Management of malignant Gastric Outlet Obstruction (mGOO) due to pancreatic cancer in the era of EUS-Gastrojejunostomy: an international practice survey and case vignette study by Pancreas 2000 from the European Pancreatic Club

Charles De Ponthaud; Bahadir Bozkirli; Giacomo Emanuele Maria Rizzo; Stuart Robinson; Filipe Vilas-Boas; Gabriele Capurso; Sébastien Gaujoux; Giuseppe Vanella

doi:10.1007/s00464-024-10803-0

Management of malignant Gastric Outlet Obstruction (mGOO) due to pancreatic cancer in the era of EUS-Gastrojejunostomy: an international practice survey and case vignette study by Pancreas 2000 from the European Pancreatic Club

Surg Endosc. 2024 Apr 22. doi: 10.1007/s00464-024-10803-0. Online ahead of print.

Authors

Charles De Ponthaud^{1

2

3}, Bahadir Bozkirli⁴, Giacomo Emanuele Maria Rizzo^{5

6}, Stuart Robinson⁷, Filipe Vilas-Boas⁸, Gabriele Capurso^{9

10}, Sébastien Gaujoux^{1

2}, Giuseppe Vanella¹¹

Affiliations

¹ Department of Digestive, Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France.
² Department of General, Visceral, and Endocrine Surgery, AP-HP Pitié-Salpêtriere, Sorbonne Université, Paris, France.
³ HeKA, Inria, Paris, France.
⁴ Department of General Surgery, HPB-Unit, Acıbadem Maslak Hospital, Istanbul, Türkiye.
⁵ Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy.
⁶ Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, Palermo, Italy.
⁷ Department of Hepatobiliary, Pancreatic and Transplant Surgery, Department of Surgery, Freeman Hospital, Newcastle Upon Tyne, UK.
⁸ Department of Gastroenterology, São João University Hospital, Alameda Professor Hernâni Monteiro, 4200-427, Porto, Portugal.
⁹ Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy.
¹⁰ Vita Salute San Raffaele University, Milan, Italy.
¹¹ Division of Pancreato-Biliary Endoscopy and Endosonography, Pancreas Translational and Clinical Research Center, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Via Olgettina 60, 20132, Milan, Italy. vanella.giuseppe@hsr.it.

PMID: 38649494
DOI: 10.1007/s00464-024-10803-0

Abstract

Background: Malignant Gastric Outlet Obstruction (mGOO) has been standardly treated by surgical Gastrojejunostomy (S-GJ) or Endoscopic Stenting (ES). Recently, EUS-Gastrojejunostomy (EUS-GJ) has emerged as an alternative, despite its worldwide diffusion is heterogeneous. The aim of this survey was to assess clinical decision-making around mGOO and to explore current opinions regarding EUS-GJ.

Methods: An online survey, spread through social networks and EPC newsletter, was created exploring opinions regarding indications, contraindications, benefits/risks, availability of mGOO treatments; 2 case vignettes explored clinical decision-making in different scenarios.

Results: Overall, 290 pancreatologists from 44 countries responded, of whom 35% surgeons and 65% gastroenterologists. The most common treatment for mGOO was ES (86%), followed by laparoscopic GJ (76%). EUS-GJ was accessible to 59% of respondents, with 10% proficient in this technique. Gold-standard treatment for mGOO varied by specialty; 45% of gastroenterologists preferred ES, 20% EUS-GJ, and 10% surgical GJ, while among surgeons, these were 24%, 8%, and 25%, respectively. A higher annual volume of mGOO treated correlated with increased EUS-GJ adoption and reduced surgical advice. For 51%, EUS-GJ will become the primary treatment for mGOO, notably higher among gastroenterologists and high-volume centers. For 14%, EUS-GJ spread will be limited in the future, or used only when ES fails (19%). Life expectancy, disease stage and patient's frailty are the main decision driver in therapeutic choice, whereas future surgical resectability does not contraindicate any treatment for 75%. EUS-GJ's main advantages were its minimally invasive nature and clinical efficacy, offset by its steep learning curve.

Conclusions: This survey revealed significant differences in the management of mGOO, depending on specialties, local expertise and treatment volume, suggesting the lack of standardized algorithms. Life expectancy and patients' frailty are the main decision drivers. Regarding EUS-GJ, its availability remains suboptimal, with learning curve as the main perceived barrier.

Keywords: Endoscopic ultrasound; Malignant gastric outlet obstruction; Pancreatic cancer; Survey.