Reassessment of EUS-guided gastrojejunostomy

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) has undergone significant evolution and reassessment in recent years. Initially developed as a minimally invasive alternative for gastric outlet obstruction (GOO), it is now increasingly recognized as a viable option for both malignant and select benign conditions.

Recent studies have demonstrated that EUS-GJ offers several advantages over traditional endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) approaches. Compared to enteral stenting (ES), EUS-GJ provides more durable symptom relief, significantly lowers the need for reintervention, and minimizes the risk of stent migration. When compared with surgical gastrojejunostomy (S-GJ), EUS-GJ offers similar clinical efficacy with faster recovery, less postoperative pain, and shorter hospital stays.

Technically, EUS-GJ requires advanced expertise and is associated with specific risks, including stent maldeployment and peritonitis. However, the advent of electrocautery-enhanced lumen-apposing metal stents (LAMS) and improved techniques such as balloon-assisted or EPASS methods have significantly improved technical success and safety profiles.

The role of EUS-GJ is being actively redefined, particularly in expert centers. It is now considered a preferred option for palliation in malignant GOO in patients unfit for surgery or when long-term patency is desired. In benign conditions, its use remains selective, pending more long-term data.

Drawbacks of EUS-Guided Gastrojejunostomy
Technical Complexity
Requires advanced endoscopic ultrasound (EUS) skills and familiarity with electrocautery-enhanced lumen-apposing metal stents (LAMS).
Limited to experienced interventional endoscopists and high-volume centers.
Risk of Adverse Events
Potential for serious complications such as peritonitis, stent maldeployment, bleeding, and infection. Maldeployment into the peritoneal cavity may require urgent surgical or endoscopic rescue.
Limited Access in Some Anatomies
It may be difficult or impossible in patients with significant ascites, extensive peritoneal carcinomatosis, or surgically altered anatomy that limits safe jejunal loop identification.
Equipment Dependency
Relies on specific devices such as electrocautery-enhanced LAMS, which may not be available in all centers. High equipment cost may limit access in resource-limited settings.
Learning Curve and Procedure Time
Requires a steep learning curve and has longer procedure times in early cases compared to enteral stenting or surgery.Limited Data in Benign GOO
Long-term outcomes for benign gastric outlet obstruction remain unclear. The risk of persistent fistula or the need for stent removal complicates management.
Potential for Stent-Related Complications
Stent occlusion, migration (though less than ES), and tissue ingrowth can occur and may require repeat interventions.

In summary, EUS-GJ has shifted from an experimental technique to a mainstream therapeutic strategy in specialized centers, supported by growing clinical evidence and technical refinement. Its role will likely continue to expand as more prospective data emerge and operator expertise broadens.