Post written by Laurens Janssens, MD, from the Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

A 71-year-old woman presented with abdominal pain, nausea, vomiting, and normal liver test results. A CT scan demonstrated gastric outlet obstruction (GOO). Extensive work-up could not reveal the etiology of an extrinsic duodenal compression, and we were unable to navigate the duodenal sweep during upper endoscopy.

Initially, a fully covered duodenal stent was placed but resulted in rising liver test results concerning for stent-related biliary obstruction. Hence, the stent was removed and a PEG tube with jejunal extension (PEG-J) was placed for gastric venting and jejunal feeding.

Two weeks later, liver test results again increased with new biliary dilation. The decision was made to pursue both EUS-hepaticogastrostomy and EUS-guided gastrojejunostomy to bypass biliary and duodenal obstructions.

First, EUS-guided left hepaticogastrostomy was performed using a fully covered self-expandable metal stent. Next, given that the patient had a pre-existing PEG-J tube, the jejunal extension tubing was used to instill contrast into the target limb in lieu of a nasobiliary drain. A 15- x 10-mm electrocautery-enhanced lumen-apposing metal stent (AXIOS; Boston Scientific, Marlborough, Mass, USA) was advanced into the distended target limb of jejunum and deployed under endosonographic vision.

After the procedure, the patient tolerated a stent-based diet and was ultimately diagnosed with metastatic urothelial carcinoma resulting in malignant compression of the duodenum.

EUS-guided gastroenterostomy has proven to be a safe, efficient, and minimally invasive treatment option for GOO when performed in an experienced center. Target bowel opacification with a saline-based solution is a prerequisite for using the wireless free-hand technique to deploy the lumen-apposing metal stent.

Typically, this required nasobiliary drain placement under fluoroscopic guidance. When previously placed jejunal tubes are present, this access can be leveraged to instill the saline-based solution, reducing procedural time, complexity, and equipment cost.

In patients with existing jejunal access (such as PEG-J or PEJ), EUS-guided gastroenterostomy can be simplified because of need for less time and fewer resources. Furthermore, although most malignant GOOs are caused by gastric and pancreaticobiliary malignancies, metastatic urothelial carcinoma is a rare but recognized cause of extrinsic small-bowel compression.

Deployment of the lumen-apposing metal stent in the jejunum under endosonographic guidance.

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