after examination.RESULTSThe RPAT-assisted EUS-GE method allowed placement of the stents with no complications in all six animals. All the pigs tolerated a regular diet within hours of the procedure. The animals were monitored for four weeks after the RPAT-assisted EUS-GE, during which time all of the animals exhibited normal eating behavior and no signs of infection were observed. Endoscopic imaging performed four weeks after the RPAT-assisted EUS-GE showed that the stents remained patent and stable in all the animals. No tissue overgrowth or ingrowth was observed in any case. Each animal had a mature fistula, and the stents were removed without significant bleeding. Autopsies of all six pigs revealed complete adhesion between the intestine and the stomach wall.CONCLUSIONThe RPAT method helps reduce mobility of the bowel. Therefore, the RPAT-assisted EUS-GE method is a minimally invasive treatment modality.

Su1331 PREDICTORS OF TECHNICAL AND CLINICAL SUCCESS OF ENDOSCOPIC GASTROENTEROSTOMY WITH LUMEN-APPOSING METALS STENTS

Lumen-apposing metal stents (LAMS) can be used for creation of gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO). Aim of this study was to further evaluate success and safety of this technique as well as to identify predictors of technical success. All patients that underwent EUS-guided gastrointestinal anastomosis with LAMS in our endoscopy unit between February 2016 and August 2019 were identified and evaluated retrospectively. Details on the endoscopic technique and on basic demographic and health characteristics were obtained by chart review and included in the study. Technical success was defined as successful insertion of the LAMS. In patients with GOO, an improvement ≥ 1 point in the GOO score (GOOS) was defined as clinical success. Thirty-five patients were included in the study. Twenty-two patients (62.9%) were female and the median age was 79 years (range: 32 – 93). Indication for the anastomosis was malignant GOO in 33 patients (94.3%). In one patient each the indication for the anastomosis was treatment of efferent loop syndrome and access for endoscopic retrograde cholangiography (ERC) after previous hepaticojejunostomy with Roux-en-Y reconstruction. In 10 patients the LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of the LAMS was performed. In two patients other techniques were used. The overall technical success rate was 80.0%; in four patients two attempts were necessary to successfully create the anastomosis. The main reason for technical failure was dislocation of the distal flange in 4 patients (57.1%). Clinical success rate was 74.3% in the study population and 92.3% in patients with malignant GOO and technically successful creation of the anastomosis. The procedure as well resulted in clinical success in the two patients that underwent EUS-guided anastomosis for treatment of efferent limp syndrome and as access route for ERC. Adverse events occurred in 14.3%. Technical success increased and procedure time decreased significantly during the study period. The distance between the two lumina that were connected with the LAMS was significantly shorter (median: 9 mm) in patients with technical success compared to those without (median: 20 mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis (Figure). Technical success of EUS-guided gastrointestinal anastomosis with LAMS mainly depends on the distance between the two lumina that are going to be connected by the LAMS. It is also influenced by the endoscopist’s experience. Overall this technique presents a promising and emerging treatment option, especially for patients with malignant GOO.

Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success.

Lumen-apposing metal stents (LAMS) may be inserted to create gastrointestinal anastomoses under endoscopic ultrasound (EUS) guidance. This new technique has mostly been evaluated as treatment for gastric outlet obstruction (GOO), especially of malignant origin. Technical success was high in the few and small available studies. Aim of this study was to report our experience with this technique and to identify predictors of success in the setting of a large teaching hospital in Germany. All subsequent patients who underwent EUS-guided gastrointestinal anastomosis with LAMS from 02/2016 to 08/2019 were included. We performed a retrospective chart analysis including technical procedural details, basic demographic, and health characteristics. Technical success was defined as successful insertion of LAMS. In patients with GOO, the GOO Scoring System was used; an improvement ≥ 1 point was defined as clinical success. Thirty-five patients (22 female, median age: 79years) were included. Indication for the anastomosis was malignant GOO in 33 patients. In ten patients LAMS was inserted over a guidewire, in 22 patients direct puncture with the electrocautery delivery system of LAMS was performed, and other techniques were used in two patients. Technical success rate was 80.0%. Adverse events occurred in 14.3%. Clinical success rate was 74.3%. Technical success increased and procedure time decreased significantly during the study period. Distance between the two lumina connected with LAMS was significantly shorter (median: 9mm) in patients with technical success compared to those without (median: 20mm, P = 0.004). This distance was identified as predictor of success on multivariate analysis. EUS-guided gastrointestinal anastomosis with LAMS is an emerging technique. Its success mainly depends on the distance between the two lumina that are going to be connected by the LAMS and is influenced by the endoscopist's experience.

Local Heat Treatment for Suppressing Gastroduodenal Stent-Induced Tissue Hyperplasia Using Nanofunctionalized Self-Expandable Metallic Stent in Rat Gastric Outlet Model.

Despite the promising results from the placement of covered or uncovered self-expandable metallic stent (SEMS) as a nonsurgical therapeutic option for the malignant gastric outlet obstruction (GOO), the long patency of the stent is still limited because of stent-induced tissue hyperplasia. Here, a local heat treatment using a nanofunctionalized SEMS is proposed for suppressing stent-induced tissue hyperplasia during GOO treatment. Highly efficient photothermal gold nanoparticle (GNP) transducer-coated SEMSs (GNP-SEMSs) were prepared for local heat treatment in rat gastric outlet. The in vivo heating temperature in rat gastric outlet model was evaluated and compared with in vitro heating temperature. Three groups of our developed 45 rat gastric outlet models were used: group A, noncoated SEMS only; group B, GNP-SEMS plus local heating; and group C, GNP-SEMS only to investigate in vivo efficacy of GNP-SEMS mediated local heating. Ten rats per group were sacrificed for 4 weeks, and five rats per group were sacrificed immediately after local heat treatment. The in vivo heating temperature was found to be 10.8% lower than the in vitro heating temperatures. GNP-SEMSs were successfully placed through a percutaneous approach into the rat gastric outlet (n = 45). The therapeutic effects of GNP-SEMS were assessed by histologic examination including hematoxylin-eosin, Masson trichrome, immunohistochemistry (TUNEL and CD31), and immunofluorescence (Ki67), and the results showed significant prevention of tissue hyperplasia following stent placement without adjacent gastrointestinal tissue damage. GNP-SEMS-mediated local heating could be an alternative therapeutic option for the suppression of tissue hyperplasia following stent placement in benign and malignant GOOs.

Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis.

Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel endoscopic procedure designed to facilitate sustained luminal patency in patients with gastric outlet obstruction. The primary aim of this study was to evaluate the efficacy and safety of EUS-GE for treatment of gastric outlet obstruction. Methods Searches of PubMed, EMBASE, Web of Science, and Cochrane Library databases were performed through April 2019. Patients with benign and malignant gastric outlet obstruction were included. Measured outcomes included: immediate technical and clinical success as well as rate of serious adverse events (AEs). Heterogeneity was assessed with Cochran Q test and I 2 statistics. Publication bias was ascertained by funnel plot and Egger regression testing. Results A total of five studies (n = 199 patients; 45.73 % male) were included in this study. Four retrospective studies and one prospective study were analyzed. Mean age of patients that underwent the EUS-GE procedure was 64.52 ± 1.37 years with a pooled mean follow-up period of 4.32 ± 1.65 months. In 21 % of patients (n = 43), gastric outlet obstruction was due to benign causes. Immediate technical success was 92.90 % (95 % CI; 88.26 – 95.79; I 2 = 0.00 %) and reported in all studies. The clinical success rate of EUS-GE was 90.11 % (95 % CI; 84.64 – 93.44; I 2 = 0.00 %). Serious AEs occurred in 5.61 % (95 % CI; 2.87 – 10.67; I 2 = 1.67 %) of cases and were related to peritonitis, perforation, bleeding, and abdominal pain. Re-intervention rate was 11.43 % (95 % CI; 7.29 – 17.46; I 2 = 17.38 %). Conclusions EUS-GE appears to provide an effective and safe minimally invasive alternative for treatment of benign and malignant gastric outlet obstruction.