Eus-Guided Gastroenterostomy (EUS-GE) For Gastric Outlet Obstruction (GOO) With A Lumen-Apposing Metal Stent (LAMS): Prospective Multicenter Procedural Standardization Of The Parallel Enteral Catheter (PEC) Method

Aims Several EUS-GE techniques are available. Fluid instillation into the small bowel using a nasobiliary drain as a PEC during transgastric LAMS insertion under EUS is simple but not yet standardized. We aimed at standardizing the PEC method for EUS-GE.

Methods Prospective IRB-approved multicenter study including consecutive consenting patients with unresectable malignant GOO undergoing primary EUS-GE between August 2019-November 2020. The PEC method involves 4 steps predefined as essential: 1) Over-the-wire, through-the-scope 7-8.5F nasobiliary drain placement distal to the stricture; 2) Over-the-catheter endoscope exchange with parallel echoendoscope gastric intubation; 3) Small bowel distention via PEC fluid instillation and targeting under EUS with fluoroscopy; 4) free-hand cautery-enhanced LAMS placement. Variables related to essential steps included procedure time, injected fluid volume and targeted small bowel diameter. Variations in non-essential steps were recorded and the dominant strategy defined. Adverse events (AE) were graded per ASGE. Clinical success defined as GOO Scoring System ≥ 2 at 30 days.

Results Six endoscopists performed EUS-GE in 38 patients: 53 % male; median (IQR) age 77.3 (65.3-84.4) years. Overall technical success was achieved in 37 (97.4 %) with a median (IQR) procedure duration of 24 (17.5-37.1)-minutes. The failed case resulted from small bowel misidentification and subsequent gastro-colostomy requiring endoscopic LAMS removal and clip-closure one week later (moderately severe AE). Stepwise technical success was obtained in all 4 essential steps of the PEC method by all operators in all patients, except step 3 in the failed case (99.3 % stepwise technical success). Median (IQR) instilled fluid volume was 415 (240-530)-ml and median (IQR) targeted small bowel diameter was 27 (22-30)-mm. Variations in nonessential steps across operators are summarized in Table-1.

Tab. 1

	Dominant Strategy	Variation 1	Variation 2
Instilled Fluid Single = water or SS Dual = SS + MB Triple = SS + MB + contrast	Triple (78.9 %)	Single (7.9 %)	Dual (13.2 %)
Instillation Method	Pump (57.9 %)	Syringe (31.6 %)	Water tap adaptor (10.5 %)
LAMS diameter	20-mm (68.4 %)	15-mm (31.6 %)	N/A.
LAMS balloon dilation	No (71.1 %)	Yes (28.9 %)	N/A.

Conclusions When prospectively assessed, the PEC method for EUS-GE was consistently reproducible across operators with varying levels of experience and associated with high technical success rates and relatively short procedure times.

Citation: Chavarría C, Martín-Álvarez V, Aparicio JR et al. OP108 EUS-GUIDED GASTROENTEROSTOMY (EUS-GE) FOR GASTRIC OUTLET OBSTRUCTION (GOO) WITH A LUMEN-APPOSING METAL STENT (LAMS): PROSPECTIVE MULTICENTER PROCEDURAL STANDARDIZATION OF THE PARALLEL ENTERAL CATHETER (PEC) METHOD. Endoscopy 2021; 53: S45.

Publication History

Article published online:
19 March 2021