Gastric outlet obstruction with ascites: EUS-guided gastro-enterostomy is feasible

Abstract Background and study aims Endoscopic ultrasound-guided gastro-enterostomy(EUS-GE) is a recently described novel minimally invasive endoscopic procedure for patients having malignant gastric outlet obstruction (GOO). The safety of EUS-GE in the presence of ascites with GOO is not known. The objective of the study was to evaluate the feasibility and safety of EUS-GE in patients with GOO and ascites. Patients and methods Consecutive patients with GOO who underwent EUS-GE between January 2019 and March 2021 constituted the study population. EUS-GE was performed using either EPASS or free-hand technique. The technical success, clinical success, adverse events, and survival times were evaluated. The outcomes were compared between patients with and without ascites. Results A total of 31 patients with GOO underwent EUS-GE of whom 29 (93.5 %) had malignant and two (6.4 %) had benign etiologies. Ascites was observed in 12 out of 31 (38.7%) patients and all had underlying malignancy. Majority (27, 87 %) of the EUS-GE procedures were performed using EPASS technique, and 4 (13 %) underwent free-hand technique. Eleven of 12 patients with ascites and GOO underwent EUS GE using EPASS technique. The technical success (91.6 % vs. 89.4 %; P = 0.841), clinical success (83.3 % vs. 89.4 %; P = 0.619), mean procedure time (32 vs. 31.6 min; P = 0.968) and adverse events (0 % vs. 10.5 %; P = 0.245) were not significantly different between patients with or without ascites. However, the median survival time was significantly low in patients with ascites when compared to without ascites (36 vs. 290 days; P < 001). Conclusions Ascites is a common occurrence in patients with malignant GOO. EUS GE is feasible in presence of ascites with EPASS technique.

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Patency of endoscopic ultrasound-guided gastroenterostomy in the treatment of malignant gastric outlet obstruction

Endoscopy International Open ◽

10.1055/a-1214-5659 ◽

2020 ◽

Vol 08 (09) ◽

pp. E1194-E1201 ◽

Cited By ~ 1

Author(s):

Janine B. Kastelijn ◽

Leon M.G. Moons ◽

Francisco J. Garcia-Alonso ◽

Manuel Pérez-Miranda ◽

Viliam Masaryk ◽

...

Keyword(s):

Gastric Outlet Obstruction ◽

Endoscopic Ultrasound ◽

Palliative Treatment ◽

Clinical Success ◽

Outlet Obstruction ◽

Invasive Technique ◽

Technical Success ◽

Ultrasound Guided ◽

Malignant Gastric Outlet Obstruction

Abstract Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) is a novel, minimally invasive technique in the palliative treatment of malignant gastric outlet obstruction (GOO). Several studies have demonstrated feasibility and safety of EUS-GE, but evidence on long-term durability is limited. The aim of this study was to evaluate patency of EUS-GE in treatment of malignant GOO. Patients and Methods An international multicenter study was performed in seven centers in four European countries. Patients who underwent EUS-GE with a LAMS between March 2015 and March 2019 for palliative treatment of symptomatic malignant GOO were included retrospectively. Our main outcome was recurrent obstruction due to LAMS dysfunction; other outcomes of interest were technical success, clinical success, adverse events (AEs), and survival. Results A total of 45 patients (mean age 69.9 ± 12.3 years and 48.9 % male) were included. Median duration of follow-up was 59 days (interquartile range [IQR] 41–128). Recurrent obstruction occurred in two patients (6.1 %), after 33 and 283 days of follow-up. Technical success was achieved in 39 patients (86.7 %). Clinical success was achieved in 33 patients (73.3 %). AEs occurred in 12 patients (26.7 %), of which five were fatal. Median overall survival was 57 days (IQR 32–114). Conclusions EUS-GE showed a low rate of recurrent obstruction. The relatively high number of fatal AEs underscores the importance of careful implementation of EUS-GE in clinical practice.

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EUS-guided gastroenterostomy: Initial experience in a brazilian tertiary center

Revista da Associação Médica Brasileira ◽

10.1590/1806-9282.66.11.1521 ◽

2020 ◽

Vol 66 (11) ◽

pp. 1521-1525

Author(s):

Joel Fernandez de Oliveira ◽

Martin Andres Coronel Cordero ◽

Gustavo Rosa de Almeida Lima ◽

Gustavo Andrade de Paulo ◽

Marcelo Simas de Lima ◽

...

Keyword(s):

Adverse Events ◽

Gastric Outlet Obstruction ◽

Clinical Success ◽

Outlet Obstruction ◽

Initial Experience ◽

Technical Success ◽

Malignant Gastric Outlet Obstruction ◽

Soft Diet ◽

Tertiary Center ◽

Promising Treatment

SUMMARY INTRODUCTION: EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for palliation of malignant gastric outlet obstruction (GOO). Our aim was to evaluate the outcomes of this technique in our initial experience. METHODS: Patients with GOO from our institute were included. Technical success was defined as the successful creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a soft diet after the procedure. We assessed adverse events and diet tolerance 1 month after the procedure. RESULTS: Three patients were included. Technical and clinical success was achieved in all cases. There were no adverse events and good diet tolerance was observed 1 month after the procedure in the included patients. CONCLUSION: EUS-GE is a promising treatment for patients with GOO.

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Modified endoscopic ultrasound-guided double-balloon-occluded gastroenterostomy bypass (M-EPASS): a pilot study

Endoscopy ◽

10.1055/a-1392-4546 ◽

2021 ◽

Author(s):

Amanda Marino ◽

Ali Bessissow ◽

Corey Miller ◽

David Valenti ◽

Louis Boucher ◽

...

Keyword(s):

Gastric Outlet Obstruction ◽

Endoscopic Ultrasound ◽

Clinical Success ◽

Outlet Obstruction ◽

Stent Migration ◽

Stent Insertion ◽

Ultrasound Guided ◽

Double Balloon ◽

Low Residue Diet ◽

The Mean

Abstract Introduction We recently developed a double-balloon device, using widely available existing technology, to facilitate endoscopic ultrasound-guided gastroenterostomy (EUS-GE). Our aim is to assess the feasibility of this modified approach to EUS-guided double-balloon-occluded gastroenterostomy bypass (M-EPASS). Methods This was a single-center retrospective study of consecutive patients undergoing M-EPASS from January 2019 to August 2020. The double-balloon device consists of two vascular balloons that optimize the distension of a targeted small-bowel segment for EUS-guided stent insertion. The primary end point was the rate of technical success. Results 11 patients (45 % women; mean [standard deviation (SD)] age 64.9 [8.6]) with malignant gastric outlet obstruction were included. Technical and clinical success (ability to tolerate an oral diet) were achieved in 91 % (10/11) and 80 % (8/10) of patients, respectively. There was one adverse event (9 %) due to stent migration. Two patients (18 %) required re-intervention for stent obstruction secondary to food impaction. The mean (SD) time to a low residue diet was 3.5 (2.4) days. Conclusion M-EPASS appears to facilitate the technique of EUS-GE, potentially enhancing its safety and clinical adoption. Larger studies are needed to validate this innovative approach to gastric outlet obstruction.

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A pilot study of novel duodenal covered self-expandable metal stent fixation

Scientific Reports ◽

10.1038/s41598-021-99265-1 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Yasuki Hori ◽

Kazuki Hayashi ◽

Itaru Naitoh ◽

Katsuyuki Miyabe ◽

Makoto Natsume ◽

...

Keyword(s):

Pilot Study ◽

Adverse Events ◽

Gastric Outlet Obstruction ◽

Clinical Success ◽

Performance Status ◽

Outlet Obstruction ◽

Poor Performance ◽

Stent Migration ◽

Poor Performance Status ◽

Sems Placement

AbstractMigration of duodenal covered self-expandable metal stents (C-SEMSs) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction (mGOO). Because endoscopic SEMS placement is frequently selected in patients with poor performance status, we concurrently focused on the safety of the treatment. This pilot study included 15 consecutive patients with mGOO who underwent duodenal partially covered SEMS (PC-SEMS) placement with fixation using an over-the-scope-clip (OTSC). Technical feasibility, clinical success for oral intake estimated by the Gastric Outlet Obstruction Scoring System (GOOSS) score, and adverse events including stent migration were retrospectively assessed. All procedures were successful, and clinical success was achieved in 86.7% (13/15). Mean GOOSS scores were improved from 0.07 to 2.53 after the procedure (P < 0.001). Median survival time was 84 days, and all patients were followed up until death. Stent migration occurred in one case (6.7%) at day 17, which was successfully treated by removal of the migrated PC-SEMS using an enteroscope. For fixation using an OTSC, additional time required for the procedure was 8.9 ± 4.1 min and we did not observe OTSC-associated adverse events. Poor performance status was associated with clinical success (P = 0.03), but we could provide the treatment safely and reduce mGOO symptoms even in patients with poor performance status. In conclusion, duodenal PC-SEMS fixation using an OTSC is feasible for preventing stent migration in patients with mGOO including those with poor performance status.

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Feasibility of Duodenal Covered Self-Expandable Metal Stent Fixation: A Pilot Study (With Video)

10.21203/rs.3.rs-538859/v1 ◽

2021 ◽

Author(s):

Yasuki Hori ◽

Kazuki Hayashi ◽

Itaru Naitoh ◽

Katsuyuki Miyabe ◽

Makoto Natsume ◽

...

Keyword(s):

Pilot Study ◽

Adverse Events ◽

Gastric Outlet Obstruction ◽

Clinical Success ◽

Performance Status ◽

Outlet Obstruction ◽

Poor Performance ◽

Stent Migration ◽

Poor Performance Status ◽

Sems Placement

Abstract Migration of duodenal covered self-expandable metal stents (C-SEMSs) is the main cause of stent dysfunction in patients with malignant gastric outlet obstruction (mGOO). Because endoscopic SEMS placement is frequently selected in patients with poor performance status, we concurrently focused on the safety of the treatment. This pilot study included 15 consecutive patients with mGOO who underwent duodenal C-SEMS placement with fixation using an over-the-scope-clip (OTSC). Technical feasibility, clinical success for oral intake estimated by the Gastric Outlet Obstruction Scoring System (GOOSS) score, and adverse events including stent migration were assessed. All procedures were successful, and clinical success was achieved in 86.7% (13/15). Mean GOOSS scores were improved from 0.07 to 2.53 after the procedure (P < 0.001). Stent migration occurred in one case (6.7%) with no other adverse events. For fixation using an OTSC, additional time required for the procedure was 8.9 ± 4.1 minutes. Poor performance status was associated with clinical success (P = 0.03), but we could provide the treatment safely and reduce mGOO symptoms even in patients with poor performance status. In conclusion, duodenal C-SEMS fixation using an OTSC is feasible for preventing stent migration in patients with mGOO including those with poor performance status.

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Efficacy and safety of endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD): A systematic review and meta-analysis of 714 patients

Endoscopy International Open ◽

10.1055/a-1236-3350 ◽

2020 ◽

Vol 08 (11) ◽

pp. E1664-E1672

Author(s):

Saurabh Chandan ◽

Babu P. Mohan ◽

Shahab R. Khan ◽

Lena L. Kassab ◽

Suresh Ponnada ◽

...

Keyword(s):

Adverse Events ◽

Pancreatic Duct ◽

Endoscopic Ultrasound ◽

Clinical Success ◽

Meta Analysis ◽

Fluid Collection ◽

Technical Success ◽

Ultrasound Guided ◽

Anastomotic Strictures ◽

Pancreatic Duct Drainage

Abstract Background and study aims Endoscopic ultrasound guided pancreatic duct drainage (EUS-PDD) is a minimal-invasive therapeutic option to surgery and in patients with failed endoscopic retrograde pancreatography (ERP). The aim of this review was to quantitatively appraise the clinical outcomes of EUS-PDD by meta-analysis methods. Methods We searched multiple databases from inception through March 2020 to identify studies that reported on EUS-PDD. Pooled rates of technical success, successful drainage of pancreatic duct, clinical success, and adverse events were calculated. Study heterogeneity was assessed using I2% and 95 % prediction interval. Results A total of 22 studies (714 patients) were included. The pooled rate of technical success in EUS-PDD was 84.8 % (95 % CI 79.1–89.2). The pooled rate of successful PD drained by EUS-PDD was 77.5 % (95 % CI 63.1–87.4). The pooled rate of clinical success of EUS-PDD was 89.2 % (95 % CI 82.1–93.7). The pooled rate of all adverse events was 18.1 % (95 % CI 14.2–22.9). On sub-group analysis, the pooled technical success and clinical success of EUS-PDD from Japanese data were considerably superior (91.2 %, 83–95.6 & 92.5 %, 83.9–96.7, respectively). The pooled rate of post EUS-PDD acute pancreatitis was 6.6 % (95 % CI 4.5–9.4), bleeding was 4.1 % (95 % CI 2.7–6.2), perforation and/or pneumoperitoneum was 3.1 % (95 % CI 1.9–5), pancreatic leak and/or pancreatic fluid collection was 2.3 % (95 % CI 1.4–4), and infection was 2.8 % (95 % CI 1.7–4.6). Conclusion EUS-PDD demonstrates high technical success and clinical success rates with acceptable adverse events. Technical success was especially high for anastomotic strictures.

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Clinical and Technical Outcomes of patients undergoing EUS-Guided Gastroenterostomy using 20 mm vs 15 mm LAMS

Endoscopy ◽

10.1055/a-1654-6914 ◽

2021 ◽

Author(s):

Michael Bejjani ◽

Bachir Ghandour ◽

Jose Carlos Subtil ◽

Belén Martínez ◽

Reem Z Sharaiha ◽

...

Keyword(s):

Gastric Outlet Obstruction ◽

Primary Outcome ◽

Clinical Success ◽

Outlet Obstruction ◽

Metal Stent ◽

Technical Success ◽

Malignant Gastric Outlet Obstruction ◽

Complete Diet ◽

Secondary Outcomes

Background/Aims: The majority of studies on EUS-guided gastroenterostomy (EUS-GE) for palliation of malignant gastric outlet obstruction (GOO) have utilized a 15mm lumen apposing metal stent (LAMS). More recently, a 20mm LAMS has become available. The aim of this study was to compare rates of technical and clinical success, and adverse events (AEs) in patients undergoing EUS-GE using a 20mm vs 15mm LAMS. Methods: Patients who underwent EUS-GE with 15mm or 20mm LAMS for malignant GOO during the period of 1/2018-10/2020 were included. The primary outcome was clinical success, defined as an increase in the gastric outlet obstruction score (GOOS) by at least 1 point during follow-up. Secondary outcomes were technical success, maximum tolerated diet, rate of reintervention, and the rate/severity of AEs. Results: A total of 267 patients (mean age 67yr, F 43%) with malignant GOO from 19 centers underwent EUS-GE. The rate of clinical success was similar between the 15mm and 20mm stents (89.2% [95% CI 84.2-94.2] vs 84.1% [95%CI 77.4-90.6]). However, a significantly higher proportion of patients in the 20mm group tolerated a soft solid/complete diet at the end of follow-up (91.2% [95%CI 84.4-95.7] vs 81.2% [95%CI 73.9-87.2] p=0.04). Overall, AEs occurred in 33 (12.4% [95%CI 8.4-16.3]) patients, with rates being similar between 15mm and 20mm stents (12.8% [95%CI 7.5-18.2] vs 11.8% [95%CI 6-17.6]), including incidence of severe/fatal AEs (2% [95%CI 0.4-5.8] vs 3.4% [95%CI 0.9-8.4]). Conclusions: The 20mm LAMS is similar to the 15mm LAMS in terms of safety and efficacy for patients undergoing EUS-GE for malignant GOO. The 20 mm LAMS allows a more advanced diet and is, thus, the preferred LAMS during EUS-GE.

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Endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for high risk surgical patients with acute cholecystitis: a systematic review and meta-analysis

Endoscopy ◽

10.1055/a-0929-6603 ◽

2019 ◽

Vol 51 (08) ◽

pp. 722-732 ◽

Cited By ~ 12

Author(s):

Sally Wai-Yin Luk ◽

Shayan Irani ◽

Rajesh Krishnamoorthi ◽

James Yun Wong Lau ◽

Enders Kwok Wai Ng ◽

...

Keyword(s):

Systematic Review ◽

Adverse Events ◽

Acute Cholecystitis ◽

Clinical Success ◽

Meta Analysis ◽

Surgical Patients ◽

Technical Success ◽

Ultrasound Guided ◽

Post Procedure ◽

Hospital Stays

Abstract Background Recent evidence suggests that endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an effective and safe alternative to percutaneous drainage (PT-GBD). We conducted a systematic review and meta-analysis to compare these two procedures in high risk surgical patients with acute cholecystitis. Methods A comprehensive electronic literature search was conducted for all articles published up to October 2017 to identify comparative studies between EUS-GBD and PT-GBD. A meta-analysis was performed on outcomes including technical success, clinical success, post-procedure adverse events, length of hospital stay, unplanned hospital readmission, need for reintervention, recurrent cholecystitis, and disease- or treatment-related mortality for these two procedures. Results Five comparative studies (206 patients in the EUS-GBD group vs. 289 patients in the PT-GBD group), were included in the final analysis. There were no statistically significant differences in technical success (odds ratio [OR] 0.43, 95 % confidence interval [CI] 0.12 to 1.58; P = 0.21; I 2 = 0 %) and clinical success (OR 1.07, 95 %CI 0.36 to 3.16; P = 0.90; I 2 = 44 %) between the two procedures. EUS-GBD had fewer adverse events than PT-GBD (OR 0.43, 95 %CI 0.18 to 1.00; P = 0.05; I 2 = 66 %). Moreover, patients undergoing EUS-GBD had shorter hospital stays, with pooled standard mean difference of – 2.53 (95 %CI – 4.28 to – 0.78; P = 0.005; I 2 = 98 %), and required significantly fewer reinterventions (OR 0.16, 95 %CI 0.04 to 0.042; P < 0.001; I 2 = 32 %) resulting in significantly fewer unplanned readmissions (OR 0.16, 95 %CI 0.05 to 0.53; P = 0.003; I 2 = 79 %). Conclusions EUS-GBD was associated with lower rates of post-procedure adverse events, shorter hospital stays, and fewer reinterventions and readmissions compared with PT-GBD in patients with acute cholecystitis who were unfit for surgery.

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Endoscopic ultrasound-guided gastroenterostomy using an oroenteric catheter-assisted technique: a retrospective analysis

Endoscopy ◽

10.1055/a-1392-0904 ◽

2021 ◽

Author(s):

Nam Q. Nguyen ◽

Christopher M. Hamerski ◽

Andrew Nett ◽

Rabindra R. Watson ◽

Morgan Rigopoulos ◽

...

Keyword(s):

Patient Outcomes ◽

Endoscopic Ultrasound ◽

Clinical Success ◽

Symptom Relief ◽

Outlet Obstruction ◽

Oral Intake ◽

Metal Stent ◽

Technical Success ◽

Ultrasound Guided

Abstract Background This study evaluated an oroenteric catheter (OEC)-assisted technique to distend the enteric loop for endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in patients with gastric outlet obstruction (GOO). Methods Patient outcomes were reviewed. Proximal enteric loops were filled with water via an OEC (7 Fr or 8 Fr), providing a target for EUS-GE using a lumen-apposing metal stent (15-mm caliber). Clinical success was defined as toleration of a non-liquid diet by Day 3. Results 42 patients (mean age 73.1 [SEM 2.8] years; 23 male) underwent EUS-GE for malignant (n = 37) and benign (n = 5) duodenal strictures. EUS-GE creation was successful in 41/42 (98 %), with mean procedure time of 36 (SEM 3) minutes and no serious complications. Clinical success was achieved in 39/42 (93 %) at 5.7 (SEM 2.6) months’ follow-up. Of 14 patients who died, 13 (93 %) maintained oral intake until death. EUS-GE provided good symptom relief in all 28 surviving patients until follow-up. Conclusions OEC-assisted EUS-GE provided satisfactory relief of GOO symptoms, with high technical success (98 %) and no serious complications.

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EUS-guided gastroenterostomy in management of benign gastric outlet obstruction

Endoscopy International Open ◽

10.1055/s-0043-123468 ◽

2018 ◽

Vol 06 (03) ◽

pp. E363-E369 ◽

Cited By ~ 24

Author(s):

Yen-I Chen ◽

Theodore James ◽

Amol Agarwal ◽

Todd Baron ◽

Takao Itoi ◽

...

Keyword(s):

Gastric Outlet Obstruction ◽

Clinical Success ◽

Outlet Obstruction ◽

Oral Intake ◽

Maximum Diameter ◽

Gastric Leak ◽

Technical Success ◽

Ulcer Disease ◽

Secondary Endpoints ◽

Promising Treatment

Abstract Background and study aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in malignant gastric outlet obstruction (GOO) appears to be promising; however, its role in benign GOO is unclear. The aim of this study was to ascertain the clinical efficacy and safety of EUS-GE in benign GOO. Patients and methods This was an international retrospective series involving 5 tertiary centers. Consecutive patients who underwent EUS-GE between 1/2013 – 10/2016 for benign GOO were included. The primary endpoint was the rate of clinical success defined as ability to tolerate oral intake without vomiting. Secondary endpoints included technical success and rate of adverse events (AE). Results Overall, 26 patients (46.2 % female; mean age 57.7 ± 13.9 years) underwent EUS-GE for benign GOO due to strictures from chronic pancreatitis (n = 11), surgical anastomosis (n = 6), peptic ulcer disease (n = 5), acute pancreatitis (n = 1), superior mesentery artery syndrome (n = 1), caustic injury (n = 1), and hematoma (n = 1). Technical success was achieved in 96.2 %. Dilation of the lumen apposing metal stent was performed in 13/25 (52 %) with a mean maximum diameter of 14.6 ± 1.0 mm. Mean procedure time was 44.6 ± 26.1 min. Clinical success was observed in 84.0 % with a mean time to oral intake of 1.4 ± 1.9 days and a median follow-up of 176.5 (IQR: 47 – 445.75) days. Rate of unplanned re-intervention was 4.8 %. 3 AE were noted including 2 misdeployed stents and 1 gastric leak needing surgical intervention following elective GE stent removal. Conclusions EUS-GE is a promising treatment for benign GOO. Larger and prospective data are needed to further validate this novel endoscopic technique in treating benign GOO of various etiologies.

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