ASGE Postgraduate Course at ACG 2022: Expanding the Scope of Fundamental and Advanced Endoscopy | October 2022-13_Khashab_Malignant Gastric Outlet Obstruction Gastro Jejunostomy

13_Khashab_Malignant Gastric Outlet Obstruction Gastro Jejunostomy

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In this article, Dr. Mouen Khashab discusses the preferred endoscopic therapy for malignant gastric outlet obstruction (GOO) in 2022. The current therapies for GOO have several shortcomings, including invasiveness, significant morbidity, increased cost, and delayed cancer treatment. Surgical gastro-jejunostomy (GJ) can lead to recurrent GOO due to stent obstruction, while endoscopic stenting has the risk of tumor ingrowth/overgrowth.<br /><br />The potential benefits of endoscopic ultrasound-guided gastro-jejunostomy (EUS-GJ) are highlighted. It combines the advantages of endoscopic stenting and surgical GJ, offering long-lasting luminal patency without the risk of tumor ingrowth/overgrowth. Furthermore, it avoids the morbidity associated with surgical procedures in terminally-ill patients.<br /><br />The article discusses various techniques of EUS-GJ, including balloon-assisted EUS-GJ, direct EUS-GJ, and balloon-occluded gastrojejunostomy bypass. Procedural outcomes are presented, showing high technical success rates and favorable clinical outcomes for EUS-GJ compared to endoscopic stenting.<br /><br />Recurrent GOO is less common with EUS-GJ compared to endoscopic stenting, and the rates of adverse events are low. The article also mentions the use of natural orifice transluminal endoscopic surgery (NOTES) to rescue displaced lumen-apposing metal stents (LAMS).<br /><br />In conclusion, EUS-GJ is deemed safe and effective for palliation of malignant GOO. Endoscopists should have expertise in interventional EUS, and technical challenges can be overcome with experience and various endoscopic techniques. EUS-GJ is likely superior to duodenal stenting in terms of stent patency and may be equivalent to surgical GJ in terms of efficacy but with obvious advantages. Prospective trials are ongoing to further evaluate the benefits of EUS-GJ compared to other therapies.

Keywords

endoscopic therapy

malignant gastric outlet obstruction

EUS-GJ

luminal patency

recurrent GOO

endoscopic stenting

procedural outcomes

adverse events

NOTES

palliation