Role of Endoscopic Ultrasound-guided Gastroenterostomy for Benign Gastric Outlet Obstruction

Abstract

Benign gastric outlet obstruction (GOO) often results from intrinsic conditions like peptic strictures, caustic-induced stricture, and surgical anastomoses, and extrinsic conditions like pancreatitis, hematoma, and superior mesenteric artery syndrome. While traditional management involved surgery or endoscopic balloon dilation, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative using lumen-apposing metal stents (LAMS). We aimed to summarize the currently available literature on EUS-GE in treating benign GOO. EUS-GE demonstrates high technical success rates, ranging from 95% to 100%, and significant clinical success, typically exceeding 80% in patients with benign GOO. It offers advantages by bypassing the obstruction and potentially providing longer-lasting relief compared to enteral stenting without the morbidity of surgery. Furthermore, it can serve as a bridge to definitive treatment, allowing for nutritional optimization before surgery or resolution of the underlying condition with subsequent stent removal in a notable proportion of patients. Despite the high efficacy, EUS-GE is associated with multiple adverse events like maldeployment, bleeding, and ascites with or without infection. Thus, EUS-GE is a promising and effective minimally invasive modality for managing benign GOO, particularly in patients who fail conventional endoscopic therapies or are poor surgical candidates. However, current evidence is limited by the retrospective nature of many studies, small sample sizes, and the need for longer-term follow-up to assess stent durability and the optimal management of indwelling LAMS. Larger prospective studies are warranted to further define the role of EUS-GE in benign GOO and compare it with other treatment strategies.

Keywords: duodenal stricture; endoscopic ultrasound; gastric outlet obstruction; gastroenterostomy; gastrojejunostomy.

FIGURE 1

The two most common methods currently used for puncture during endoscopic ultrasound‐guided gastroenterostomy (EUS‐GE): (A) Wireless endoscopic simplified technique using oroenteric catheter and (B) EUS‐guided double‐balloon‐occluded gastrojejunostomy bypass (EPASS), followed by (C) lumen apposing metal stent placement.

FIGURE 2

Step‐wise approach to the management of benign gastric outlet obstruction with the current placement of endoscopic ultrasound‐guided gastroenterostomy in the management (EUS‐GE). EBD: endoscopic balloon dilatation; EUS‐GE: endoscopic ultrasound‐guided gastroenterostomy; LAMS: lumen‐apposing metal stent; SEMS: self‐expanding metal stent; SGE: surgical gastroenterostomy. ^#[3, 53, 54]. *Other factors that need to be considered include reversibility of the condition (EUS‐GE to be preferred in reversible conditions), presence of altered anatomy (EUS‐GE and SGE for altered anatomy), cost, and the availability of expertise.