Technical feasibility and clinical success of direct “free hand” EUS-guided gastroenterostomy in patients with gastric outlet obstruction

Background: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with lumen-apposing metal stents (LAMS) appears to be a promising intervention in the management of gastroduodenal obstruction particularly for patients of surgical high-risk or in a palliative setting. Objective: This study evaluates the technical feasibility, procedure-associated adverse events and clinical outcome of direct “free hand” EUS-GE. Methods: This retrospective bicenter study included patients who underwent direct “free hand” EUS-GE (April 2017 to March 2021) investigating technical success (correctly placed LAMS), clinical outcome (successful oral nutrition) and management of procedure-associated adverse events.. “Free hand” was defined as the use of the electrocautery enhanced stent delivery system alone without additional guide wire-assistance for EUS-GE creation. Results: 45 patients (58% women/42% men; mean age 65 years) with malignant (n=39), benign (n=4) or unclear (n=2) gastroduodenal obstruction underwent direct “free hand” EUS-GE. The technical success rate was 98% (44/45). 95% (42/44) showed reduced vomiting and the ability of oral food intake after the intervention. In one patient, a second EUS-GE was necessary to achieve sufficient clinical improvement. Procedure-associated adverse events were observed in 24% (11/45) of cases including stent misplacement (n=7), leakage (n=1), development of a gastrojejunocolic fistula (n=1) and bleeding (n=2), which could be all managed endoscopically. Conclusion: Direct EUS-GE has a favorable risk-benefit-profile for patients with gastroduodenal obstruction, showing high technical success rates, manageable adverse events and rapid symptom relief.