EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction

Abstract

Background and aims: Benign gastric outlet obstruction (GOO) has typically been managed surgically. However, many patients are poor operative candidates because of comorbidities. EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has previously demonstrated efficacy as a definitive treatment for benign and malignant GOO; however, limited data exist on use as a bridge to resolution of the obstruction in an attempt to avoid or delay definitive surgery.

Methods: A retrospective series of consecutive patients who underwent EUS-GE between January 2013 and July 2019 for benign GOO at a tertiary referral center were included in the study. The primary outcome was the rate of definitive surgery; secondary outcomes included technical success and rate of adverse events.

Results: During the study period, 22 patients with benign GOO underwent EUS-GE (40% female; mean age, 54.2 years). The mean procedure time was 66 minutes, and technical success was achieved in 21. Five patients developed recurrent GOO while the LAMS was in place after a mean dwell time of 228 days; 1 patient was converted to surgical GE. LAMSs were removed electively in 18 patients after GOO resolution and a mean dwell time of 270 days; 1 patient developed a recurrent GOO after LAMS removal and was converted to surgical GE. The rate of recurrent GOO after LAMS removal was 5.6%. Three severe adverse events occurred in the cohort.

Conclusions: EUS-GE was able to prevent surgery for GOO in 83.3% of cases. LAMSs needed to stay in place for a mean of 8.5 months to allow resolution of GOO, and there was a low rate of recurrent GOO (5.6%) after LAMS removal. Prospective, randomized trials comparing surgical and endoscopic anastomoses are needed in patients with benign causes of GOO.

Figure 1.

0.025” guidewire passing into the small bowel using echosonographic and fluoroscopic guidance.

Figure 2.

Endoscopic view of a gastric ulcer that developed at the anastomotic site on postprocedure day 2 leading to hemorrhage.

Figure 3.

Fluoroscopic view of a malpositioned gastrojejunostomy stent traversing from the stomach through the colon and into jejunum. Despite this, an upper GI series demonstrated no evidence of contrast leaking around the stent proximally or distally.

Figure 4.

Endoscopic view of a patient with NSAID-induced pyloric stenosis that failed to respond to 3 separate endoscopic balloon dilations. This patient’s anastomosis was ultimately converted to a surgical gastroenterostomy at a separate site after the EUS anastomotic site was closed.