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.

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

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