Irani Shayan, Baron Todd H, Itoi Takao, Khashab Mouen A
aDigestive Disease Institute at Virginia Mason Medical Center, Seattle, Washington bDivision of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA cDepartment of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan dDivision of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA.
Curr Opin Gastroenterol. 2017 Sep;33(5):320-329. doi: 10.1097/MOG.0000000000000389.
Gastric outlet obstruction (GOO) can result from benign and malignant causes. Until recently, surgical gastrojejunostomy was the treatment of choice for patient with benign and malignant GOO with a good functional status. Endoscopic placement of luminal self-expandable metal stents is currently widely accepted as the first line of treatment for malignant GOO because of its effectiveness and minimally invasive nature. The main shortcoming of luminal stents is the high incidence of recurrent GOO most commonly because of tumor ingrowth/overgrowth. More recently, endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) has emerged as an alternative to both luminal stent placement and surgical gastrojejunostomy. Advantages of EUS-GE include its minimally invasive nature, efficacy and low incidence of recurrent GOO in cancer patient. We will describe five different techniques to perform this novel and rapidly evolving procedure using a biflanged, lumen-apposing metal stent and compare benefits and risks of each approach. These approaches include antegrade EUS-GE or 'traditional/downstream' and 'rendezvous' methods, retrograde EUS-GE or 'enterogastrostomy,'17 (EPASS), and antegrade EUS-GE 'direct' method.
A preprocedural computed tomography scan allows the proximity of the duodenum or jejunum to the stomach to be determined and to assess for the presence of significant ascites, which is a contraindication to EUS-GE. Technical success rates even in the early studies approximate 90%, regardless of the technique used. Clinical success rates have been exceptionally high as well, with only a minority of patients experiencing persistent symptoms despite technical success. One procedure-related death has been reported so far with an overall low morbidity. Pain, bleeding, pneumoperitoneum and peritonitis have been reported in one patient each. However, duration of follow-up in these studies has been short.
We describe five different techniques to performing EUS-GE. Early studies show excellent efficacy. Stent misdeployment/displacement is the most frequent relevant adverse event. Prospective and preferably randomized trials with comparison to endoluminal enteral stents and surgical gastroenterostomy are needed.
胃出口梗阻（GOO）可由良性和恶性原因引起。直到最近，外科胃空肠吻合术仍是功能状态良好的良性和恶性GOO患者的首选治疗方法。由于其有效性和微创性，腔内自膨式金属支架的内镜置入目前被广泛接受为恶性GOO的一线治疗方法。腔内支架的主要缺点是复发性GOO的发生率高，最常见的原因是肿瘤向内生长/过度生长。最近，内镜超声（EUS）引导下胃造口术（EUS-GE）已成为腔内支架置入和外科胃空肠吻合术的替代方法。EUS-GE的优点包括其微创性、有效性以及癌症患者复发性GOO的发生率低。我们将描述使用双凸缘、管腔贴合金属支架进行这一新颖且快速发展的手术的五种不同技术，并比较每种方法的益处和风险。这些方法包括顺行EUS-GE或“传统/下游”和“会师”方法、逆行EUS-GE或“肠胃造口术”、顺行EUS-GE“直接”方法。
术前计算机断层扫描可确定十二指肠或空肠与胃的接近程度，并评估是否存在大量腹水，大量腹水是EUS-GE的禁忌证。即使在早期研究中，无论使用何种技术，技术成功率都接近90%。临床成功率也非常高，尽管技术成功，但只有少数患者仍有持续症状。迄今为止，已报告1例与手术相关的死亡，总体发病率较低。分别有1例患者报告出现疼痛、出血、气腹和腹膜炎。然而，这些研究的随访时间较短。
我们描述了进行EUS-GE的五种不同技术。早期研究显示疗效极佳。支架放置错误/移位是最常见的相关不良事件。需要进行前瞻性、最好是随机试验，并与腔内肠内支架和外科胃肠吻合术进行比较。
