Endoscopic Ultrasound-Guided Gastroenterostomy for the Palliation of Gastric Outlet Obstruction (GOO): A Systematic Review and Meta-analysis of the Different Techniques

Abstract

Introduction: Gastric outlet obstruction (GOO) is usually associated with a poor prognosis and a significant decrease in a patient's quality of life. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMS) has emerged as a safe and effective palliation procedure for GOO in patients that are unfit for surgery. Without an exclusive gold-standard technique for EUS-GE, we aimed to compare the currently available ones in this systematic review and meta-analysis, the first on this subspecialty.

Methods: A comprehensive search from multiple electronic databases was performed. The search had a particular emphasis on the techniques used in performing EUS-GE. We identified all the studies in which EUS-GE was performed as palliation for GOO from its inception to the current date. The outcomes analyzed were the following: technical and clinical success, total and severe adverse events (AEs), procedure duration, and length of hospital stay (LOHS).

Results: Twenty studies involving 863 patients were the basis of this statistical analysis. Patients underwent the following techniques: direct gastroenterostomy (DGE) (n=718), balloon-assisted gastroenterostomy (BAGE) (n=27), and endoscopic ultrasound (EUS)-guided double-balloon-occluded gastrojejunostomy bypass (n=118). In comparison to balloon-assisted techniques, DGE had a lower rate of AEs, -0.121 (95% CI -0.191 to -0.051 p=0.001); and LOHS for the DGE group, -2.684 (95% CI -1.031 to -4.337 p=0.001). The other analyzed outcomes presented no statistically significant differences. On a sub-analysis, BAGE showed a lower rate of AEs than EUS-guided double-balloon-occluded gastrojejunostomy bypass, -0.196 (95% CI -0.061 to -0.331 p=0.004).

Conclusions: EUS-GE is a safe and effective procedure for palliating GOO. When correctly administered, any of the analyzed techniques may be used to palliate GOO with similar technical and clinical outcomes. DGE had significantly lower rates of AEs and LOHS, which can be inferred as a safer procedure. These results should be interpreted cautiously due to the limited few studies that are available and accessible. Therefore, further well-designed, randomized clinical studies on the topic are warranted to compare the different techniques from more sources.

Keywords: endoscopic ultrasound (eus); eus-ge; gastric outlet obstruction; goo; lams; lumen apposing metal stent; palliation; palliative care.

Figure 1. PRISMA flow diagram.

PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analysis

Figure 2. Forest plot for risk difference in technical success between BTGE and DGE.

DGE, direct gastroenterostomy; BTGE, balloon-assisted techniques gastroenterostomy

Figure 3. Forest plot for risk difference in clinical success between BTGE and DGE.

DGE, direct gastroenterostomy; BTGE, balloon-assisted techniques gastroenterostomy

Figure 4. Forest plot for risk difference in TAEs between BTGE and DGE.

DGE, direct gastroenterostomy; BTGE, balloon-assisted techniques gastroenterostomy; TAEs, total adverse events

Figure 5. Forest plot for risk difference for SAEs between BTGE and DGE.

DGE, direct gastroenterostomy; BTGE, balloon-assisted techniques gastroenterostomy; SAEs, severe adverse events

Figure 6. Forest plot for difference in means in procedure duration for BTGE and DGE.

DGE, direct gastroenterostomy; BTGE, balloon-assisted techniques gastroenterostomy

Figure 7. Forest plot for difference in means in LOHS for BTGE and DGE.

DGE, direct gastroenterostomy; BTGE, balloon-assisted techniques gastroenterostomy; LOHS, length of hospital stay