Novel endoscopic procedure: EUS-GE superior to conventional endoscopic duodenal stenting in treating patients with malignant GOO

Malignant gastric outlet obstruction (GOO) is a debilitating symptom experienced by patients with locally advanced pancreatobiliary or gastroduodenal malignancy.1 As only a small percentage of these malignancies are resectable, palliative measures such as surgical gastrojejunostomy or endoscopic stenting are usually performed to manage GOO.1,2 Endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) is a novel non-surgical procedure that simulates a gastrojejunostomy and has been associated with better clinical outcomes compared to duodenal stenting.1 In a multicenter, randomized, controlled trial led by researchers from The Chinese University of Hong Kong’s Faculty of Medicine, the improved stent patency and a reduction in reinterventions that EUS-GE offers was presented.1

Malignant GOO is the mechanical malignant blockage of the upper digestive tract, leading to abdominal pain, repeated vomiting, and an inability to consume foods orally, resulting in a general decrease in patients’ quality-of-life.1,2,3 Conventional treatments for GOO like surgical gastrojejunostomy offer a wide cross-luminal anastomosis, but are highly invasive and incur increased morbidity.1,2,3 Conversely, endoscopic stenting is less invasive but is associated with a high risk of stent obstruction which requires reintervention.3 The EUS-GE is a novel method that allows endoscopic placement of a stent between the stomach and the duodenum or jejunum, simulating a surgical gastrojejunostomy without incurring the risks of an invasive surgery.1,3 Prior to the captioned study, no randomized trials had compared the use of EUS-GE and duodenal stent for malignant GOO.1,3

This international, multicenter, randomized controlled trial was conducted at seven sites across Hong Kong, Belgium, Brazil, India, Italy, and Spain.1 Adult patients unable to orally consume food or liquid due to malignant GOO and had an Eastern Cooperative Oncology Group performance status (ECOG-PS) score of ≤3 were included in this study.1 They were randomized 1:1 to receive EPASSassisted EUS-GE (n=48) or an uncovered duodenal stent (n=49) after guidewire cannulation of the obstruction.1 All randomized participants completed 6 months of follow-up and were assessed on symptoms of obstruction and their quality-of-life.1

The primary outcome was the 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction within 6 months of randomization.1 Causes of stent dysfunctions requiring restenosis included stent migration, stent fracture, tumor ingrowth, tumor overgrowth, or the presence of food residue.1 The study found that the EUS-GE group had a significantly lower 6-month reintervention rate compared with the duodenal stent group (4% vs. 29%; p=0.002; RR=0.15; 95% CI: 0.04-0.61).1 Secondary outcomes included technical success (defined as successful placement of the stent), clinical success [defined as at least 1-point improvement in gastric outlet obstruction score (GOOS) within 3 days after stent insertion], 30-day adverse event rate, 30-day mortality, duration of stent patency, post-stent GOOS, and changes in quality-of-life scores.1 Stent patency also lasted longer in the EUS-GE group (HR=0.13; 95% CI: 0.08-0.22; p<0.0001) and they scored better on the 1-month GOOS (mean=2.41; SD=0.7) than the duodenal stent group (mean=1.91; SD=0.9; p=0.012).1 No statistically significant differences between the two groups were observed in technical success, clinical success, 30-day mortality, or quality-of-life scores at 1 month.1

The rates of adverse events within 30 days were also similar (p=1.00) with 2 cases of pneumonia in the EUS-GE group and 1 in the duodenal stent group considered to be procedure-related.1 The use of the EPASS device might also be associated with a longer procedural time which could increase the risk of aspiration pneumonia.1 Post-hoc analysis revealed that the median procedural time was significantly longer in the EUS-GE group (35 min vs. 19.5 min; p<0.001) but the median length of hospital stay was significantly shorter (4 days vs. 6 days; p=0.013) compared to patients who received the duodenal stent.1

The advantages of EUS-GE over duodenal stenting in patients with malignant GOO have been affirmed in this randomized trial.1 In settings where the expertise and required devices are available, EUS-GE should be considered preferentially over duodenal stenting.1 However, as the EPASS device has yet to become widely available, whether similar outcomes can be reproduced with the free-hand or other device-assisted techniques remains unclear.1


Get access to our exclusive articles.