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DOI: 10.1055/a-1190-3228
Successful treatment of superior mesenteric artery syndrome by endoscopic ultrasound-guided gastrojejunostomy
An 88-year-old man with a history of extensive cardiovascular co-morbidities was admitted to our tertiary center following prolonged vomiting, anorexia, and upper abdominal pain. He had lost 10 kilograms over the course of 4 months as a result. An abdominal computed tomography (CT) scan was performed to rule out neoplasia. Surprisingly, the scan revealed extensive gastroduodenal distention and a high-grade stenosis of the third part of the duodenum (D3) caused by extrinsic compression by the superior mesenteric artery ([Fig. 1], arrow). Furthermore, a significantly reduced aortomesenteric angle was identified (9.1°, normal: 25 – 60°) ([Fig. 2]); these findings are compatible with superior mesenteric artery syndrome [1]. Nasogastric tube decompression and parenteral feeding were commenced, resulting in only temporary relief of symptoms. Unfortunately, endoscopic placement of a nasojejunal feeding tube also failed.
Only very recently has endoscopic ultrasound (EUS)-guided gastroenterostomy also been evaluated in the context of a benign gastric outlet obstruction [2] [3]. Because our patient was deemed unfit to undergo surgery, this technique was proposed to the patient and his family, who consented to the procedure. Under endoscopic and fluoroscopic guidance, a 0.035-inch guidewire was advanced through the extrinsic stenosis of D3 ([Fig. 3]) and subsequently exchanged for a nasobiliary catheter. Water was infused into the jejunum ([Video 1]), dilating the latter and facilitating visualization on EUS ([Fig. 4]). Lastly, a 20 × 10-mm lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system (Hot AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) was deployed through the gastric wall into the dilated jejunum ([Fig. 5]), creating a gastrojejunostomy. No complications occurred and the patient was started on clear liquids the same evening. During the following days, intake increased progressively and the patient was discharged on day 7.
Video 1 Endoscopic ultrasound-guided gastrojejunostomy for treatment of superior mesenteric artery syndrome.
Quality:
This video case illustrates the diverse indications for which this minimally invasive technique can be used and confirms previous work that even patients with benign disease can benefit from EUS-guided gastroenterostomy.
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Publication History
Article published online:
19 June 2020
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References
- 1 Neri S, Signorelli SS, Mondati E. et al. Ultrasound imaging in diagnosis of superior mesenteric artery syndrome. J Intern Med 2005; 257: 346
- 2 McCarty TR, Garg R, Thompson CC. et al. Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2019; 7: 1474-1482
- 3 James TW, Greenberg S, Grimm IS. et al. EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction. Gastrointest Endosc 2020; 91: 537-542