Background:
Malignant gastric outlet obstruction (MGOO) is a morbid complication of pancreatic cancer. Endosonography-guided gastroenterostomy (EUS-GE) has been shown to have higher rates of clinical success and decreased risk for MGOO recurrence compared to enteral stenting (ES). Decreased muscle mass is associated with poor nutritional status and adverse outcomes in cancer patients. The impact of EUS-GE on muscle mass has not been evaluated.

Aim:
The aim was to evaluate muscle mass using an objective and validated tool, the total skeletal muscle index (SMI), in patients with MGOO following EUS-GE or ES. Secondary objectives included diet tolerated at discharge, MGOO recurrence rate, and survival post-procedure.

Method:
This was a retrospective, single centre study using consecutive patients with MGOO undergoing either ES from 2012-2020 or EUS-GE from 2019-2023. Patients were included if they had baseline abdominal CT imaging within six months pre-procedure and follow up CT imaging within seven months post-procedure. Follow up scans done within one month of death were excluded. Images were downloaded as DICOM files and SMI was calculated at the L3 level using CoreSlicer (v.1.0, CoreSlicer, Canada). SMI was adjusted for height, and the change in SMI from follow up to baseline was divided by follow up time. Independent T tests, chi-square analysis, and Fisher’s Exact tests were done to compare differences between treatment groups. Survival analysis was also performed.

Results:
A total 70 patients were identified: 34 EUS-GE and 36 ES. Following exclusion of patients without appropriate imaging, 20 patients in the ES group (30% female, average age 65.8 ± 9.9 years) and 14 patients in the EUS-GE group (50% female, average age 61.8 ± 2.9 years) were included for analysis. Average follow up time was 3.97 ± 1.8 months in the ES group and 3.69 ± 2.1 months in the EUS-GE group. While baseline SMI was similar between groups (39.4 ± 7.4 cm²/m² in ES group and 41.1 ± 5.7 cm²/m²in the EUS-GE group), patients in the EUS-GE group had on average a significant increase in SMI while patients in the ES group had a reduction in SMI (1.23 ± 3.4 compared to -1.37 ± 2.8 respectively, p=0.022) at follow up. There was no difference in diet at discharge, adverse events, or survival between groups. More patients in the ES group needed additional procedures due to recurrent MGOO as compared to the EUS-GE group (75% compared to 21% respectively, p=0.002). No significant difference in survival was noted.

Conclusion:
To our knowledge, our study is the first to demonstrate objective improvements in muscle mass with EUS-GE over ES in MGOO. Higher skeletal muscle index with EUS-GE suggests better nutritional status with the potential to decrease the risk for chemotoxicity. Prospective studies are needed to confirm these findings.

Table 1. Patient demographics, clinical outcomes, and SMI in patients with MGOO receiving ES or EUS-GE

Ali Bessissow

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