EUS-guided gastrojejunostomy for managing GOO

Vivek Kumbhari, MD from the Department of Medicine and Division of Gastroenterology and Hepatology at the Johns Hopkins Medical Institutions in Baltimore, Maryland, USA shares this VideoGIE case, “EUS-guided gastrojejunostomy for management of complete gastric outlet obstruction.”

An 86-year-old female presents for management of gastric outlet obstruction (GOO) secondary to locally advanced pancreatic adenocarcinoma. An enteral stent was not possible as a guidewire was unable to pass through the stricture.

A linear echoendoscope was inserted into the stomach and a loop of small bowel in apposition to the stomach was identified. Transgastric puncture of the small bowel lumen with a 19-gauge needle was performed and contrast injected. Small bowel loops opacified with no downstream obstruction. A guidewire was inserted deep into the small bowel. The tract was dilated using a needle knife papillotome connected to cautery and a 4mm dilating balloon. A fully covered self-expandable lumen apposing metallic stent (15mm lumen, 10mm in length and 24mm flares) was deployed creating a G-J anastomosis. Upper endoscopy at day 7 revealed no residual gastric residue and the standard gastroscope was able to pass through the stent into the jejunum.

EUS-GJ using the “direct access” technique is technically feasible with the advent of lumen apposing metallic stents. It may be a suitable alternative to surgery in those patients that have failed enteral stent placement. The use of the lumen apposing metal stent with cautery will further simply this procedure.

Figure 1. Fluoroscopic images during EUS-guided gastrojejunostomy using the direct-access technique. A, Passage of the guidewire into the jejunum. B, Upper GI series on postprocedure day 1 demonstrating a patent stent.

There are 2 methods of performing EUS- G-J. We demonstrate the “direct” technique. The alternative technique, which is preferred where possible, is the  “balloon-assisted” method.  When performing the “direct” technique, it is imperative that 1) the needle tip is confirmed to be in the jejunum using contrast, 2) the gastrojejunal fistula is rapidly created to minimize leakage, 3) all faculties (endoscopic view, sonographic view, and fluoroscopic view) are used to deploy the stent.

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The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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