International multicenter comparative trial of endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction

Abstract

Background and study aims EUS-guided gastroenterostomy (EUS-GE) is a novel procedure that potentially offers long-lasting luminal patency without the risk of tumor ingrowth/overgrowth. This study compared the clinical success, technical success, adverse events (AEs), length of hospital stay (LOHS) and symptom recurrence in EUS-GE versus SGJ. Methods This was a multicenter international retrospective comparative study of EUS-GE and SGJ in patients with malignant gastric outlet obstruction (GOO) who underwent either EUS-GE or SGJ. EUS-GE was performed using lumen apposing metal stents. Results A total of 93 patients with malignant GOO treated with either EUS-GE (n = 30) or SGJ (n = 63) were identified. Peritoneal carcinomatosis was present in 13 (43 %) patients in the EUS-GE group and 7 (11 %) patients in the SGJ group (P < 0.001). Although the technical success rate was significantly higher in the SGJ group as compared to the EUS-GE group (100 % vs. 87 %, P = 0.009), the clinical success rate was not different (90 % vs. 87 %, P = 0.18, OR 0.8, 95 %CI 0.44 - 7.07). The rate of AEs was lower in the EUS-GE group, but the difference was not statistically significant (16 % vs 25 %, P = 0.3). The mean LOHS was similar in the EUS-GE group compared to SGJ (P = 0.35). The rate of recurrent GOO was not different between the two groups (3 % vs. 14 %, P = 0.08). Similarly, the mean time to reintervention was similar (88 days vs. 121 days, P = 0.83). Conclusions EUS-GE is associated with equivalent efficacy and safety as compared to surgical GJ. This is the first comparative trial between both techniques and suggests EUS-GE as a non-inferior but less invasive alter to surgery.

Fig. 1

EUS-guided gastrojejunostomy using the direct puncture technique. a The small bowel is filled with fluid (saline, contrast and methylene blue) and is easily visualized transgastrically with EUS. It is first punctured with a 19-gauge fine-needle aspiration needle under EUS guidance with aspiration of blue-tinged fluid. Needle is removed and then the loop is directly accessed using the lumen apposing stent system. b The distal anchor flange is deployed first under EUS guidance followed by c deployment of the proximal flange under either endoscopic or sonographic guidance. c Stent is dilated with a balloon to 15 mm under endoscopic and fluoroscopic guidance. e The jejunum can be seen from within the deployed stent. f Contrast material is injected and confirms absence of leakage.

Fig. 2

Kaplan Meier plot estimates the overall survival for patients undergoing EUS-GE vs SGJ. EUS-GE: Median survival 103 days with 95 % CI 45 – 160. SGJ: Median survival 148 days with 95 % CI 100 – 195. Median overall survival for the entire cohort is 130 days with 95 % CI 97 – 162. There was a significant difference in survival times between the 2 groups (P = 0.02 using Tarone-Ware; P = 0.006 using log rank)