EUS-guided gastrojejunostomy for management of malignant gastric outlet obstruction in a patient with Roux-en-Y anatomy

Post written by Rishi Pawa, MD, FACG, from the Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.


A 56-year-old man with a medical history of metastatic duodenal adenocarcinoma, status postpartial gastrectomy, and duodenectomy with Roux-en-Y gastrojejunostomy (GJ) presented with gastric outlet obstruction.

Endoscopy revealed an ulcerated stricture at the gastrojejunal anastomosis, with biopsies confirming recurrent adenocarcinoma. CT scans of the abdomen and pelvis showed a proximal distended stomach with an air-fluid level.

The patient underwent a successful EUS-guided GJ (EUS-GJ) using a lumen-apposing metal stent (LAMS), with the distal flange deployed in the proximal jejunum and the proximal flange in the gastric pouch. A CT scan obtained the following day showed appropriate LAMS position and decreased gastric distension with oral contrast opacifying the stomach and small bowel.

The patient was started on a clear liquid diet and gradually advanced to a soft mechanical diet over 24 hours. At the 4-week follow-up, he was tolerating a regular diet without nausea and vomiting and had gained 12 pounds since the procedure.

The off-label use of LAMSs for management of malignant gastric outlet obstruction has continued to evolve. In comparison with enteral stenting, EUS-GJ has lower rates of stent failure and symptom recurrence requiring reintervention. The clinical efficacy of EUS-GJ is similar to that of laparoscopic GJ with fewer adverse events, lower costs, and shorter hospital stays.

Although this procedure is well-described among patients with normal GI anatomy, it can be safely performed in patients with Roux-en-Y reconstruction. Technical failure and adverse events associated with EUS-GJ are commonly related to stent misdeployment, which can be overcome by using the direct-puncture technique, with subsequent LAMS deployment without a guidewire.

In conclusion, increased familiarity with this technique has been shown to mitigate adverse events associated with this procedure.

Pawa_figureEndoscopic image following deployment of lumen-apposing metal stent for creation of gastrojejunostomy.

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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