Duodenal self-expandable metal stenting is the most common treatment for duodenal
malignant obstruction. However, when it is impossible to pass a guidewire through
the obstruction, gastroenterostomy using a lumen-apposing metal stent (LAMS) is an
effective alternative [1]. Nevertheless, it is commonly necessary to introduce a filling catheter to fill
the bowel with water [2] or to place a guidance balloon [3].
Our case involved an obstruction so severe that even a guidewire could not be passed
through the tumor. The patient was a 72-year-old man, with a past history of terminal
colostomy for colon cancer, who was referred for a duodenal obstruction due to pancreatic
adenocarcinoma. Two attempts at duodenal stenting failed and we decided to perform
an endoscopic ultrasound (EUS)-guided gastroenterostomy as an alternative.
EUS-guided identification of the duodenum where it was exiting from the large tumor
([Fig. 1]; [Video 1]) allowed targeted puncture with a 19G needle. To fill the bowel quickly, we first
injected contrast and then immediately connected the water pump directly to the 19G
needle ([Fig. 2]) to increase the liquid flow rate in the bowel and obtain a large expansion. When
the duodenum was distended, a guidewire was placed and a 20 × 10-mm LAMS (Axios; Boston
Scientific, Marlborough, Massachusetts, USA) was inserted. No leakage was apparent
on the radiographic check.
Fig. 1 First part of the procedure of endoscopic ultrasound (EUS)-guided gastroenterostomy.
a, b EUS images showing: a the tumor with the small bowel disappearing into the lesion; b the normal appearance of the duodenum beyond the tumor. c, d Expansion of the small bowel with rapid water-jet injection of saline and contrast:
c photograph of the procedure being performed; d EUS view of the distended duodenum.
Video 1 Endoscopic ultrasound-guided gastroenterostomy with water pump filling to expand
the duodenum.
Fig. 2 Second part of the procedure with placement of the lumen-apposing metal sent (LAMS).
a Radiographic image showing opacification with contrast and filling of the small bowel.
b, c Placement of the LAMS, as shown on: b endoscopic ultrasound view; c endoscopic view. d Fluoroscopic check following LAMS placement showing no leakage of contrast.
The same evening, transit has resumed through the colostomy and, despite initial dietary
instructions, the patient left the unit to eat a hamburger.
At 1-month follow-up, no postoperative complications had occurred and the patient
had gained 4 kg.
The use of the water pump directly on the needle is a simple technique to obtain bowel
filling as quickly as possible, allowing a large distension without multiple manipulations
of the syringe.
Endoscopy_UCTN_Code_TTT_1AO_2AH
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
