Endoscopic ultrasound-guided gastroenterostomy versus duodenal stenting: the retrospective story’s been told, now it’s time for a prospective one

Historically, surgical gastrojejunostomy was considered the standard of care for patients with gastric outlet obstruction (GOO) and good functional status, regardless of etiology. Endoscopic placement of a luminal self-expandable metal stent (SEMS) is efficacious and minimally invasive, and remains the widely accepted alternative to surgery for the management of malignant GOO. However, patency of luminal SEMSs due to tumor ingrowth/overgrowth remains a significant limitation. Recently, endoscopic ultrasonography (EUS)-guided gastroenterostomy (EUS-GE) has emerged as a viable alternative to both the above options for malignant and benign etiologies, with early data demonstrating high technical and clinical success and acceptable rates of adverse events [1].

“Even though the outcomes were excellent in patients undergoing EUS-GE (only 10 % adverse events), there remains a difficulty in generalizing these results to institutions that are not high volume tertiary care centers.”

Compared with surgical gastrojejunostomy, duodenal stents have similar efficacy and are significantly less invasive, yet they require more frequent reinterventions for obstruction from tissue/tumor ingrowth and/or overgrowth [2]. However, surgical gastrojejunostomy has superior long-term results with fewer reinterventions required and has been considered by some experts to be the treatment of choice in patients with a life expectancy exceeding 3 months [3] [4].

EUS-GE remains an infrequently performed procedure at many institutions despite the growing clinical experience. A recent systematic review and meta-analysis by Boghossian et al., including 513 patients from seven studies, revealed a slightly lower technical success when compared with surgical GJ but a significantly shorter length of hospital stay [5]. All other outcomes including clinical success, severe adverse events, reintervention rate, and 30-day mortality were not significantly different. When compared with duodenal stenting, EUS-GE demonstrated a higher clinical success, fewer severe adverse events, and decreased stent obstruction resulting in a reduced need for reintervention [5]. In studies looking at longer follow-ups, symptom recurrence or need for reintervention does not appear to rise precipitously [6]. One study identified an overall reintervention rate of 15 % in patients with malignant GOO who were followed for a median of 196 days and in patients with benign GOO who were followed for 319 days [7].

In this issue of Endoscopy, the nicely conducted study by van Wanrooij et al. compared the efficacy, safety, and stent dysfunction rates of EUS-GE vs. duodenal stenting in patients with malignant GOO using propensity score matching [8]. The study was conducted between 2015 and 2021 across three European centers with expertise in EUS-guided interventions. A total of 214 patients were identified, who underwent either EUS-GE (n = 107) or duodenal stenting (n = 107). After propensity score matching, 176 patients were compared. There was no difference between EUS-GE vs. duodenal stenting in technical success rates (94 % vs. 98 %; P = 0.44) or adverse event rates (10 % vs. 21 %; P = 0.09). However, clinical success rates were higher with EUS-GE (91 % vs. 75 %; P = 0.008) and stent dysfunction rates were lower (1 % vs. 26 %; P < 0.001). This confirms the findings of nonpropensity-matched, previously published data. Furthermore, the median time to clinical success was shorter in the EUS-GE group (1 vs. 2 days; P < 0.001).

The authors offer the following explanations for this clinical difference between the two approaches: 1) lumen-apposing metal stents (LAMSs) used for EUS-GE are covered, reducing the risk of tissue ingrowth (something previously established in studies comparing covered and uncovered duodenal SEMS) [9]; 2) LAMSs, being short (1.5 cm in length), are less likely to become obstructed by food than even the shortest duodenal stent, which is 6 cm (resulting in a longer aperistaltic segment of the bowel); 3) LAMSs, being placed away from the tumor (i. e. through healthy tissue) should, theoretically, allow complete stent expansion compared with a duodenal stent placed through the malignant stricture itself. I find this last point less compelling as tissue hyperplasia (benign or malignant) is typically the more common reason for early failure rather than failure of complete expansion of the duodenal stent.

The two main limitations of the study are its retrospective nature, although somewhat compensated for by the propensity matching, and a short follow-up (median follow-up of only 85 and 57 days in the EUS-GE and duodenal stent groups, respectively). Even though the outcomes were excellent in patients undergoing EUS-GE (only 10 % adverse events), there remains a difficulty in generalizing these results to institutions that are not high volume tertiary care centers. This has led the ESGE to recommend that EUS-GE is performed in an expert setting for malignant gastric outlet obstruction as an alternative to duodenal stenting or surgery [10].

In conclusion, this study shows that in patients with malignant GOO, EUS-GE has similar technical success and adverse event rates to duodenal stenting, but higher clinical success and lower recurrence rates, suggesting that EUS-GE should be preferred over duodenal stenting in centers with available expertise. Further developments of current EUS-GE techniques should focus on minimizing risks and further simplification of the procedure. Comparative trials between the most commonly used techniques could be helpful in determining which method provides the highest technical and clinical success, with the lowest risk for adverse events. Finally, randomized controlled trials comparing EUS-GE with surgical gastrojejunostomy and duodenal stenting are needed to identify optimal candidates for EUS-GE and to determine the exact role for each technique in patients with malignant GOO.

Publication History

Article published online:
04 May 2022

• References

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