EUS-guided gastroenterostomy preferred for palliation of malignant gastric outlet obstruction

 Palliation of malignant gastric outlet obstruction (MGOO) with endoscopic ultrasonography–guided gastroenterostomy (EUS-GE) reduces reintervention, improves stent patency and results in better patient-reported eating habits compared with conventional duodenal stenting, an international study led by researchers at the Chinese University of Hong Kong (CUHK) has shown.

According to the researchers, EUS-GE should be used preferentially over duodenal stenting for palliation of MGOO when expertise and required devices are available. [Lancet Gastroenterol Hepatol 2023;doi:10.1016/S2468-1253(23)00242-X]

The international randomized controlled trial (RCT), conducted at seven sites in Hong Kong, Belgium, Brazil, India, Italy and Spain, included 97 adult patients with MGOO (female, n=51) due to unresectable primary gastroduodenal or pancreatobiliary malignancies who had a gastric outlet obstruction score (GOOS) of 0 (indicating inability to take in food or liquids orally) and an Eastern Cooperative Oncology Group performance status score of ≤3. The patients, recruited between 1 December 2020 and 28 February 2022, were randomized 1:1 to undergo either EUS-GE with a double balloon occluder (n=48; mean age, 69.5 years) or conventional duodenal stenting (n=49; mean age, 64.8 years).

The primary outcome of 6-month reintervention rate, defined as the percentage of patients requiring additional endoscopic intervention due to stent dysfunction (ie, restenosis of stent due to tumour ingrowth, tumour overgrowth or food residue; stent migration; or stent fracture), was significantly lower in the EUS-GE vs duodenal stenting group (4 percent vs 29 percent; risk ratio, 0.15; 95 percent confidence interval [CI], 0.04–0.61; p=0.002).

Stent patency was also significantly improved in the EUS-GE vs duodenal stenting group (median, not reached in either group; hazard ratio, 0.13; 95 percent CI, 0.08–0.22; log-rank p<0.0001).

Median postprocedural hospital stay was 4 days in the EUS-GE group vs 6 days in the duodenal stenting group. “The shorter hospital stays with EUS-GE were due to reduced reinterventions for early stent dysfunction, as well as patients’ earlier adaptation to a soft or solid diet,” explained first author, Professor Anthony Teoh of the Department of Surgery, CUHK.

At 1 month, mean GOOS was significantly better in the EUS-GE vs duodenal stenting group (2.41 vs 1.91; p=0.012).

No statistically significant differences were observed between EUS-GE and duodenal stenting in terms of 30-day mortality rate (21 percent vs 12 percent; p=0.286), technical success, clinical success, and quality-of-life scores at 1 month.

Adverse events were reported in 23 percent vs 24 percent (p=1.00) of patients in the EUS-GE vs duodenal stenting group within 30 days, with three cases of pneumonia (two cases vs one case in the EUS-GE vs duodenal stenting group) considered to be procedure-related.

“Our study is the world’s first RCT confirming superiority of EUS-GE in MGOO management,” said Teoh. “Based on our findings, patients with MGOO with a reasonable life expectancy are suggested to consider EUS-GE in an expertise setting.”

“EUS-GE was first introduced by CUHK to Hong Kong and internationally for MGOO treatment in 2016,” said Dr Shannon Chan of the Department of Surgery, CUHK. “At the Prince of Wales Hospital, more than 100 EUS-GE procedures have been performed, with favourable outcomes and a very low rate of complications.”

“In Hong Kong, there are about 500 cases of MGOO each year. EUS-GE is increasingly used in MGOO management,” said Dr Hon-Chi Yip of the Department of Surgery, CUHK.