Post written by Michael Lajin, MD, from Sharp HealthCare, San Diego, California, USA.

A 73-year-old man with a history of distal gastrectomy presented with jaundice and 20-pound weight loss.

Abdominal CT with intravenous contrast showed cholelithiasis and a dilated biliary tree without evidence of choledocholithiasis or neoplasm. MRCP was not possible because of shrapnel. He had a failed enteroscopy-assisted ERCP and was transferred to our hospital. 

To verify his anatomy, push enteroscopy revealed distal gastrectomy, gastrojejunostomy, and jejuno-jejunostomy consistent with distal gastrectomy with Roux-en-Y reconstruction. 

Because of the clinical suspicion of pancreatic malignancy, an EUS-guided cholangiogram was obtained. It revealed a distal common bile duct stricture with a dilated biliary tree upstream. Hence, we decided to deploy a lumen-apposing metal stent (LAMS) connecting the remainder of the stomach to the proximal jejunum to enable retrograde endosonography of the head of the pancreas. 

The proximal jejunum was partially opacified after the cholangiogram and identified on EUS. It was further distended with contrast using a direct puncture technique. An electrocautery-enhanced LAMS (2 cm) was deployed and dilated up to 2 cm. CT confirmed a gastroenterotomy located just distal to the ligament of Treitz. This location allows the echoendoscope (125-cm working length) to reach the proximal duodenum. 

Given the risk of perforation associated with stent dislodgement and lack of urgency, we elected to allow the track to mature before imaging the head of the pancreas with EUS. A temporary internal-external percutaneous drain was inserted to avoid cholangitis. 

Four weeks later, a linear echoendoscope entered through the LAMS and advanced retrograde to the proximal duodenum. Endosonography of the head of the pancreas showed a hypoechoic mass measuring 3 cm. The mass was predominantly blue on elastography and hypoenhancing after contrast injection. These imaging features are suspicious for pancreatic cancer. There were no liver metastases or vascular invasion. Fine-needle biopsy with on-site pathology evaluation was consistent with adenocarcinoma.  

Finally, rendezvous ERCP was performed replacing the percutaneous drain with a fully covered metal stent. There were no adverse events. The patient was referred for oncological evaluation and treated with neoadjuvant chemotherapy followed by a Whipple procedure. 

EUS with fine-needle biopsy is the standard of care for establishing diagnosis of pancreatic cancer because of its high diagnostic yield and accuracy. However, selected altered anatomies present a challenge in imaging the head of the pancreas with EUS because of the inability of the echoendoscope to reach the duodenum.  

We demonstrated the feasibility of using EUS in a patient with distal gastrectomy and Roux-en-Y reconstruction to establish an early diagnosis of imaging-occult cancer at the head of the pancreas.

EUS-guided gastrojejunostomy enables endosonography of the head of the pancreas in a patient with distal gastrectomy and Roux-en-Y reconstruction. A direct needle puncture technique can facilitate EUS-guided gastroenterotomy when positioning a catheter to distend the targeted jejunal loop is infeasible.

A fluoroscopic image of the echoendoscope through lumen-apposing metal stent reaching the proximal duodenum.

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