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

• Abstract
• Introduction
• Methods
• Statistical analysis
• Results
• Technical outcomes
• Clinical success
• Long-term outcomes
• Adverse events
• Discussion
• References

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.

Introduction

Gastric outlet obstruction (GOO) due to duodenal obstruction can be treated either surgically or endoscopically [1]. Although placement of an enteral stent has lower morbidity, shorter hospital stays, higher initial clinical success, and faster relief of obstructive symptoms than surgical gastroenterostomy [2] [3], the rate of late stent occlusion is relatively high and the technique has inferior long-term relief of symptoms [4] [5]. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent (LAMS) was first reported by Binmoeller et al. [6], with subsequent studies confirming its efficacy and safety [7] [8] [9] [10] as a first-line treatment or after failed enteral stenting [11]. As EUS-GE bypasses the site of obstruction, its efficacy has been found to be comparable to laparoscopic gastroenterostomy [7]. When compared with enteric stent placement, EUS-GE shows comparable effectiveness and safety for patients with malignant GOO, with fewer symptom recurrences and requirements for reintervention [9].

The use of a retrieval or dilation balloon catheter [8] [12] and a specialized double-balloon catheter [13] have been reported to improve visualization of the targeted enteric loop by EUS. Advancing the balloon catheter into the proximal jejunum, however, can be difficult owing to looping of the guidewire in the stomach and flaccidity of the balloon-catheter shaft. Without the balloon in the proximal jejunum, technical success would be low as the targeted jejunal loop cannot be identified [9] [12]. Although the jejunal loops can be distended by directly pumping water through the duodenal stricture via the gastroscope [12], this is not always feasible with tightly obstructing strictures. Such weaknesses can be overcome by advancing an oroenteric catheter (OEC) across the stricture into the proximal jejunum to deliver the fluid. This study evaluated the outcomes of OEC-assisted EUS-GE for patients with GOO.

Methods

A prospectively collected database of consecutive patients referred to our center for treatment of GOO between 2015 and 2019 was retrospectively reviewed. Institutional Review Board approval was obtained. All patients had provided written informed consent prior to the procedure. Patient demographics, clinical/laboratory data, procedural details, and outcomes were recorded in a database. Technical success, procedural adverse events, and clinical success were assessed. Technical success was defined as successful deployment of the LAMS with creation of a gastroenterostomy. Clinical success was defined as the ability to tolerate a non-liquid diet post-procedure by Day 3, which involved the ability to consume semi-solid food. Adverse events were defined as bleeding, stent migration, perforation, and infection.

All procedures were performed by interventional endosonographers who were experienced in performing EUS-GE (K.F.B., C.M.H., R.R.W., A.N.). A therapeutic gastroscope (GIF-1TH190; Olympus, Tokyo, Japan) was used to clear the stomach and duodenum of retained contents. A 0.035-inch flexible guidewire (HydraJag; Boston Scientific, Marlborough, Massachusetts, USA) was passed across the stricture into the downstream small bowel under endoscopic and fluoroscopic guidance. A 7-Fr or 8-Fr OEC, 255 cm in length (Cook Medical, Winston-Salem, North Carolina, USA) was then advanced over the guidewire. The gastroscope was slowly removed, leaving the OEC in place. The therapeutic linear echoendoscope (GF-UCT180; Olympus, Central Valley, Pennsylvania, USA) was then inserted alongside the OEC and advanced to the mid-stomach body. Sterile water was infused through the OEC to fill and distend the small-bowel lumen. The use of glucagon to reduce peristalsis and contrast injection to assist with loop identification under fluoroscopic guidance were performed at the discretion of the endoscopist. An enteric loop adjacent to the stomach wall was punctured with the electrocautery-enhanced LAMS delivery system (15 mm caliber, “Hot” Axios; Boston Scientific) and deployed as previously described. After LAMS deployment, the LAMS lumen was dilated using a through-the-scope dilating balloon (CRE; Boston Scientific) up to 15 mm ( [Fig.1, ] [Video 1]). The echoendoscope was exchanged for a diagnostic gastroscope for trans-LAMS confirmation of successful gastroenterostomy.

Video 1 Endoscopic ultrasound-guided gastroenterostomy using an oroenteric catheter-assisted technique.

Statistical analysis

Data were expressed as mean and standard error of the mean (SEM), and assessed for normality. Binary outcomes were compared by Fisher’s exact test and continuous outcomes were compared with Student’s t test. A P value of < 0.05 was considered statistically significant. Statistical analysis was performed using GraphPad Prism 8 (San Diego, California, USA).

Results

Over 4 years, 42 consecutive patients (mean age 73.1 [SEM] 2.8 years; 23 male) underwent EUS-GE for both malignant and benign duodenal strictures. All patients with GOO presented with nausea and vomiting with inability to tolerate any oral intake. The etiologies of the strictures were: pancreaticoampullary cancer (n = 29), gallbladder cancer (n = 1), ampullary cancer (n = 1), duodenal cancer (n = 1), metastatic cancer (n = 4), neuroendocrine tumor (n = 1), peptic stricture (n = 3), “groove” pancreatitis (n = 1), and superior mesenteric artery syndrome (n = 1).

Technical outcomes

Technical success was achieved in 41/42 patients (98 %). Mean procedure time was 36 (SEM 3) minutes. Although strictures could not be traversed with the therapeutic gastroscope in 5/42 patients (12 %), insertion of the OEC into the proximal jejunum was successful in 100 %, with clear visualization of water-distended loops of the jejunum in all cases. After puncture of the enteric loop, the LAMS was successfully deployed in 41/42 patients (98 %).

Clinical success

Oral intake of a soft, low-residue diet was achieved in 39/42 patients (93 %) by post-procedure Day 3. Symptoms of GOO persisted or recurred in three patients (7 %), in whom repeat endoscopic evaluation and appropriate intervention were performed. One patient was found to have a patent EUS-GE, but owing to advanced disease and comorbidities, a venting percutaneous endoscopic gastrostomy (PEG) was inserted at Day 22 after EUS-GE; however, the patient remained symptomatic and died 5 days after PEG insertion. The remaining two patients experienced stent migration, which caused recurrent symptoms at Day 20 and 22, respectively, after EUS-GE.

Long-term outcomes

A total of 14 patients (33 %) died after a mean follow-up period of 5.7 (SEM 2.6) months. Of these patients, 13 (93 %) were able to maintain oral intake until death. Among the 28 surviving patients, EUS-GE provided good symptom relief for 5.4 (SEM 0.7) months. The LAMS was electively upsized to 20 mm at 6 months in one patient (2 %) who was doing well.

Adverse events

Adverse events occurred in three patients (7 %), including failure of LAMS deployment (n = 1) and stent occlusion (n = 2). LAMS maldeployment was related to the failure of the stent sheath to retract after successful cauterized puncture of the LAMS into the enteric lumen, thus, preventing stent deployment. The gastric puncture was immediately closed by endoscopic suturing (Overstich; Apollo Endosurgery, Austin, Texas, USA). The patient was treated conservatively with intravenous antibiotics and remained asymptomatic without signs of peritonitis. A successful EUS-GE was performed 2 days later and the patient was able to tolerate an oral diet by Day 3. Two patients developed recurrent symptoms of GOO at Day 20 and 22, respectively, after EUS-GE. This was due to the distal margin of the LAMS migrating toward the gastric end, resulting in stent occlusion at the jejunal side. The occlusion was managed by inserting a 6 cm × 22 mm fully covered metal stent through the existing LAMS in one case, and a 20-mm LAMS replacement in the other case. Both patients had full resolution of GOO symptoms. None of the patients experienced bleeding (immediate or delayed) or infection.

Discussion

EUS-GE with LAMS for treatment of GOO overcomes the operative risks of surgical bypass and the short-term efficacy of enteral self-expandable metal stents [1] [2] [3] [4] [11]. Identifying the appropriate small-bowel loop for puncture on EUS, however, is critical to the success of the procedure. Unassisted, the targeted enteral loop can be visualized in less than 20 % of cases [10] [12]. We report on the outcomes of OEC-assisted EUS-GE using a 15-mm LAMS in 42 patients with both benign and malignant duodenal strictures. Technical (98 %) and clinical (93 %) success rates were high, with minor adverse events (7 %) and a low rate of required reintervention (7 %). Over a mean follow-up period of 5.7 months, the technique provided relief of symptoms as well as enabling sustained oral intake of solid food in 93 % of patients.

Single- and double-balloon-assisted EUS-GE have been reported by several groups [7] [9] [10] [12] [13] [14]. There are several advantages of using OEC over balloons in assisting EUS-GE. The ability to insert the OEC under direct endoscopic vision through the therapeutic gastroscope ensures targeted and correct placement of the catheter. This procedure overcomes the technical challenges of inserting the balloon catheter into the downstream small bowel associated with either gastric looping or the flaccidity of the balloon catheter [7] [8] [10]. It is likely that the 100 % technical success of inserting the OEC into the downstream small bowel is responsible for the high technical success rates, as well as to the avoidance of prolonged procedure times. Compared with the balloon-assisted technique, our mean procedure time (36 minutes) was half or less than that reported for the balloon-assisted technique (66, 89, and 96 minutes) [8] [9] [10].

More importantly, clear visualization of the water-distended bowel loop with the OEC in situ ensures correct identification of the enteric loop for puncture and avoidance of accidental targeting of the colon. LAMS maldeployment due to device malfunction was responsible for the only technical failure in this study. The electrocautery-enhanced LAMS delivery system was used to puncture the targeted small-bowel loop under direct EUS visualization from the gastric lumen in all cases. This “one-step, one-device” system eliminated multiple over-the-wire catheter exchanges (Seldinger technique), which can lead to separation between the gastric and small-bowel walls and/or to loss of visualization of the enteric loop, increasing the risk of technical failure.

Our rate of reintervention for recurrence of symptoms was lower than that reported in a recent long-term follow-up study of EUS-GE (5 % vs. 15 %) [7] [8] [9] [10] [12]. Stent dysfunction from food impaction, tissue ingrowth, and migration have been reported to be the most common causes of recurrent GOO symptoms. In our study, stent migration occurred in two patients, and was successfully managed by reinsertion of a covered metal stent or replacement LAMS. One patient experienced persistent symptoms despite a widely patent EUS-GE, which has been reported previously [10]. This is consistent with severe gastric dysmotility as the likely cause of the nausea and vomiting [15].

The main limitations of this study are the retrospective design, short follow-up duration, and lack of comparative arms with either a direct approach or balloon-assisted techniques. Our results may not be generalizable, as the procedures were performed by expert interventional endosonographers. The main strengths of the study are its relatively large sample size (n = 42) and homogeneity in the technical methodology of EUS-GE.

In conclusion, OEC-assisted EUS-GE with a 15-mm LAMS was associated with high technical success (98 %), minimal serious adverse events, and satisfactory relief of GOO symptoms in both malignant and benign duodenal strictures. Simplicity is an advantage of this technique over the balloon-assisted methods.

Competing interests

KFB is the inventor of the AXIOS LAMS and delivery system and a paid educator for Boston Scientific. The other authors declare that they have no conflict of interest.

• References

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Corresponding author

Publication History

Received: 05 August 2020

Accepted after revision: 11 January 2021

Article published online:
15 April 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Uemura S, Iwashita T, Iwata K. et al. Endoscopic duodenal stent versus surgical gastrojejunostomy for gastric outlet obstruction in patients with advanced pancreatic cancer. Pancreatology 2018; 18: 601-607
  CrossrefPubMedSearch in Google Scholar
• 2 Rudolph HU, Post S, Schluter M. et al. Malignant gastroduodenal obstruction: retrospective comparison of endoscopic and surgical palliative therapy. Scand J Gastroenterol 2011; 46: 583-590
  CrossrefPubMedSearch in Google Scholar
• 3 Wong YT, Brams DM, Munson L. et al. Gastric outlet obstruction secondary to pancreatic cancer: surgical vs endoscopic palliation. Surg Endosc 2002; 16: 310-312
  CrossrefPubMedSearch in Google Scholar
• 4 Sasaki T, Isayama H, Nakai Y. et al. Clinical outcomes of secondary gastroduodenal self-expandable metallic stent placement by stent-in-stent technique for malignant gastric outlet obstruction. Dig Endosc 2015; 27: 37-43
  CrossrefPubMedSearch in Google Scholar
• 5 Park JH, Song HY, Yun SC. et al. Gastroduodenal stent placement versus surgical gastrojejunostomy for the palliation of gastric outlet obstructions in patients with unresectable gastric cancer: a propensity score-matched analysis. Eur Radiol 2016; 26: 2436-2445
  CrossrefPubMedSearch in Google Scholar
• 6 Binmoeller KF, Shah JN. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503
  Thieme ConnectPubMedSearch in Google Scholar
• 7 Perez-Miranda M, Tyberg A, Poletto D. et al. EUS-guided gastrojejunostomy versus laparoscopic gastrojejunostomy: an international collaborative study. J Clin Gastroenterol 2017; 51: 896-899
  CrossrefPubMedSearch in Google Scholar
• 8 Khashab MA, Kumbhari V, Grimm IS. et al. EUS-guided gastroenterostomy: the first US. clinical experience (with video). Gastrointest Endosc 2015; 82: 932-938
  CrossrefPubMedSearch in Google Scholar
• 9 Chen YI, Itoi T, Baron TH. et al. EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surg Endosc 2017; 31: 2946-2952
  CrossrefPubMedSearch in Google Scholar
• 10 Tyberg A, Karia K, Zerbo S. et al. Endoscopic ultrasound-guided choledochojejunostomy with a lumen-apposing metal stent: a shortcut for biliary drainage. Endoscopy 2015; 47: E342-E343
  Thieme ConnectPubMedSearch in Google Scholar
• 11 Tyberg A, Kumta N, Karia K. et al. EUS-guided gastrojejunostomy after failed enteral stenting. Gastrointest Endosc 2015; 81: 1011-1012
  CrossrefPubMedSearch in Google Scholar
• 12 Chen YI, Kunda R, Storm AC. et al. EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc 2018; 87: 1215-1221
  CrossrefPubMedSearch in Google Scholar
• 13 Itoi T, Tsuchiya T, Tonozuka R. et al. Novel EUS-guided double-balloon-occluded gastrojejunostomy bypass. Gastrointest Endosc 2016; 83: 461-462
  CrossrefPubMedSearch in Google Scholar
• 14 Khashab MA, Tieu AH, Azola A. et al. EUS-guided gastrojejunostomy for management of complete gastric outlet obstruction. Gastrointest Endosc 2015; 82: 745
  CrossrefPubMedSearch in Google Scholar
• 15 Chasen M, Bhargava R. Gastrointestinal symptoms, electrogastrography, inflammatory markers, and PG-SGA in patients with advanced cancer. Support Care Cancer 2012; 20: 1283-1290
  CrossrefPubMedSearch in Google Scholar