Endoscopic ultrasound–guided gastroenterostomy (EUS-GE) using lumen-opposing metal stents has demonstrated high technical and clinical success rates for the treatment of malignant gastric outlet obstruction (GOO). It’s an alternative to surgical gastrojejunostomy (SGJ) as well as the use of uncovered self-expanding metal stents, both of which are associated with morbidity rates of about 40%.
Peritoneal carcinomatosis is common in patients with GOO and a major risk factor for adverse events after SGJ, according to a recent report in World Journal of Surgical Oncology. Ali Abbas, MD, MPH, a fellow in the Division of Gastroenterology, Hepatology and Endoscopy at Brigham and Women’s Hospital, Christopher C. Thompson, MD, MSc, director of endoscopy in the division, and colleagues have conducted the first study of EUS-GE for palliation of GOO that focused on patients who also had peritoneal carcinomatosis. In Endoscopy, they report similar technical success rates for EUS-GE and SGJ, despite more advanced cancer stage and worse performance status in the EUS-GE cohort.
Using a prospective registry maintained at the Brigham, the researchers retrospectively identified 25 patients who underwent EUS-GE and 27 who underwent SGJ for malignant GOO with peritoneal carcinomatosis.
100% of patients in the EUS-GE group had stage 4 disease prior to intervention, compared with 67% of the SGJ group. 44% vs. 30%, respectively, had Eastern Cooperative Oncology Group performance status of 3 or 4.
Primary Outcome: Technical Success
The technical success of EUS-GE was defined as the ability to deploy a stent in the correct position; for SGJ, it was defined as a successful performance of the gastrojejunal anastomosis. The technical success rate was 100% in both groups.
Secondary Outcome: Adverse Events
The adverse event rate was 8% in the EUS-GE group and 41% in the SGJ group (P=0.01). Infectious complications occurred in 0% and 30%, respectively.
One of the two adverse events in the EUS-GE group was serious. The patient, who had pancreatic cancer and a hereditary intestinal polyposis syndrome, developed intense abdominal pain about 12 hours postoperatively, while tolerating a clear liquid diet. CT showed dislodgement of the proximal flange of the stent from the gastric wall; the distal flange remained within the jejunal lumen with complete separation of the gastric and jejunal walls.
Following emergent endoscopy to close the gastric perforation, the patient was transferred to the operating room for stent retrieval and closure of the jejunal perforation. The GOO was later addressed by placing an uncovered duodenal stent.
This case illustrates why postoperative inpatient observation is important. A clear liquid diet for one to three days will facilitate further endoscopic or surgical intervention if needed.
Clinical success was defined as the ability to tolerate oral intake during the first 30 days postoperatively without recurrence of bowel obstruction that precluded oral intake. Clinical success rates were similar in the two cohorts (88% with EUS-GE and 85% with SGJ).
However, recurrent bowel obstruction was common (28% and 41%; P=0.13), presumably related to the pathology of peritoneal carcinomatosis.
The two cohorts were similar with regard to 30-day postoperative mortality and overall mortality.
Consider EUS-GE Earlier
Of the 27 patients in this study who underwent SGJ, 25 (93%) were diagnosed with peritoneal carcinomatosis at the time of their surgery. Surgeons should consider aborting surgery in favor of EUS-GE when they encounter peritoneal carcinomatosis intraoperatively.
18 of the 27 patients in the SGJ group had been diagnosed with stage 4 disease before their surgery, and the other nine (three with stage 2 disease and six with stage 3) were increased to stage 4 at the time of surgery. Because of the progressive behavior of malignant GOO and peritoneal carcinomatosis, and the minimally invasive nature of EUS-GE, earlier endoscopic intervention should be considered before the patient suffers nutritional compromise and reduced performance status.