EUS-guided gastroenterostomy in patients with ascites: What lies beneath?

In December 2021, the retrospective analysis by Jahangeer Basha et al was published online, illustrating the feasibility of endoscopic ultrasound-guided gastroenterostomy (EUS-GE) in patients with ascites ¹ . Although historically regarded as a contraindication, we agree that EUS-GE can be performed in patients with ascites, provided that it does not interfere with the electrocautery-enhanced lumen apposing metal stent trajectory. However, we feel that several crucial remarks are in order before such an approach is considered in everyday practice.

First, the presence of ascites should direct the endoscopist’s attention toward underlying peritoneal metastatic disease, as this may severely affect the clinical success and rate of gastric outlet obstruction(GOO) recurrence following EUS-GE ² . Peritoneal disease may also increase the risk of downstream enteral obstruction or gastrointestinal dysmotility, and may complicate subsequent rescue surgery. Meticulous revision of preprocedural cross-sectional imaging should be performed in an effort to rule out underlying obstructive or diffuse peritoneal involvement, which both should be regarded as a contraindication. Second, ascites may increase technical difficulty ³ and also lead to an increased risk of secondary bacterial peritonitis. Although data on antimicrobial prophylaxis are practically non-existent in therapeutic endosonography, a longer course of broad-spectrum antibiotics seems indicated in patients with cirrhosis and ascites undergoing EUS-GE. And last, the authors suggest that this is the first report of EUS-GE in the presence of ascites. In our recently published multicenter analysis, evaluating the outcomes of EUS-GE (n = 77) compared to laparoscopic gastroenterostomy, almost one-quarter (n = 17) of all patients undergoing EUS-GE had varying degrees of ascites ⁴ . We do, however, agree that the current authors provide us with a more in-depth analysis on the pre- and postprocedural precautions required for successful EUS-GE in patients with ascites.

By respecting the aforementioned considerations, we believe that EUS-GE in patients with ascites can indeed be performed safely and effectively ⁵ . It should, however, prompt a high degree of suspicion about underlying, potentially obstructive, peritoneal disease and a longer course of prophylactic antibiotics may be in order. In general, we should worry less about the ascites itself, yet more about what lurks beneath its surface!