Post written by Bruno Costa Martins, MD, PhD, from the Hospital Alemão Oswaldo Cruz, Endoscopy Unit, São Paulo, Brazil.

We described a case of an 88-year-old patient with obstructive symptoms due to advanced head pancreatic neoplasm. EUS-guided gastrojejunal bypass (EUS-GJ) was chosen to palliate gastric outlet obstruction symptoms. EUS-GJ bypass was attempted with the aid of a dedicated double-balloon catheter (EPASS). However, the first attempt was unsuccessful due to misplacement of the LAMS’s distal flange, which transfixed the bowel loop. Stent relocation by pulling the proximal flange was unsuccessful, so the stent was completely removed while we kept the double-balloon catheter inflated in the same position. NOTES was unsuccessfully attempted to rescue the transfixed loop with a slim scope inserted through the gastric orifice of previous EUS puncture. Thus, a second EPASS attempt was performed inserting the LAMS delivery system into the same gastric orifice. The LAMS was adequately deployed on the second attempt. LAMS dilation up to 15 mm was performed and the bowel loop was inspected with a standard gastroscope intending to close the defects caused by the failed EPASS attempt. Surprisingly, duodenal defects were small orifices identified by minor clots, which were closed with the placement of 3metallic clips.

EUS-GJ for the treatment of gastric outlet obstruction has gained attention since the advent of lumen-apposing metal stents (LAMSs). This technique provides an elegant, minimally invasive approach with good long-term outcomes for the relief of obstructive symptoms. However, adverse events can occur, and the endoscopist must be aware of the possibility and management.  

Learning points from our experience:

1. Maximum dilation of the jejunal segment with saline solution is fundamental to avoid transfixing the jejunal loop.

2. Certifying the location of the catheter tip and avoiding advancing it too far is fundamental before deployment of the stent.

3. Maintenance of double-balloon catheter inflation was important to keep the bowel loop in place and perform the second EPASS attempt.

4. Exploration of the perigastric cavity through the gastric orifice revealed only retroperitoneal fat, with no clearly visible bowel and no leakage of saline solution.

5. The second attempt was possible through the same gastric orifice.

6. Duodenal defects caused by LAMSs were small orifices that could be safely treated by endoscopic clipping.

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