ECHOENDOSCOPIC GASTRO-ENTEROANASTOMOSIS
ECHOENDOSCOPIC GASTRO-ENTEROANASTOMOSIS
Authors: Voicu Rednic, Denisa Șagău, Theodor Bot, Cristina Pojoga, Andrada Seicean
Case presentation
A 75-year-old patient with ischemic stroke with right spastic hemiparesis and mixed aphasia, supraventricular extrasystolic arrhythmia, wide aortic stenosis was hospitalized complaining of pain in the right hypochondrium, nausea and vomiting with food ingested for more than 24 hours, which started several weeks ago, aggravated in the last days. The patient had an altered general condition, ECOG performance index – 3, was disorientated temporospatially, hemodynamically and respiratoryly stable. A large amount of stasis fluid was externalized on the nasogastric tube.
Abdominal ultrasound revealed a distended stomach with food content and a cephalic pancreatic tumor. CT confirmed the pancreatic formation with invasion of the celiac trunk and superior mesenteric artery and secondary liver findings. The diagnosis was completed by echoendoscopy with fine aspiration puncture, histologically identifying a pancreatic adenosquamous carcinoma. Gastroscopically, the passage from the bulb to the second portion of the duodenum could not be achieved due to tumor invasion at this level.
Due to the metastatic tumor and the patient’s status and comorbidities, the oncology committee decided on palliative treatment. Alleviation of gastric evacuator insufficiency was performed by mounting an endoscopic gastro-enteroanastomosis, with the help of a metal apposition prosthesis (LAMS), under general anesthesia and orotracheal intubation.
With the patient in supine position, a guide wire was passed through the pediatric gastroscope up to the level of the jejunum, on which a naso-cystic drain was advanced under radiological control. Physiological serum with methylene blue was instilled through the drain. Under ultrasound and radiological control, an intestinal loop adjacent to the gastric wall was detected. After Doppler control of the presence of blood vessels at the gastric and intestinal parietal level, the metal LAMS prosthesis was advanced, followed by highlighting the physiological serum with methylene blue at the intragastric level. The duration of the procedure was 55 minutes. The patient resumed oral liquid nutrition at 24h and solid food at 72h. No pain or fever occurred, and bowel movements were normal.
Discussions
Palliative gastroenteroanastomosis is indicated in cases of gastro-duodenal obstruction due to malignancy (gastric antro-pyloric cancer, pancreatic cancer, duodenal or ampulla of Vater cancer) in which curative treatment is no longer possible. Laparoscopic surgical gastroentero-anastomosis, endoscopic enteral prosthesis under radiological control and echoendoscopic gastroentero-anastomosis can be performed.
The endoscopic enteral prosthesis method has long been preferred for patients with a life expectancy of less than two months, being associated with a clinical success rate of 85%, even 76% when the duodenal obstruction is at the level of the papilla (Staub et al . Gastrointest Endosc 2018). The main problem of this method is the risk of dysfunction of the enteral prosthesis of up to 12% (Troncone et al.WJG 2020). The advantage is that it can also be performed in patients with a large amount of ascites and significant peritoneal carcinomatosis. Palliative laparoscopic surgical gastroenteroanastomosis can be performed in patients who have an estimated life expectancy of more than two months, but it should be noted that it is not indicated in patients with large amounts of ascites or peritoneal carcinomatosis and that the majority of patients with this pathology, they have comorbidities that increase the anesthetic risk.
Echoendoscopic gastroenteroanastomosis is a new method, indicated for palliative purposes in patients with the mentioned malignant pathology, preferably without ascites or with minimal ascites, especially if the estimated survival is 3-4 months and the patient presents a high surgical risk. It is contraindicated in patients who have significant peritoneal carcinomatosis or tumor infiltration of the gastric wall. The procedure is performed with a clinical success rate of 88-90% and a rate of adverse reactions of 7-12% represented by defective placement of the stent, hemorrhages, occlusion of the stent by tumor invasion (Van der Merwe et al. Endoscopy 2022, Abbass A et al, Gastrointest Endosc 2022).
Compared to the surgical procedure, the results are similar in terms of clinical success, but the echoendoscopic procedure has a shorter duration, a shorter hospital stay and a faster resumption of nutrition (Kouanda et al. Surg Endosc 2021).
A meta-analysis comparing the results of enteral prosthesis and endoscopic endoscopic gastroenteroanastomosis found that the endoscopic endoscopic procedure was superior in terms of clinical success (95% vs 85%), reoperation rate (4% vs 23%), while the rate of complications was similar (Kumar et al. Endosc Int Open 2021).
Further studies will establish the exact place and role of gastroenteroanastomosis in the palliative management of gastric emptying insufficiency of malignant origin.
Reference
Abbas A, Dolan RD, Thompson CC. Optimizing outcomes for EUS-guided gastroenterostomy: results of a Standardized Clinical Assessment and Management Plan (with video). Gastrointestinal Endosc. 2022 Apr;95(4):682-691
van der Merwe SW, van Wanrooij RLJ, Bronswijk M, Everett S, Lakhtakia S, Rimbas M, Hucl T, Kunda R, Badaoui A, Law R, Arcidiacono PG, Larghi A, Giovannini M, Khashab MA, Binmoeller KF, Barthet M , Perez-Miranda M, van Hooft JE. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Feb;54(2):185-205.
Kumar A, Chandan S, Mohan BP, Atla PR, McCabe EJ, Robbins DH, Trindade AJ, Benias PC. EUS-guided gastroenterostomy versus surgical gastroenterostomy for the management of gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open. 2022 Apr 14;10(4):E448-E458.
Kouanda A, Binmoeller K, Hamerski C, Nett A, Bernabe J, Watson R. Endoscopic ultrasound-guided gastroenterostomy versus open surgical gastrojejunostomy: clinical outcomes and cost effectiveness analysis. Surg Endosc. 2021 Dec;35(12):7058-7067.
Staub J, Siddiqui A, Taylor LJ, Loren D, Kowalski T, Adler DG. ERCP performed through previously placed duodenal stents: a multicenter retrospective study of outcomes and adverse events. Gastrointestinal Endosc. 2018 Jun;87(6):1499-1504.
Troncone E, Fugazza A, Cappello A, Del Vecchio Blanco G, Monteleone G, Repici A, Teoh AYB, Anderloni A. Malignant gastric outlet obstruction: Which is the best therapeutic option? World J Gastroenterol. 2020 Apr 28;26(16):1847-1860.
Figure 1. Passage of duodenal stenosis succeeded only with the pediatric endoscope. A nasojejunal tube was placed under radiological control.
Figure 2. Echoendoscopically, the distended jejunal loop is identified and the metal apposition stent is inserted.
Figure 3. The gastroenteral prosthesis is visualized endoscopically in the distended intestinal loop
Figure 4. The externalization of saline with methylene blue (which was instilled on the nasojejunal tube) confirms the correct positioning of the prosthesis.
Figure 5. Radiological appearance of placement of the LAMS prosthesis with the distal end at the level of the small intestine