Large experience of EUS-guided gastroentero-anastomosis (EUS-GEA) validating the drain-assisted technique: we are ready for benign indications

Aims EUS guided GEA is a serious alternative to duodenal stenting and surgical GEA in malignant gastric outlet obstruction (GOO). Indeed, efficacy and reintervention rates are significantly better than stenting, whereas non inferiority was demonstrated compared to surgery, with faster recovering. That is why recent ESGE guidelines recommended EUS-GEA as an alternative for malignant obstruction. However, because of adverse events such as misdeployment with the direct technique, the EUS-GEA was contra-indicated to benign indications. We propose our experience with the evolution toward drain assisted technique (DA-EUSGEA) and the increasing of benign indications.

Methods This was a retrospective monocenter study of consecutive cases conducted in two expert centers between October 2016 and August 2023. Patients included had either malignant or benign GOO, Gastroparesis, or other pathology indicated for EUS-GEA. Procedures were discussed and validated in multidisciplinary meeting and were performed with therapeutic linear scopes, and techniques applied were the direct approach until August 2021, then the DA-EUSGEA technique since then. The main objective was to evaluate the technical success at first attempt, defined by the ability to place the lumen apposing stent (Axios, Boston scientific, USA) without dislodgment. The secondary objective was the final technical success (after rescue), the adverse events rate and the clinical efficacy depending on the etiologies.

Results In total, 87 patients were included, 41 women and 46 men, with mean age of 64.61±18.67 years old. The indications were malignant in 60.1% (n=53) dominated by pancreatic adenocarcinoma (n=39) and duodenal (n=14), and benign in 39.1% (n=34) dominated by gastroparesis (n=16) and chronic pancreatitis (n=9). Direct EUS-GEA were applied in 33 patients (37.9%) whereas DA-EUSGEA were attempted in 54 patients (62.1%).

Technical success rate at 1^st attempt was 88.5% (n=77). Among the other 10 patients, we experienced 8 misdeplyoment: 6 were addressed with rescue technique, 1 was closed with over-the-scope clip, 1 operated). The 2 others were bleeding and failure to place the drain.

The final success rate was 96.6% and the clinical success rate was 94.25% (n=82). Postoperative adverse event (AE) rate was 14.9% (sepsis (6), bleeding/anemia (4)), grade I or II in AGREE classification. One patient in poor condition died following the procedure.

Comparing malignant with benign indications, technical, clinical success, misdeployment rates and AE rates were similar. Comparing the two approaches, misdeployment rate was significantly decreased using the WEST approach compared to the direct one: 3.7% versus 18% (p<0.05).

Conclusions This study, including more than one third of benign indications, demonstrated the increasing safety of the DA-EUS-GEA, reducing the risk of misdployment to less than 4%. This represents an additional step towards proposing EUS-GEA in benign indications.

Publication History

Article published online:
15 April 2024