EUS GASTROENTEROSTOMY (EUS-GE) FOR TREATMENT OF GASTRIC OUTLET OBSTRUCTION IN PATIENTS WITH ACUTE NECROTIZING PANCREATITIS

Background: Severe and necrotizing acute pancreatitis can lead to symptomatic gastric outlet stenosis due to external compression. In addition, intestinal motility can be reduced in severe pancreatitis. These patients may require a gastric decompression tube and jejunal (or parenteral) nutrition. Gastric outlet stenosis can be treated using endosonographic gastroenterostomy (EUS-GE), which has not yet been evaluted in the setting of acute pancreatitis.
Methods: We conducted a retrospective multicenter trial at seven international centers. Patients with acute necrotizing pancreatitis who underwent EUS-GE due to symptoms of delayed gastric emptying were identified and included in the study.
Results: Thirty-eight patients were identified. They had a median age of 55 years (27 – 76) and 14 were female (36.8%). Etiology of pancreatitis was as follows: biliary: n = 14, alcoholic: n = 13, post-ERCP: n = 3, other: n = 8. According to the Atlanta classification, 9 cases were mild, 12 were moderate and 17 cases were severe. Median time between onset of pancreatitis and EUS-GE was 54 days. In three cases (7.9%), EUS-GE could not be performed because the distance between stomach and small intestine was too large (n = 2) or no suitable site for puncturing could be identified (n = 1). In the remaining 35 cases EUS-GE was technically successful. The most common technique used, was the so-called direct puncture technique (without guidewire) in n = 25 cases (65.8%). In all cases, a LAMS with an electrocautery-enhanced delivery device was used (HotAxios, Boston Scientific). All stents had a length of 10 mm and a diameter of 10 mm (n = 1), 15 mm (n = 17), or 20 mm (n = 17). Thirty-four patients (89.5%) showed improvement in the Gastric Outlet Obstruction Scoring ystem (GOOSS). Before the intervention, the median value was 0, afterward it was 2. There were no periinterventional complications. Post-interventionally, gastrocolic fistula occurred in one case (2.6%) due to stent erosion of the colon. This could be treated endoscopically. Stent revision was necessary in two cases; one balloon dilatation and one stent exchange each. In another case, persistent duodenal stenosis was treated surgically. In 18 cases, the LAMS was subsequently removed endoscopically. These patients did not experience any recurrence of symptoms.
Conclusions: EUS-GE for the treatment of gastric emptying disorder in necrotizing pancreatitis represents a promising alternative to jejunal or parenteral nutrition combined with a gastric decompression tube.