A case of cystic paraduodenal pancreatitis with gastric outlet obstruction: technical pitfalls in EUS-guided gastroenteroanastomosis

Post written by Cecilia Binda, MD, from the Gastroenterology and Digestive Endoscopy Unit, Forlì-Cesena Hospitals, AUSL Romagna, Forlì-Cesena, Italy.


Our video focuses on some of the technical aspects of EUS-guided gastroenteroanastomosis (EUS-GEA). We report on the case of an 84-year-old man with symptoms of gastric outlet obstruction. A diagnosis of cystic paraduodenal pancreatitis was made on the basis of radiologic and endoscopic examinations. The patient was deemed unfit for surgery at multidisciplinary evaluation, and EUS-GEA was chosen as a minimally invasive approach.

After making irrigations from the duodenal stenosis with saline solution, contrast medium, and indigo carmine, the fluid-filled jejunal loop was punctured with a 19-gauge needle to confirm the target loop visualization. Then an electrocautery-enhanced lumen-apposing metal stent (EC-LAMS) was inserted with a free-hand technique in the jejunal loop, and a guidewire was introduced to ensure access into the jejunal loop during stent deployment.

Unfortunately, guidewire manipulation pushed the jejunal loop far from the gastric wall, displacing the tip of the EC-LAMS immediately outside the small-bowel wall. After removing the guidewire and maintaining access into the gastric wall and the target loop under EUS-view, the EC-LAMS was immediately reinserted in the target loop and the 20- × 10-mm stent was deployed. Outflowing of water and indigo carmine in the stomach confirmed success of the procedure. 

Our experience demonstrates that every single step could potentially affect the success of a procedure, so it is important to know every technical pitfall. Interventional EUS offers incredible therapeutic possibilities at the price of technically challenging procedures. In addition, it is vital to know that some complications could be rescued intraprocedurally, as we reported in this case.

Furthermore, it is interesting to report on EUS-GEA as a therapeutic option for gastric outlet obstruction of benign origin as an alternative to surgery in unfit patients. 

Many endoscopists who practice interventional EUS come from a background of biliary endoscopy where the use of guidewire is mandatory. Interventional EUS is rapidly expanding, and new advancements in devices are available, and new indications are emerging.

In this scenario, it could be time to change some old paradigms such as guidewire use in favor of new techniques such as free-hand LAMS deployment. 

Binda_figureEndoscopic view showing duodenal stenosis.

Read the full article online.

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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