What is the difference between Endoscopic Ultrasound-Guided Gastroenterostomy (EUS GE) and gastrojejunostomy?

Difference Between EUS-Guided Gastroenterostomy and Gastrojejunostomy

EUS-guided gastroenterostomy (EUS-GE) is a less invasive endoscopic procedure that creates a fistulous tract between the stomach and jejunum, while surgical gastrojejunostomy (GJ) is a more invasive surgical procedure that requires laparoscopic or open surgery to create the same bypass. 1

Procedural Differences

EUS-Guided Gastroenterostomy (EUS-GE)

• Technique: Uses endoscopic ultrasound to create a fistulous tract between the stomach and jejunum, typically deploying a lumen-apposing metal stent (LAMS) 1, 2
• Approach: Minimally invasive endoscopic procedure performed through the mouth 3
• Procedure time: Generally shorter than surgical approaches 4
• Hospital stay: Shorter hospital stay compared to surgical GJ 5, 4
• Technical success rate: Approximately 88-92% 1, 5
• Clinical success rate: Approximately 90% 1, 6

Surgical Gastrojejunostomy (GJ)

• Technique: Creates a surgical anastomosis between the stomach and jejunum 1
• Approach: Can be performed via laparoscopic (preferred) or open surgery 1
• Procedure time: Generally longer than EUS-GE 4
• Hospital stay: Longer hospital stay compared to EUS-GE 5, 4
• Technical success rate: Approximately 100% 4
• Clinical success rate: Similar to EUS-GE 4

Comparative Outcomes

Efficacy

• Recurrent obstruction: EUS-GE has lower rates of recurrent obstruction compared to enteral stenting, similar to surgical GJ 1, 5
• Re-intervention rates: Lower for EUS-GE compared to enteral stents 1
• Clinical success without recurrent GOO: Higher with EUS-GE compared to enteral stenting 5

Safety

• Adverse events: Significantly lower with EUS-GE (12%) compared to surgical GJ (41%) 4
• Common adverse events with EUS-GE: Stent misdeployment (most common), pain, bleeding, pneumoperitoneum, peritonitis 1, 2
• Common adverse events with surgical GJ: Higher rates of bleeding, longer recovery time, wound complications 1, 4

Patient Selection

EUS-GE is preferred for:

• Patients with poor functional status who are not surgical candidates 1
• Patients with malignant gastric outlet obstruction (GOO) with limited life expectancy 1
• Patients who need a minimally invasive approach with shorter recovery time 4

Surgical GJ is preferred for:

• Patients with life expectancy >2 months, good functional status, and who are surgically fit 1
• When EUS-GE expertise is not available 1
• Patients where technical success of EUS-GE might be limited (e.g., significant ascites) 1

Technical Considerations

EUS-GE Techniques:

• Direct gastroenterostomy (DGE) - lower adverse event rates 6
• Balloon-assisted gastroenterostomy (BAGE) 6
• EUS-guided double balloon-occluded gastrojejunostomy bypass 6

Surgical GJ Approaches:

• Laparoscopic approach is favored over open approach due to lower blood loss and shorter hospital stay 1

Important Caveats

• EUS-GE requires specialized expertise and is not widely available due to limited experienced endoscopists 1
• No dedicated FDA-approved devices specifically for EUS-GE are currently available 1
• EUS-GE should not be performed in patients with significant ascites 3
• Patient selection is crucial for optimal outcomes with either procedure 1

Algorithm for Procedure Selection

1. Assess patient's life expectancy and functional status:

   • If life expectancy >2 months with good functional status and surgically fit → Consider surgical GJ 1
   • If limited life expectancy or poor surgical candidate → Consider EUS-GE 1

2. Evaluate local expertise:

   • If experienced EUS endoscopist available → EUS-GE is a viable option 1
   • If EUS expertise limited → Surgical GJ or enteral stenting 1

3. Consider anatomical factors:

   • Presence of significant ascites → Avoid EUS-GE 3
   • Multiple luminal obstructions → Neither EUS-GE nor enteral stenting ideal 1

4. For patients not candidates for either GJ (surgical or EUS-guided):

   • Consider enteral stent placement 1