Endoscopic ultrasound guided-gastroenterostomy is the best choice in the treatment of gastric outlet obstruction

Abstract

First of all, I would like to congratulate Vilas-Boas et al on an interesting publication. In this letter the authors write about very interesting topics in the management of patients with malignant gastric outlet obstruction (GOO). GOO developed in up to 20% of patients with advanced hepatopancreatobiliary disease both in benign and malignant form. For this reason, the issue is very current. I fully agree with Vilas-Boas et al that technical aspect of the procedures (surgeon’s view) often differs from the patient’s view (regarding such factors as cancer-related survival, overall survival, body mass composition, nutritional biomarkers, chemotherapy tolerance and patient-reported quality of life). The mentioned factors should be taken into account when interpreting the effectiveness of treatment modalities for malignant GOO (mGOO), which should be also considered in the future studies in this subject. In my opinion, all above mentioned factors could be summarized in one term: “Improving quality of life of patients with mGOO”.

Key Words: Gastric outlet obstruction; Gastroenterostomy; Endoscopic ultrasound; Endoscopic stenting; Pancraetic cancer; Endoscopy

Core Tip: Gastric outlet obstruction (GOO) developed in up to 20% of patients with advanced hepatopancreatobiliary disease both in benign and malignant form. For this reason, the issue is very current. In this article I present various endoscopic techniques in treatment of patients with GOO. Technical aspects of the endoscopic procedures (surgeon’s view) often differ from the patient’s view (regarding such factors as cancer-related survival, overall survival, body mass composition, nutritional biomarkers, chemotherapy tolerance and patient-reported quality of life). The mentioned factors should be taken into account when interpreting the effectiveness of treatment modalities for malignant GOO, which should be also considered in the future studies in this subject.

TO THE EDITOR

First of all, I would like to congratulate Vilas-Boas et al[1] on an interesting publication in the World Journal of Gastrointestinal Endoscopy. In this review the authors write about very interesting topics in the managment of patients with malignant gastric outlet obstruction (GOO). Vilas-Boas et al[1] highlight the fact, that most studies describing the different treatment modalities for malignant GOO (mGOO) focus on mechanical outcomes, such as technical success (stent placement or being able to create a gastroenteric anastomosis), clinical success (ability to eat soft solids without vomiting), and adverse events. Therefore Vilas-Boas et al[1] in the publication titled “Unveiling hidden outcomes in malignant gastric outlet obstruction research - insights from a "Pancreas 2000" review” do not focus on technical outcomes of procedures in patients with mGOO, but describe the patient’s viewpoints (cancer-related survival, overall survival, body mass composition, nutritional biomarkers, chemotherapy tolerance and patient-reported quality of life), which had not been described in the available literature. This holistic approach to the treatment of patients with mGOO present new perspectives that should be explored in future comparative research around mGOO treatment options.

GOO developed in up to 20% of patients with advanced hepatopancreatobiliary disease[2,3] both in benign and malignant form. For this reason, the issue is very current. Available literature tells us about three methods of treatment of patients with mGOO such as endoscopic stenting of malignant stricture of gastrointestinal tract, endoscopic ultrasound (EUS)-guided gastroenterostomy and surgical gastroenterostomy (both laparoscopic and traditional open gastroenterostomy). Endoscopic stenting and surgical gastroenterostomy are standard treatment modalities for mGOO[1]. However, EUS-guided gastroenterostomy is rather new endoscopic approach, which reduces the invasiveness and similar efficacy compared to surgical gastroenterostomy and offers higher durability and the same minimal invasiveness compared to endoscopic stenting[4,5]. The conclusion this that EUS-guided gastroenterostomy is the best choice in the management of patients with mGOO, but the long learning curve of this endoscopic procedure very often limits its use in the clinical practice.

A recent survey from the Pancreas 2000 group aimed to assess worldwide approaches to mGOO showed that preferences for mGOO treatment varied by specialty, with gastroenterologists favoring enteral stenting and surgeons more inclined towards surgical gastroenterostomy[1]. Personally, I fully agree with information mentioned above. As an endoscopic surgeon in the gastrointestinal surgery, who completed the learning curve in EUS-guided gastroenterostomy, I confirm that given the three methods of treatment, currently the EUS-guided gastroenterostomy is the best choice in the patient with benign and malignant GOO. I fully agree with Vilas-Boas et al[1] that technical aspects of the procedures (surgeon’s view) often differs from the patient’s view (regarding such factors as cancer-related survival, overall survival, body mass composition, nutritional biomarkers, chemotherapy tolerance and patient-reported quality of life). The mentioned factors should be taken into account when interpreting the effectiveness of treatment modalities for mGOO, which should be also considered in the future studies in this subject. In my opinion, all above mentioned factors could be summarized in one term: “Improving quality of life of patients with mGOO”.