Post written by Samuel Han, MD, from The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.

In this video with 2 cases, we describe a technique for performing an EUS-guided gastrojejunostomy using commonly available endoscopic devices, including an 18- to 20-mm dilation balloon (CRE Balloon Dilatation Catheter; Boston Scientific, Marlborough, Mass, USA).

Upon identifying the site of obstruction, we passed a long-angled guidewire (Hydra Jagwire; Boston Scientific) into the small bowel past the obstruction. We then removed the scope and advanced the dilation balloon over the guidewire using fluoroscopy past the site of obstruction.

Next, we inflated the dilation balloon to 20 mm and injected a mixture of water and contrast to distend the jejunum. This allows for easy identification of the jejunum and facilitates freehand deployment of the lumen-apposing metal stent into the jejunum from the stomach.

We felt it was important to showcase this video to make it easier for endoscopists to perform an EUS-guided gastrojejunostomy using commonly available tools. In inflating a dilation balloon past the site of obstruction, we found that contrast did not backflow into the stomach (a common problem with the typical antegrade method of direct irrigation through the endoscope or use of a slim catheter for contrast irrigation). This allowed for the jejunum to distend well and really simplified visualization of it.

Furthermore, this enabled easy control of contrast irrigation into the jejunum using an irrigation foot pedal, which kept the jejunum nicely distended and enabled reconfirmation that the target was indeed the jejunum. We saw that freehand deployment of the stent was particularly easy to perform, making the overall procedure faster to conduct.  

We hope that this provides endoscopists with a safe and easier method for EUS-guided gastrojejunostomy. In our initial experience with these procedures, the greatest challenge was often distending the jejunum adequately to create enough of a runway to deploy the lumen-apposing metal stent.

We discovered that the stability of the inflated dilation balloon makes distention of the jejunum much easier, and we actually use less irrigation solution. In addition, being able to distend the jejunum even when puncturing with the stent made stent deployment much safer.

Successful deployment of lumen-apposing metal stent with jejunum visible through stent.

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