Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy
Abstract
:1. Introduction
2. Management
2.1. Surgical Gastrojejunostomy
2.2. Self-Expandable Metallic Stents
2.3. EUS-Guided Gastroenterostomy
- Antegrade EUS-GE direct method
- Step 1:
- Visualize the target intestinal limb by injecting saline or diluted contrast (methylene blue) distal to the obstruction through an orojejunal tube that was previously inserted under endoscopic guidance.
- Step 2:
- Perform an EUS-guided puncture of the target intestinal limb using a 19-gauge needle.
- Step 3:
- Aspirate; methylene blue aspiration confirms correct localization of the needle in the target jejunal limb.
- Step 4:
- Pass either a guidewire through the needle, in order to place a LAMS over it, or use directly a cautery-enhanced LAMS (HOT AXIOS; Boston Scientific Corp.).
- Antegrade EUS-GE direct method using the wireless endoscopic simplified technique (WEST)
- Step 1:
- As in Technique 1.
- Step 2:
- Advance and deploy directly a cautery-enhanced LAMS (HOT AXIOS; Boston Scientific Corp.) in cut mode.
- Antegrade EUS-GE traditional downstream method
- Step 1:
- Position a guidewire in the jejunal lumen past the obstruction under endoscopic guidance. Withdraw the endoscope and keep guidewire in place.
- Step 2:
- Using fluoroscopy advance a dilating balloon over the wire to the jejunum. Dilate the balloon.
- Step 3:
- From the stomach perform an EUS-guided puncture of the balloon with a 19-gauge needle.
- Step 4:
- Pass another guidewire through this needle into the jejunum.
- Step 5:
- Deploy the LAMS over the second guidewire.
- Antegrade EUS-GE with direct technique over a guidewire (DTOG)
- Step 1:
- Administer intravenous anticholinergic agent to slow bowel movements
- Step 2:
- Puncture the target intestinal limb with a 19-gauge needle.
- Step 3:
- Fill the jejunal limb with contrast medium through the needle and insert a guidewire using fluoroscopy.
- Step 4:
- Advance the cautery-enhanced LAMS catheter over the guidewire into the jejunal limb in cut mode. Deploy the LAMS.
- 5.
- Antegrade EUS-GE rendezvous method
- Steps 1 to 3:
- See Technique 3.
- Step 4:
- Entrap the puncturing guidewire in the dilating balloon that was punctured, or capture it with an ERCP extraction balloon and/or basket and pull it back outside the mouth, in order to secure it.
- Step 5:
- Deploy the LAMS using this guidewire under traction.
- 6.
- Retrograde EUS-EG Enterogastrostomy
- Steps 1 to 4:
- See Technique 5.
- Step 5:
- Advance a therapeutic endoscope over the guidewire till you locate the inserted guidewire in the duodenum/jejunum.
- Step 6:
- Deploy the LAMS in a retrograde fashion by opening the gastric flange first.
- 7.
- EUS balloon occluded GE Bypass (EPASS)
- Step 1:
- Using a double-balloon enteroscope (DBE) position a guidewire in the jejunum.
- Step 2:
- Withdraw the DBE, while keeping the overtube in the antrum or duodenal bulb.
- Step 3:
- Use a double-balloon-occlusion catheter. This catheter has two balloons (with 20 cm distance between them). Insert it distal to the obstruction under endoscopic control and then inflate both balloons to stabilize the target intestinal limb. Then fill this segment with contrast.
- Step 4:
- Perform an EUS-guided puncture between the two balloons.
- Step 5:
- Deploy the LAMS.
3. Comparison of the Available Treatments
3.1. Comparison of the Available LAMS
3.2. Comparison for the Different Techniques for EUS-GE
3.3. Comparison between Methods
3.3.1. EUS-GE vs. SGE
3.3.2. EUS-GE vs. SEMS
4. Technique Choice
5. Misdeployment
- For SM Type 1 removal of the LAMS and closure the gastrotomy was performed using over-the-scope clips (OTSCs), through-the-scope clips (TTSCs), or endoscopic suturing. Two patients, who were treated conservatively with no closure of the gastrotomy, recovered with no adverse events. This type of error was addressed during the same endoscopic session via EUS-GE at the same or different gastric site or via placement of a duodenal stent. In this cohort, three patients were operated due to peritonitis and a SGE was performed [9]. Overall, the majority of Type I SM events were assessed as mild (n = 22, 75.9%), two were moderate (6.9%), and five severe (17.2%). The five severe cases included the three patients who required surgical treatment and two patients who were admitted to the ICU [9].
- For Type II SM, LAMS was removed and a new LAMS using the same EUS-GE method or the NOTES (natural orifice transluminal endoscopic surgery) method was placed; alternatively a fcSEMS through the initial misdeployed LAMS was placed to bridge the gap. Endoscopic closure of the gastrotomy only with OTSC or TTSC was also an alternative for five patients. Of those patients, two developed abdominal pain requiring narcotics and one patient pneumoperitoneum requiring drainage, but two experienced no adverse events. Only 50% of Type II SM patients experienced adverse events; abdominal pain requiring narcotics was the most common (28.6%). Overall, most Type II SM adverse events were graded as mild (n = 6, 42.9%) or moderate (n = 7; 50.0%). Only one patient was operated due to peritonitis [9].
- For the one case of Type III SM, the NOTES method was used, but it was not successful. For this reason, the LAMS had to be removed surgically and a SGE was performed [9].
- Type IV SM occurred twice; one was recognized during the procedure, while the second one was identified 3 weeks post procedure due to diarrhea induced by food intake. In both cases, LAMS was removed followed by endoscopic closure of the gastrocolic anastomosis, either with an endoscopic suturing or TTS [9].
6. Conclusions and Future Perspectives
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Method | Advantages | Disadvantages |
---|---|---|
Surgical Gastroenterostomy | Long-term durability Salvage solution if endoscopic treatments have failed | Invasive method High morbidity, contraindicated in critically ill patients Gastroparesis |
SEMS | Less invasive, safe Widely available in daily clinical practice Rapid alleviation of symptoms, early resumption of chemotherapy, oral intake | High reintervention rate due to stent obstruction |
EUS-GE | Less invasive, safe procedure compared to SGE Sustained patency, long-term efficacy Rapid alleviation of symptoms, early resumption of chemotherapy, oral intake Feasible in patients with concomitant biliary obstruction | Not standardized More expertise is required Poor performance in case of uncontrolled ascites, diffuse peritoneal disease, or diffuse infiltration of gastric wall |
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Ziogas, D.; Vasilakis, T.; Kapizioni, C.; Koukoulioti, E.; Tziatzios, G.; Gkolfakis, P.; Facciorusso, A.; Papanikolaou, I.S. Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy. Med. Sci. 2024, 12, 9. https://doi.org/10.3390/medsci12010009
Ziogas D, Vasilakis T, Kapizioni C, Koukoulioti E, Tziatzios G, Gkolfakis P, Facciorusso A, Papanikolaou IS. Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy. Medical Sciences. 2024; 12(1):9. https://doi.org/10.3390/medsci12010009
Chicago/Turabian StyleZiogas, Dimitrios, Thomas Vasilakis, Christina Kapizioni, Eleni Koukoulioti, Georgios Tziatzios, Paraskevas Gkolfakis, Antonio Facciorusso, and Ioannis S. Papanikolaou. 2024. "Revealing Insights: A Comprehensive Overview of Gastric Outlet Obstruction Management, with Special Emphasis on EUS-Guided Gastroenterostomy" Medical Sciences 12, no. 1: 9. https://doi.org/10.3390/medsci12010009