CLINICAL REVIEW
Clinical Review of EUS-guided Gastroenterostomy (EUS-GE)
Ana Y. Carbajo, MD,* Michel Kahaleh, MD,†
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and Amy Tyberg, MD†
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Abstract: Gastric outlet obstruction (GOO) refers to mechanical
obstruction of the distal stomach or proximal duodenum and it is
associated with a significant decrease in quality of life. Surgical gas-
trojejunostomy and self-expandable metal stents were the traditional
treatment for GOO. Recently, endoscopic ultrasound guided gastro-
enterostomy (EUS-GE) has emerged as a third therapeutic option for
patients with GOO. Most EUS-GE techniques utilize the placement
of a lumen-apposing metal stent under echoendoscopy but differ in
the method of localizing the jejunal loop prior to EUS puncture. Data
supporting EUS-GE have been promising. Case series including 10 or
more cases showed the technical success rate to be approximately
90%. Clinical success is achieved in approximately 85–90% and a less
than 18% risk of adverse events is reported. EUS-GE was associated
with a lower recurrence of GOO and need for re-intervention when
compared to enteral stenting. In addition, EUS-GE shows sig-
nificantly fewer adverse events compared with surgical gastro-
jejunostomy. In conclusion, EUS-GE provides symptom relief with-
out the risks of surgical intervention and the limited patency of enteral
SEMS placement. EUS-GE is an exciting new option in the man-
agement of GOO. Despite the excellent results, randomized studies
comparing these different modalities of treatment for GOO are
needed before EUS-GE can be accepted as standard of care.
Key Words: therapeutic endoscopic ultrasound, EUS-guided gastro-
jejunostomy, gastric outlet obstruction, lumen-apposing metal stent
(J Clin Gastroenterol 2020;54:1–7)
G astric outlet obstruction (GOO) refers to mechanical
obstruction of the distal stomach or proximal duode-
num. Malignancy is the most common cause of GOO in the
era of adequate medical therapy for acid suppression,
accounting for 50% to 80% of cases. In patients with pan-
creatic cancer, it is estimated that 15% to 20% of patients
develop GOO.1–3 Immediate treatment of GOO is indicated,
as dehydration and malnutrition can quickly develop in these
patients.4 The aim of treatment is to relieve symptoms from
obstruction, allowing for resumption of oral diet and
improved quality of life. Surgical gastrojejunostomy (SGJ)
and self-expandable metal stents (SEMS) were the traditional
treatment for GOO. SGJ achieves high long-term efficacy, but
From the *University Hospital Rio Hortega, Valladolid, Spain; and
†Rutgers Robert Wood Johnson University Hospital, New Bruns-
wick, NJ.
A.T. has done consulting work for EndoGastric Solutions, NinePoint
Medical, and Obalon Therapeutics. M.K. has Grant support from
Boston Scientific, MaunaKea, Apollo Endosurgery, Cook Endos-
copy, ASPIRE Bariatrics, NinePoint Medical, Merit Medical,
Olympus, and Interscope Med. Consultant for Boston Scientific,
Concordia Laboratories Inc., Interscope Med. and ABBvie. A.Y.C.
declares that there is nothing to disclose.
Address correspondence to: Michel Kahaleh, MD, Rutgers, The State
University of New Jersey, Robert Wood Johnson University Hos-
pital, 1 RWJ Place, MEB 491B, New Brunswick, NJ 08901 (e-mail:
mkahaleh@gmail.com).
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/MCG.0000000000001262
J Clin Gastroenterol  Volume 54, Number 1, January 2020
Copyright r 2019 Wolters Kluwer Health, Inc. All rights reserved.
carries a complication risk of up to 40%. These include
delayed gastric emptying, prolonged hospital stay, and delay
in cancer treatment.5–7 SEMS placement for GOO have found
technical and clinical success rates in over 80% to 90% of
cases.8 However, long-term efficacy is limited with recurrent
obstruction occurring in up to 50% of patients after
6 months.9 When comparing these 2 techniques, SEMS has
been shown to be associated with lower complication rates,
decrease time to initiation of oral feeding, and shorter hospital
stay but with a suboptimal patency suggesting benefit of SGJ
in patients with longer life expectancies ( > 6 mo).10,11
Endoscopic ultrasound-guided gastroenterostomy
(EUS-GE) has emerged as a third therapeutic option for
patients with GOO. EUS-GE provides symptom relief
without the risks of surgical bypass and without the limited
long-term efficacy of enteral SEMS placement. Many
patients with GOO, especially those with malignant GOO,
are too debilitated to be considered surgical candidates.
However, EUS-GE can be offered to the majority of
patients with GOO. In this article, we will review the indi-
cations, techniques, safety and efficacy, and current con-
troversies of EUS-GE.
EUS-GE
With this technique, a bypass is created by inserting a
stent from the stomach to the small bowel distal to the
obstruction under endoscopic ultrasound guidance. EUS-
GE includes 2 options based on the target anastomotic site,
gastroduodenostomy (into the distal part of the duodenum),
and gastrojejunostomy.
Endoscopic gastroenterostomy was first described in
1991 in an animal model using a forward viewing flexible
endoscope and a compression button.12 Since then, several
other animal models using different types of stents, acces-
sories, and techniques including natural orifice transluminal
endoscopic surgery (NOTES) were then performed.10,13–16
The first concept of EUS-GE was introduced by Fritscher-
Ravens et al17 in 2002 in a porcine model.18 However, the
technique was not adopted because of the complexity of the
procedure, need for special devices, and endoscope
exchange.
In 2012, Binmoeller et al19 first introduced EUS-GE
with a lumen-apposing metal stent (LAMS), (AXIOS TM
stent; Boston Scientific, Marlborough, MA) in an animal
model. Theoretically, LAMS allows adhesion between 2
organs as is done with a surgical anastomosis minimizing
the risk for leakage and stent migration. With this stent,
creation of an endoscopic GE under EUS guidance became
feasible. This was quickly adopted in humans by endo-
scopists with expertise in interventional EUS.20–27
Currently, the 2 available endoscopic methods for
gastroenterostomies are EUS-GE and NOTES. Barthet
et al28 reported the first clinical experience of NOTES
approach to endoscopic gastroenterostomy by using LAMS.
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However, very limited data exist in humans and the appli-
cation of NOTES-GE is limited.
INDICATIONS AND CONTRAINDICATIONS
Symptomatic GOO is amenable for EUS-GE regard-
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TECHNIQUES
Several techniques can be used to create an EUS-GE.
All methods require a therapeutic linear echoendoscope and
use a biflanged LAMS but differ in the method of localizing
the jejunal loop before EUS puncture.

less of the etiology (benign or malignant). In addition, sev- Direct EUS-GE

eral cases of EUS-guided gastrojejunostomy for the treat-
ment of afferent loop syndrome have been reported.29–34
Afferent loop syndrome is an obstruction of the afferent
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A duodenal or jejunal loop adjacent to the stomach is
identified by EUS.20,21,37 This may be difficult when the
loops are poorly distended or contain air. Careful EUS

intestinal limb that can occur after gastrointestinal surgery

and causes intestinal dilation with subsequent biliary
obstruction. Traditionally, limited treatment options have
been available for this condition, sometimes requiring sur-
gical intervention. Retrograde endoscopic decompression of
the afferent loop is not always possible because of a long
enteric segment, completely obstructing mass, tight angu-
lation, or long stricture. Therefore, EUS-GE may also be
useful for the treatment of this syndrome.
An additional benefit of EUS-GE is to provide access to the
ampulla for patients with concurrent biliary obstruction. This can
be done by deploying the LAMS with the proximal end in the
small bowel loop near to the ampulla and then advancing
the duodenoscope through the LAMS in a retrograde manner to
the ampulla in order to perform conventional endoscopic retro-
grade cholangiopancreatography.35,36
Some consideration must be taken into account before
the procedure. Localization of an appropriate target small-
bowel loop close enough to the gastric wall is essential. Any
distance longer than 2 cm may result in incomplete apposi-
tion of the lumens by the metal stent. If there is diffuse
malignant gastric infiltration, a gastroenterostomy may not
be safe or technically feasible (similarly, in case of cancer
extending into the fourth portion of duodenum and prox-
imal jejunum around the ligament of Treitz). Ascites is not a
contraindication to performing the procedure, but should be
drained before the procedure to minimize intestinal mobi-
lization. Indications and contraindications to perform EUS-
GE are shown in Table 1.
PERIPROCEDURAL CARE AND PREREQUISITES
A clear liquid diet or low-residue diet should be
established days before the procedure to minimize gastric
residue. In case of large amounts of food residue, endo-
scopic removal should be accomplished before starting the
procedure. All patients receive intravenous antibiotics
immediately before the procedure. The procedure requires
fluoroscopy and general anesthesia with endotracheal intu-
bation. Carbon dioxide insufflation should be used
throughout the procedure. Most patients remain in the
hospital and receive a course of antibiotics (gram negative
and anaerobe coverage). Liquid diet is often started the
following day, and diet is advanced slowly as tolerated.
examination can usually yield an appropriate loop for direct
puncture by a 19-G needle (Fig. 1). If jejunal loops cannot
be adequately imaged, a 22-G needle puncture can be per-
formed first with injection of saline to distend the bowel
loops before puncture with a 19-G needle.21 Similarly, a
gastroscope or nasojejunal tube can be first inserted and
fluid infused into the small bowel distal to the obstruction.
Generally, a total of 500 mL of fluid (more can lead to the
development of hyponatremia) is infused. As such, isotonic
saline may be the preferred solution. After transgastric
puncture of the small bowel, an enterogram is obtained by
injection of contrast under fluoroscopic guidance to ensure
correct positioning of the needle tip within the lumen of the
small bowel (Fig. 2). Either a 1-step or 2-step procedure can
be then performed to create the gastrojejunostomy (GJ).
Like other EUS-guided procedures, in the 2-step method, a
guidewire is advanced into the jejunal lumen. The 19-G
needle is then exchanged under endosonographic guidance
leaving the wire in place. The gastrojejunal tract is dilated to
allow for passage of the 10.8 Fr LAMS delivery catheter,
which is subsequently passed over the wire transgastrically
into the jejunum. More aggressive dilation is discouraged
because this may result in peritoneal leakage. The intro-
duction of a commercially available cautery-enabled LAMS
delivery catheter (Hot-Axios; Boston Scientific) has allowed
single-step insertion, without the need for prior dilation,
either over a wire or freehand.21,22 The LAMS is deployed
with the distal end in the small bowel lumen and the prox-
imal end in the stomach (Fig. 3). The lumen of the LAMS is
then dilated using a through-the-scope balloon dilator
(Fig. 4).
Assisted Technique
An endoscope is advanced into the stomach and across
the obstruction into the distal small bowel if feasible. A wire
is then advanced and coiled in the jejunum beyond the
obstruction. If the stenosis cannot be traversed with the
endoscope, the wire is advanced from the stomach through
the stenosis under fluoroscopic guidance alone.20,37–39 A
dilating balloon, biliary extraction balloon, or nasobiliary
drain catheter is advanced over the wire into the jejunum
under fluoroscopic guidance.21 Then, a linear echoendo-
scope is advanced into the stomach alongside the balloon or

TABLE 1. Indications and Contraindications of Endoscopic Ultrasound (EUS)-guided Gastroenterostomy

Indications Contraindications
Symptomatic GOO Diffuse cancer invasion into the site of puncture (stomach or small bowel)
Afferent loop syndrome Inability to identify an appropriate small bowel loop close to the gastric wall under EUS
Allow access for performing an ERCP in the Luminal obstruction distal to the jejunum puncture site (in the setting of peritoneal
setting of GOO carcinomatosis or extensive lymphadenopathy)
Large volume ascitis
ERCP indicates endoscopic retrograde cholangiopancreatography; GOO, gastric outlet obstruction.

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 J Clin Gastroenterol  Volume 54, Number 1, January 2020
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FIGURE 1. Echosonographic view of direct puncture
jejunum.
catheter. Contrast is injected into the balloon or directly into
the jejunal lumen through the nasobiliary drain to help
identify the jejunal loop echosonographically and fluo-
roscopically (Fig. 5). The loop is accessed with a 19-G
needle. The fistulous tract is then created, and the LAMS
deployed as previously described. Alternatively, a snare can
be advanced into the jejunum and once puncture occurs, the
guidewire is advanced through the snare, which is then
closed onto the wire and pulled through the patient’s mouth
giving the endoscopist access to both ends of the wire to
facilitate stent deployment.40
Variations on the use of an assisted device to fill and
subsequently localize a jejunal loop have also been described
with an ultraslim endoscope (hybrid rendezvous) passed
through the stricture.41,42 This scope can be advanced
orally, or through a previously placed percutaneous gas-
trostomy tract when present.41 Water is injected through the
ultraslim scope to distend the bowel lumen. A linear
echoendoscope is then advanced into the stomach (alongside
the ultraslim scope). After the puncture, a guidewire is
advanced through the needle and coiled within the bowel
FIGURE 2. Fluoroscopic enterogram after direct puncture
injection.
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Clinical Review of EUS-guided Gastroenterostomy
of
FIGURE 3. Fluoroscopic image of deployed lumen-apposing
metal stent.
lumen. Forceps through the ultraslim scope is used to grasp
the guidewire for traction and the LAMS is then deployed.
EUS-guided Balloon-occluded Gastrojejunostomy
Bypass (EPASS)
This technique was described by Itoi et al.22,43,44 A
specialized double balloon enteric tube (Tokyo Medical
University Type; Create Medic, Yokohoma, Japan) is
advanced through the obstruction over a guidewire. If
needed, an overtube may be used to facilitate passage of the
balloon catheter to avoid looping in the fornix of the
stomach as it passes through the stenosis. The 2 balloons are
then inflated with saline or contrast to seal the small bowel
at 2 ends. Saline is used also to fill the lumen between the
balloons leading to easier and safer transgastric EUS
puncture and stent insertion with the LAMS (using the 1
step or 2 step method described previously).
NOTES-GE
A 19-G needle is used to puncture the gastric wall
under EUS guidance. A guidewire is then passed into the
peritoneal cavity close to the ligament of Treitz. The
echoendoscope is then removed, leaving the guidewire in
place. The double-channel endoscope is advanced over the
FIGURE 4. Endoscopic image of deployed lumen-apposing
metal stent.
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 Clinical Review of EUS-guided Gastroenterostomy
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FIGURE 5. Echosonographic view of inflated balloon catheter in
the target small bowel loop.
wire into the stomach. An incision on the gastric wall is
performed with a needle-knife and then it is dilated. The
gastroscope is passed into the peritoneal cavity, the jejunum
is identified, and the jejunum is incised with the needle-knife
under endoscopic visualization. Afterwards, a guidewire is
introduced into the lumen. A LAMS is advanced over the
wire through the jejunal incision and the distal flange is
deployed inside the jejunum. The gastroscope is then pulled
back into the stomach, with both the opened LAMS flange
and a rat-tooth forceps through the second working channel
used as retractors. The proximal LAMS flange is then
deployed inside the stomach, and a balloon can be used to
dilate the LAMS to its diameter.28
Technical Considerations
EUS-GE technique has not been standardized yet, as
there are several advantages and disadvantages in each
technique. The major concern using the direct technique is
the difficulty in accessing the small bowel via needle punc-
ture, because the lumen is often collapsed. In addition, the
injection of a large amount of fluid distends both the tar-
geted small intestine and the colon, which can lead to a miss-
puncture. However, the use of methylene blue infusion into
the small intestinal lumen followed by needle puncture and
aspiration of blue tinge fluid before stent insertion minimizes
the risk for inadvertent colonic stent insertion. Unlike the
direct technique, the assisted and the EPASS techniques
facilitate small bowel puncture. However, advancement of
the balloon catheter or the double balloon enteric tube may
be challenging in cases of tight strictures.
OUTCOME OF EUS-GE
Data supporting EUS-GE have been promising. Case
series including ≥ 10 cases showed the technical success rate
to be ~90% regardless of the technique used. Table 2 sum-
marizes the available literature on the success of EUS-GE.
The first large clinical experience was reported in
201520 in which 10 patients with GOO (3 malignant and 7
benign) underwent EUS-GE using a LAMS. EUS-GE was
performed by using direct or balloon-assisted technique. The
authors reported technical and clinical success rate of 90%.
All patients underwent placement of a 15 mm×10 mm
LAMS. There were no procedure-related adverse events
and there was no symptom recurrence during the follow-up
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J Clin Gastroenterol  Volume 54, Number 1, January 2020
period. In 2016, Itoi et al22 described the first clinical study
of EUS-GE using the EPASS technique in 20 patients with
malignant GOO. The technical success rate was 90% due to
2 unsuccessful stent deployment cases. After technique
adjustment, technical success rate increased from 81.8% to
100% when the authors abandoned the use of an over-the-
wire method. In those 2 patients the stent was removed, and
the patients were treated by conservative therapy. No stent
occlusion or migration was observed. The third experience is
a multicenter study in 26 patients (benign obstruction in 9
cases), in which multiple EUS-GE techniques were used.21
They incorporated novel methods to help locate the target
bowel (nasobiliary drain catheter and hybrid rendezvous),41
and salvage strategies for LAMS misplacement. Technical
success was achieved in 24 patients (92%) and clinical suc-
cess in 22 (85%). In this series, misplacement occurred in 7
of 26 cases (27%) and was the only reason for technical
failure overall. Five misplacements were able to salvaged
with a telescoping fully covered SEMS.45–47 Adverse events
such as bleeding, peritonitis, and surgery occurred in 3
patients (11.5%). After successful LAMS placement, no
migration or dysfunction was noted. Most recently, a ret-
rospective study evaluated EUS-GE in 26 patients with
benign GOO.26 Several patients in this study were reported
in other separate publications. Outcomes are comparable to
other studies with malignant GOO; technical and clinical
success rates were 96.2% and 84.0% respectively, with 3
adverse events noted (2 mild AE).
EUS-GE compared with enteral stenting was evaluated
in a retrospective series of 82 patients:23 30 who underwent
EUS-GE and 52 who underwent enteral stenting. There was
no observed difference in technical success, clinical success,
or adverse events between the 2 groups. In addition, EUS-
GE was associated with a lower recurrence of GOO and
need for reintervention when compared with ES. In other
words, EUS-GE is at least as effective and safe as ES with
the benefit of improved long-term patency.
EUS-GE was compared with SGJ in a retrospective
study of 93 patients with malignant GOO: 30 in the EUS-
GE and 63 in the SGJ arm.24 In the EUS-GE cohort, 23
patients were previously reported in a separate study. The
rate of clinical success was similar between both groups
(92% vs. 87%, P = 0.42) and there was no significant dif-
ference in the rate of AEs (16% vs. 25%, P = 0.3). Impor-
tantly, the rate of GOO recurrence was equally low in both
groups (3% vs. 14%, P = 0.08), which suggests that EUS-GE
provides long-lasting symptom palliation of GOO similar to
that of surgical bypass. However, this was a retrospective
study in which patients in the SGJ group were recruited
from 1 center, whereas patients in the EUS-GE group were
recruited from multiple centers. This may have introduced
heterogeneity to the study population. In addition, patients
in the surgical group underwent open surgery which may
not be the standard of care at some centers.
A similar study comparing EUS-GE with SGJ retro-
spectively evaluated 25 patients who underwent EUS-GE and
29 patients who underwent laparoscopic gastrojejunostomy
(Lap-GJ).25 The indication for GE included malignant and
benign GOO. No significant differences in terms of technical
and clinical success rates were observed between the 2 groups.
This is especially notable because the EUS-GE group con-
tained more patients with symptomatic GOO with failed prior
attempts at palliation, and all patients in the EUS-GE group
were deemed unsuitable for surgical intervention indicative of
a sicker group of patients preprocedurally. These discrepancies
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J Clin Gastroenterol
TABLE 2. Outcomes of EUS-guided Gastroenterostomy (Studies With ≥ 10 Patients)


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LAMS Technical Clinical

Volume 54, Number 1, January 2020

Study Patients Type of Diameter Type of Success Success* Misplacement Recurrent Follow-
References Design (n) Indication Technique LAMS (mm) EUS-EE (%) (%) (%) Adverse Events (%) GOO up (wk)
Khashab RS 10 Malignant: 3 D: 1 N-C: 10 15×10: 10 GJ: 6 9/10 (90) 9/10 (90) None None None 21
et al20 MC Benign: 7 A: 9 GD: 3
Itoi et al22 PS 20 Malignant: 20 EPASS: 20 N-C: 11 15×10: 20 GJ: 20 18/20 (90) 18/20 (90) 2 (10) 1 Pneumoperitoneum None 14
C: 9 NS: 2
Tyberg et al21 RS 26 Malignant: 17 D: 3 N-C: 17 15×10: 25 — 24/26 (92) 22/26 (85) 7 (27) 3 (11.5) None 8
MC Benign: 9 A: 21 (B: 13/ C: 9 10×10: 1 SS: 5 Pain: 1
NBD: 3/ NS: 2 Bleeding: 1
UUS: 5) Peritonitis: 1
NOTES: 2
Chen et al23, RS 30 Malignant: 30 D: 2 N-C: 7 15×10: 30 GJ: 26 26/30 (87) 25/30 (83) 3 (10) 5 (17) 1 15
Khashab MC A: 6 C: 21 GD: 4 NS: 3 —
et al24 Comp EPASS: 22 Spaxus:
2
Perez-Miranda RS 25† Malignant: 17 D: 6 N-C: 12 — — 22/25 (88) 21/25 (84) 9 (36) 3 (12) None 8
et al25 MC Benign: 8 A: 19 (B: 9/ C: 13 SS: 6 Peritonitis: 1
Comp NBD: 3/ NS: 3 Bleeding: 2
USS: 7)
Chen et al23 RS 77† Malignant: 52 D: 55 N-C: 16 15×10: 72 GJ: 63 72/77 (94) 71/77 (92) 5 (7) 5 (7) 4 17
MC Benign: 25 A: 22 C: 56 GD: 14 SS: 3 —
Comp NS: 2
Chen et al26 RS 26† Benign: 26 D: 15 N-C: 2 15×10: 26 GJ: 21 25/26 (96) 21/26 (81) 2 (8) 3 (11.5) 1 25
MC A: 7 C: 24 GD: 5 SS: 2 MD: 2 (mild)
EPASS: 4 Gastric leak: 1

Clinical Review of EUS-guided Gastroenterostomy

*Intention-to-treat analysis.
†Several patients in this study may have also been included in other publications.
Definitions of technical and clinical success.
Tyberg et al21 and Perez-Miranda et al:25
Technical success: successful placement of a gastrojejunal LAMS.
Clinical success: patient’s ability to tolerate oral intake.
Other studies: Technical success: adequate positioning and deployment of the stent.
Clinical success: patient’s ability to tolerate oral intake without vomiting.
A indicates assisted methods EUS-gastrojejunostomy (B, balloon; NBD, nasobiliary drain; USS, ultraslim scope); C, cautery LAMS; EUS-EE, endoscopic ultrasound enteroenterostomy; Comp, comparative; D, direct
EUS gastrojejunostomy; EPASS, EUS-guided double balloon-occluded gastrojejunostomy bypass; GD, gastroduodenostomy; GJ, gastrojejunostomy; MC, multicenter; MD: misdeployment; N-C, noncautery LAMS;
NOTES, natural orifice transluminal endoscopic surgery; NS, not salvaged; PS, prospective study; RS, retrospective study; SS, successfully salvaged.
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 Clinical Review of EUS-guided Gastroenterostomy
may have masked a potential efficacy advantage associated
with the EUS-GJ procedure. Significantly fewer AEs were seen
in the EUS-GJ group than the Lap-GJ group as well as
lower cost.
Chen et al27 presented the largest retrospective cohort
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of EUS-GE in the literature as well as the first data com-
paring 2 different techniques of EUS-GE (direct and assisted
methods). A total of 77 patients underwent EUS-GE for
GOO (n = 55 direct and n = 22 balloon assisted). Approx-
imately 90% of the patients achieved technical and clinical
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success irrespective of the technique used. These clinical
outcomes are consistent with previous published data. The
main advantage of direct GE was decreased procedure
times, on average 54.8 minutes shorter than the assisted
technique. In addition, the assisted method did not seem to
enhance the safety of the procedure.
Patients with periampullary malignancies may present
concomitantly with GOO and biliary obstruction. Brewer et al48
presented the first case series of double endoscopic bypass.
Seven patients with malignant GOO and biliary obstruction
underwent EUS-GE and EUS-BD during the same session or
on separate occasions with good results.
CURRENT CONTROVERSIES AND CONCLUSIONS
Multiple studies have demonstrated that EUS-GE is an
effective, minimally invasive option for patients with both
malignant and benign GOO. It achieves high clinical suc-
cess, comparable with that of current standard therapies
without the morbidity associated with a surgical procedure.
In addition, EUS-GE offers longer luminal patency than
enteral stents. However, despite the excellent results,
randomized studies comparing these different modalities of
treatment for GOO are needed before EUS-GE can be
accepted as standard of care (Table 3). Similarly, data
comparing the different techniques of EUS-GE are limited
and show no differences in technical or clinical success rates
and in the incidence of adverse events making stand-
ardization of technique difficult.49 And lastly, published
data have evaluated 15 mm LAMS, which is a smaller dia-
meter than the typical SGJ (25 to 30 mm).50 A 20-mm-dia-
meter LAMS is now available that may further improve
efficacy.
EUS-GE is an exciting new option in the management of
GOO. However, EUS-GE remains a technically challenging
procedure that at present should be performed only at high
volume expert centers.
TABLE 3. A Comparative Assessment of Current Techniques for
Gastric Outlet Obstruction
Outcome SEMS SGJ EUS-GE
High efficacy X X
Bypass tumor — X
Invasive treatment — X
Short time to oral feeding X —
Short hospital stay X —
Contraindicated in critically ill patients — X
High complication rates — X
Difficult endoscopic procedure — —
Limited long-term efficacy X —
EUS-GE indicates endoscopic ultrasound-guided gastroenterostomy;
SEMS, self-expandable metal stents; SGJ, surgical gastrojejunostomy; X, yes.
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J Clin Gastroenterol  Volume 54, Number 1, January 2020
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