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.