Learning curve of endoscopic ultrasound-guided gastroenterostomy for the management of malignant gastric outlet obstruction: data from a bicentric retrospective study

Aims Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a promising alternative to surgery and duodenal stenting to manage gastric outlet obstruction (GOO). The use of HOT-LAMS stents and duodenojejunal loop distension has simplified the procedure. This study aimed to analyze the learning curve for EUS-GE.

Methods This is a retrospective international bicentric study including patients with malignant GOO who underwent EUS-GE. Two techniques were used for duodenojunal loop distention: the WEST technique, distending the jejunal loop with a nasobiliary drain, and a “modified” WEST technique, using a nasofibroscope for irrigation. The primary outcome was to analyze the learning curve of EUS-GE for each center, using a composite score based on clinical success rate, severe complications rate (≥ grade III per AGREE), and procedure time. Learning curve were plotter using a smoother (lamba 0.01) to assess trends in composite score over the sequence of procedure. Secondary outcomes included clinical and technical success rates of EUS-GE. The clinical success was defined as the increase of 1-point GOOS score at one month.

Results Ninety-six patients (54% women), with a median age of 65 years [IQR 60-77], were included between April 2021 and August 2024. In the first center, 53 patients underwent the WEST technique (n=55%) while in the second one, 43 patients (n=45%) underwent the modified WEST technique (n=35) and 8 patients underwent the standard WEST. Technical and clinical success rates were 94% (n=90/96) and 90% (n=81/90), respectively. The complication rate was 10% (n=10), with 6% (n=6) being grade III to IV according to AGREE (severe complication). The mortality rate was 1% (n=1). The primary cause of technical failure was the misdeployment of the LAMS, with a distal flange deployed between the stomach and the intestinal wall in 83% of cases (n=5). Three cases were managed endoscopically, the other 2 cases were managed par surgery. In Center 1, two cases of severe complications (67%) occurred within the first 20 procedures versus 33% in the following. In contrast, in Center 2, all severe complications occurred during the initial procedures (100%), except for one mortality case, which occurred after 20 procedures. The learning curves were relatively similar in both centers. We observed a plateau after approximately 20 procedures [1].

Conclusions EUS-GE remains a complex endoscopic procedure that carries the risk of serious complications. However, it can be mastered by an expert interventional endoscopic team after approximately 20 interventions per center, allowing high clinical success rates and low complication rates.

 

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Conflicts of Interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Jovani M, Ichkhanian Y, Parsa N, Singh S, Brewer Gutierrez OI, Keane MG, Al Ghamdi SS, Ngamruengphong S, Kumbhari V, Khashab MA.. Assessment of the learning curve for EUS-guided gastroenterostomy for a single operator. Gastrointest Endosc 2021; 93 (05): 1088-1093 Epub 2020 Sep 28. PMID 32991868

Publication History

Article published online:
27 March 2025