A stent too far: endoscopic ultrasonography-guided duodenojejunostomy for malignant duodenal obstruction after placement of a stent in the horizontal part

Endoscopic ultrasonography-guided gastroenterostomy offers distinctive benefits in the management of malignant gastric outlet obstruction [11] [22]. When faced with unusual obstruction, the endoscopist must find an appropriate place to “build a bridge” [33]. Here, we report a case of EUS-guided duodenojejunostomy following placement of a duodenal stent in the horizontal part.

A 60-year-old man with a history of pancreatic cancer was admitted because of long-term indigestion and acute melena. The patient had received chemotherapy and endoscopic retrograde biliary drainage for jaundice 2 years previously, and duodenal stent placement (at the horizontal part) for malignant obstruction 1 year ago. Esophagogastroduodenoscopy and computed tomography showed severe tumor ingrowth ([Fig. 1Fig. 1] a, [Fig. 2Fig. 2]) and active bleeding at the distal end of the stent ([Fig. 1Fig. 1] b).

Fig. 1 Fig. 1 Endoscopic images showing tumor ingrowth and bleeding. a The inner lumen of the duodenal stent was narrowed by tumor ingrowth. b An active oozing hemorrhage was found at the distal end of the stent.

Fig. 2 Fig. 2 Abdominal computed tomography image of the narrowed duodenal stent. a Axial view. b Reconstruction image.

Given the poor general status and the duodenal obstruction, a double-balloon-assisted gastrojejunostomy was planned after complete hemostasis. Unexpectedly, the distance between the stomach and the jejunum was too great for anastomosis, and the operation approach was blocked by the stent ([Fig. 3Fig. 3] a). After repeated attempts, the distance between the duodenal bulb and the distal balloon was close enough to place the stent ([Fig. 3Fig. 3] b). EUS-guided puncture of the distal balloon was performed transduodenally with the Hot Axios system (M00553550; Boston Scientific, Marlborough, Massachusetts, USA), and the stent was then delivered into the jejunum and deployed over the guidewire. A guidewire was then successfully advanced through the stent under fluoroscopy. Finally, with the injection of contrast agent, a clear delineation of the jejunum confirmed the duodenojejunostomy ([Fig. 4Fig. 4], [Video 1Video 1]). Postoperatively, the patient presented relief of obstructive symptoms and good stent patency by barium radiography ([Fig. 5Fig. 5]).

Fig. 3 Fig. 3 Procedure for identifying the site of puncture. a The distance between the stomach and the jejunum was too great for anastomosis. b The distance between the duodenal bulb and the distal balloon was appropriate for stent placement.

Fig. 4 Fig. 4 Procedure for endoscopic ultrasonography-guided duodenojejunostomy. a Echoendoscopic view of stent deployment. b A guidewire was advanced into the jejunum through the stent.

Fig. 5 Fig. 5 Postoperative barium radiography image.

Endoscopic ultrasonography-guided duodenojejunostomy for malignant duodenal obstruction after placement of a stent in the horizontal part.Video 1Video 1

The field of therapeutic EUS has expanded greatly [44]. In this case, we highlight a particular EUS-guided duodenojejunostomy procedure demonstrating the endoscopist’s creativity. Sometimes, the endoscopist must become a pathfinder to deal with the complex conditions in the gastrointestinal tract.

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• References

• 1 Chan SM, Dhir V, Chan YYY. et al. Endoscopic ultrasound-guided balloon-occluded gastrojejunostomy bypass, duodenal stent or laparoscopic gastrojejunostomy for unresectable malignant gastric outlet obstruction. Dig Endosc 2023; 35: 512-519
• 2 Teoh AYB, Lakhtakia S, Tarantino I. et al. Endoscopic ultrasonography-guided gastroenterostomy versus uncovered duodenal metal stenting for unresectable malignant gastric outlet obstruction (DRA-GOO): a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2024; 9: 124-132
• 3 Hanscom M, Schmidt A, Cherng N. et al. EUS-guided duodenojejunostomy for the nonsurgical management of duodenal obstruction in a patient with complicated postsurgical anatomy. Gastrointest Endosc 2021; 94: 1010-1011
• 4 van der Merwe SW, van Wanrooij RLJ, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205