Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study

Background and study aims: Surgical gastroenterostomy is associated with appreciable morbidity and mortality. We evaluated the technical feasibility and outcomes of a new method of endoscopic ultrasound (EUS)-guided gastroenterostomy using novel tools designed for transluminal therapy.

Methods: In one acute and four survival female pigs, a gastroenterostomy was created under EUS guidance. Novel tools used included: (i) an anchor wire; (ii) an access device; (iii) a fully covered metal stent with bilateral lumen-apposing anchors. The anchor guide wire was inserted through a standard 19-G fine needle aspiration (FNA) needle to appose the small-bowel and stomach walls. The access device created a 3.5-mm fistula opening for insertion of the stent delivery catheter. The stent lumen was dilated to 10 mm to pass a gastroscope into the small bowel.

Results: The procedure was technically successful in all animals. No bleeding occurred. In one acute animal, necropsy showed good stent position and no tissue injury. In four survival animals, the stents remained fully patent and all animals showed normal eating behavior without signs of infection. Stents were easily removed without tissue trauma at 4.5 weeks (n = 3) or 5.5 weeks (n = 1). After stent removal, the tracts appeared mature and were easily intubated with the gastroscope. Necropsy and histopathology showed complete fusion of the stomach and small-bowel wall layers at the site of gastroenterostomy.

Conclusions: EUS-guided gastroenterostomy is feasible using novel tools with no adverse outcomes in a survival porcine model. Further study of this is indicated as an alternative to surgical bypass for the palliation of malignant gastric outlet obstruction in appropriately selected patients.

• References

• 1 Dormann A, Meisner S, Verin N et al. Self-expanding metal stents for gastroduodenal malignancies: systematic review of their clinical effectiveness. Endoscopy 2004; 36: 543-550
• 2 van Hooft JE, Uitdehaag MJ, Bruno MJ et al. Efficacy and safety of the new WallFlex enteral stent in palliative treatment of malignant gastric outlet obstruction (DUOFLEX study): a prospective multicenter study. Gastrointest Endosc 2009; 69: 1059-1066
• 3 Jeurnink SM, Steyerberg EW, van Hooft JE et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 2010; 71: 490-499
• 4 Binmoeller KF. A novel, anchor guidewire to facilitate EUS-guided translumenal interventions. Gastrointest Endosc 2011; 73: 4
• 5 Binmoeller KF, De La Mora-Levy JG. An exchange-free device for advanced translumenal therapy. Gastrointest Endosc 2010; 71: AB349
• 6 Varadarajulu S, Binmoeller KF, Lunsford J et al. Development of a prototype trocar for translumenal therapeutic interventions using EUS. Gastrointest Endosc 2009; 69: AB324
• 7 Binmoeller KF, Shah J. A novel lumen-apposing stent for transluminal drainage of nonadherent extraintestinal fluid collections. Endoscopy 2011; 43: 337-342
• 8 Cope C, Clark TW, Ginsberg G et al. Stent placement of gastroenteric anastomoses formed by magnetic compression. J Vasc Interv Radiol 1999; 10: 1379-1386
• 9 Chopita N, Vaillaverde A, Cope C et al. Endoscopic gastroenteric anastomosis using magnets. Endoscopy 2005; 37: 313-317
• 10 Cope C, Faigel DO, Ginsberg GG et al. Creation of a gastroenteric anastomosis with endoscopy and percutaneous gastrostomy in pigs. J Vasc Interv Radiol 2008; 19: 124-128
• 11 Fritscher-Ravens A, Mosse CA, Mills TN et al. A through-the-scope device for suturing and tissue approximation under EUS control. Gastrointest Endosc 2002; 56: 737-742