Learning curve of EUS-guided gastroenterostomy for the management of malignant gastric outlet obstruction: Data from a bicentric retrospective study.

BACKGROUND AND OBJECTIVES: EUS-guided gastroenterostomy (EUS-GE) is a promising alternative for managing malignant gastric outlet obstruction (GOO). This study aimed to analyze the learning curve (LC) for EUS-GE. METHODS: This retrospective European bicentric study included 96 patients with malignant GOO who underwent EUS-GE (April 2021 to August 2024) using the wireless EUS-guided gastroenterostomy simplified technique (WEST) or modified WEST. The primary outcome was to define the LC for each center through a composite score based on the clinical success rate, severe adverse events (III-IV per the AGREE classification), and procedural time. Secondary outcomes included the technical success rate, length of hospital stay, and resumption/initiation of chemotherapy. RESULTS: A total of 218 consecutive patients with GOO were screened across both centers. Twenty-seven patients were excluded because of surgically altered anatomy and/or benign GOO, leaving 191 patients with malignant GOO in the treatment-flow cohort. Among these, 96 patients underwent EUS-GE (Center 1: n = 53; Center 2: n = 43), whereas 95 patients underwent endoscopic duodenal stenting (Center 1: n = 74; Center 2: n = 21); no patient underwent surgical gastrojejunostomy during the study period. Ninety-six patients (54% women; mean age 68 years) were included. The technical and clinical success rates were 93% (n = 89/96) and 89% (n = 80/89), respectively. Severe complications occurred in 6% of patients, with a 1% mortality rate. The main cause of technical failure was misdeployment of the lumen-apposing metal stent, with the distal flange deployed between the stomach and the intestinal wall in 83% of cases (n = 5). The LC suggested a stabilization phase after approximately 20 procedures/center. The median length of stay was 8 days (IQR 6-10), and 69% (95% CI 55.6-75.6) of patients resumed or initiated chemotherapy. CONCLUSIONS: EUS-GE is a complex procedure that, at the team level, appears to reach a stable performance phase after approximately 20 procedures, with high clinical success rates and low complication rates.