Endoscopic pyloric exclusion—EUS-guided gastrojejunostomy combined with endoscopic suturing and closure of the pylorus: a novel approach to failed surgical repair of a perforated duodenal ulcer

Post written by Kambiz Kadkhodayan, MD, from the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.


We describe a novel endoscopic procedure that results in complete diversion of the gastric stream away from the duodenum and into the proximal jejunum.

Duodenal bypass was achieved using a 2-step approach. Step 1 involved diverting the gastric stream into the small bowel via a lumen-apposing metal stent that is placed under EUS guidance. Step 2 included disruption of transpyloric flow by closing the pylorus with an endoscopic suturing device.

In our video case, the procedure was used to successfully manage a duodenal ulcer perforation in a patient who unsuccessfully underwent traditional surgical treatment. Complete diversion of the acid–rich gastric stream, away from the perforation site, may have promoted ulcer healing and led to clinical improvement.   

We describe the synergistic use of EUS-guided gastroenterostomy and endoscopic suturing to achieve complete bypass of the duodenum. The procedure is arguably similar to a surgical pyloric exclusion, which has been studied in the management of perforated duodenal ulcers, biliary perforations, duodenal trauma, etc.

The procedure detailed here may provide patients with an endoscopic and minimally invasive alternative to surgery in the right clinical setting.

We were able to demonstrate that it is technically feasible to achieve complete GI bypass and exclude the duodenum from the anterograde nutrient and acid–rich gastric stream. The efficacy, safety, and clinical utility of the procedure are yet to be studied.

I would like to thank GIE for the opportunity to share this exciting video presentation.

Kadkhodayan_figureFluoroscopic image after injection of radio contrast, demonstrating extraluminal leakage at the duodenal bulb (yellow arrows).

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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