Endoscopic Treatment of Gastric Outlet Obstruction

EUS guided gastrojejunostomy: techniques and outcomes

INTRODUCTION

Surgical bypass, the traditional approach for managing gastric outlet obstruction (GOO), is effective but associated with increased morbidity and short-term complications. Enteral self-expanding metal stents (SEMS) provide a safe, effective, and minimally invasive alternative to surgical bypass, though they carry an increased risk of re-interventions due to stent blockage. Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a recently developed, novel minimally invasive procedure that serves as an alternative to enteral SEMS placement.

AREAS COVERED

We performed an electronic search in PubMed and included all the types of articles on EUS-GJ written in English language till February 2025. This review discusses both the technical details and outcomes of EUS-GJ.

EXPERT OPINION

EUS-GJ involves creating an anastomosis between the stomach and the small intestine using a lumen-apposing metal stent (LAMS). There are three basic techniques for performing EUS-GJ: the direct technique, the balloon-assisted technique, and the EPASS (EUS-guided double-balloon-occluded gastrojejunostomy bypass) technique. Among these, the free-hand direct approach is the most widely used due to its shorter procedure time and comparable technical outcomes to the other two techniques. Stent misdeployment is the most dreaded complication of EUS-GJ; however, fortunately, the majority of misdeployments can be successfully managed through rescue endoscopic methods.

What is the benefit of endoscopic ultrasound-guided gastrojejunal anastomosis for patients with benign gastric outlet obstruction? A systematic review with meta-analysis

BACKGROUND

Gastric outlet obstruction for benign indications (bGOO) is an uncommon condition, typically treated with surgery when medical therapy or endoscopic treatments fail. At present, endoscopic ultrasound (EUS)-guided gastrojejunostomy (GJ) may prove to be an effective alternative.

AIMS

We performed a systematic review with meta-analysis evaluating outcomes of EUS-GJ for bGOO.

METHODS

A comprehensive search was conducted up to February 2025. Pooled estimates were obtained using a random-effects model. Study quality was evaluated using the Newcastle-Ottawa quality scale. Heterogeneity was evaluated with I2 statistic. Technical success, clinical success, recurrence rate, and adverse events (AE) rate were the main outcomes.

RESULTS

Fifteen (15) studies, including a total of 376 patients, were identified. Pooled technical success was 95.8 % (CI 95 %, 93.8 %-97.8 %, I2 =0 %), while clinical success was 93.4 % (CI 95 %, 90.4 %-96.5 %, I2= 31.83 %). Pooled recurrence rate was 11.6 % (CI 95 %, 5.5 %-17.7 %, I2=32.36 %). The pooled rate of AE was 11.6 % (CI 95 %, 6.8-16.5 %, I2 = 57.18 %). Subgroup analyses found differences in safety when AE classification was used (17 % use vs. 6 % no use, p = 0.02) and based on quality of studies (low 22 % vs. moderate 10 % vs. high 3 %, p = 0.04).

CONCLUSION

In conclusion, our findings show that EUS-GJ is effective and safe in those patients with bGOO in whom other endoscopic treatments fail, and surgery is not an option or could be performed as bridge-to-surgery. Our results suggest that safety is influenced by the use of AE classification and the quality of studies.

Endoscopic ultrasound-guided gastroenterostomy for the treatment of gastric outlet obstruction secondary to acute pancreatitis

BACKGROUND

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a minimally invasive technique for treating gastric outlet obstruction (GOO). The aim of this study was to assess the outcomes of EUS-GE in managing benign GOO caused by duodenal stenosis in patients with acute pancreatitis.

METHODS

This international retrospective study analyzed patients treated with EUS-GE for GOO caused by acute pancreatitis until December 2023, evaluating technical and clinical success, adverse events, and reintervention.

RESULTS

39 patients (median age 55 years, 15 women) were included. There was a 92.3% technical success rate, with only three patients unable to undergo EUS-GE owing to a long distance between the stomach and small bowel or an inadequate window for puncture. Clinical success was observed in 34 patients (87.2%). The median Gastric Outlet Obstruction Scoring System (GOOSS) improved from 0 before EUS-GE to 2 afterward (P <0.001). Follow-up (≥3 months) was available in 25 patients. During a median follow-up of 23 months, four patients required reintervention. It was possible to remove the lumen-apposing metal stent in 18 patients. The only adverse event was a gastrocolic fistula detected incidentally after 3 months.

CONCLUSION

EUS-GE is an effective and safe method for managing benign GOO in the setting of acute pancreatitis.

Palliative management for malignant biliary obstruction and gastric outlet obstruction from pancreatic cancer

Pancreatic cancer is among the leading causes of gastrointestinal cancer-related death, with a dismal prognosis. Over 80% of pancreatic cancer patients present with advanced disease, making curative resection unfeasible. These patients are often presented with malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO). In these cases, palliative management is aimed to alleviate symptoms, enhance quality of life, and facilitate subsequent chemotherapy. Currently, neoadjuvant chemotherapy is frequently used in both borderline resectable and resectable pancreatic cancer, necessitating effective biliary and gastrointestinal drainage in a growing number of patients. Traditionally, surgical bypass was the gold standard, performed via either a minimally invasive or open approach. However, notable progress has emerged in developing endoscopic techniques, such as endoscopic retrograde cholangiopancreatography (ERCP) stenting for MBO and endoscopic enteral stenting for GOO. While these procedures provide rapid symptom relief, they are associated with higher stent dysfunction rates and more frequent re-intervention needs. When ERCP fails, percutaneous transhepatic biliary drainage is a widely accepted alternative for MBO. Endoscopic ultrasound (EUS)-guided techniques, including EUS-guided biliary drainage and EUS-guided gastroenterostomy, have recently gained prominence. Emerging clinical data suggest that these methods may be superior, potentially becoming the preferred first-line palliative treatment for unresectable pancreatic cancer. This review will summarize the current evidence on managing MBO and GOO in patients with pancreatic cancer.