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Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction
  1. Takao Itoi1,
  2. Kentaro Ishii1,
  3. Nobuhito Ikeuchi1,
  4. Atsushi Sofuni1,
  5. Takuji Gotoda1,
  6. Fuminori Moriyasu1,
  7. Vinay Dhir2,
  8. Anthony Yuen Bin Teoh3,
  9. Kenneth F Binmoeller4
  1. 1Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
  2. 2Baldota Institute of Digestive Sciences, Global Hospitals, Mumbai, India
  3. 3Department of Surgery, The Chinese University of Hong Kong, Hong Kong, Hong Kong
  4. 4Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA
  1. Correspondence to Professor Takao Itoi, Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan; itoi{at}

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Surgical gastrojejunostomy (GJ), which has been the standard palliative treatment for malignant gastric outlet obstruction (MGOO), is associated with good functional outcome and the long-term relief of symptoms. Endoscopic placement of a metal stent for MGOO treatment has been gaining popularity as an alternative to surgical GJ because of its high technical success rates and less invasiveness. Interestingly, several investigators have attempted endoscopic GJ as ‘endoscopic bypass’ for longer efficacy while maintaining a less invasive procedure.1 We previously reported on the feasibility and safety of EUS-guided GJ (EUS-GJ) using a lumen-apposing metal stent (LAMS)2 ,3 and a special double-balloon enteric tube in an animal model and a pilot clinical study.3 Herein, we describe the first prospective clinical study of EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) using a LAMS (figure 1). We performed EPASS in 20 patients with MGOO. The double-balloon tube (figure 2) was correctly inserted into the jejunum across from the stomach in all cases. The technical success rate of stent placement was 90%.

Figure 1

Schema of EUS-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) using a lumen-apposing metal stent.

Figure 2

Double-balloon enteric tube allows the filling-water between two balloons.

In more detail

EPASS was performed in 20 patients with MGOO between March 2014 and March 2015 (10 male) (supplementary tables 1 and 2). The median intubation time of the double-balloon tube insertion was 10.5 min (range 6–28 min). The technical success rate of stent placement was 90% (18/20) (figure 3 and supplementary table 3). The median intubation time from the double-balloon tube intubation to stent placement was 25.5 min (range 10–39 min). In the two failed cases, we recognised the maldeployment of the distal flange immediately after deployment of the proximal flange by the presence of pneumoperitonium on fluoroscopy and endoscopic visualisation of the abdominal cavity through the LAMS. Post-treatment gastric outlet obstruction …

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  • Contributors TI: literature search, study design, patient inclusion, data collection, data analysis, statistical analysis, data interpretation, drafting of the manuscript and final approval. KI, NI, AS, TG and FM: patient inclusion, data collection, critical revision and final approval of the manuscript. VD, AYBT and KFB: critical revision and final approval of the manuscript.

  • Competing interests TI: Consultant for Xlumena. KFB: the inventor of the AXIOS stent and delivery system and the founder of Xlumena.

  • Patient consent Obtained.

  • Ethics approval Ethical Committee and board of Tokyo Medical University.

  • Provenance and peer review Not commissioned; internally peer reviewed.