Endoscopic ultrasound (EUS)-guided gastroenterostomy is an experimental procedure
that is emerging as a minimally invasive alternative to surgical bypass and to luminal
endoscopic stent placement [1]
[2]. We report successful treatment of a 50-year-old woman who was referred with malignant
obstruction of the afferent loop of a Roux-en-Y anastomosis due to local recurrence
of cholangiocarcinoma following an earlier pancreaticoduodenectomy. Because the severely
dilated afferent loop was compressing the stomach, sufficient nutrition was impossible.
Additionally, the patient was jaundiced because of extrahepatic biliary obstruction.
A percutaneous transhepatic metal stent was inserted to relieve the jaundice, but
after several unsuccessful attempts to place self-expandable stents through the afferent
loop stenosis, we decided to perform an EUS-guided gastroenterostomy using a linear-scanning
echoendoscope (Pentax EG-3870UTK; Tokyo, Japan) and the Hot Axios stent system (Hot
Axios; Xlumena, Mountain View, California, USA). After the dilated jejunal loop was
visualized by EUS, the distal end of the stent delivery system was inserted through
the stomach wall into the jejunal lumen by applying electrocautery ([Fig. 1 a, b], [Video 1]). The lumen-apposing stent was then deployed resulting in immediate flow of fluid
from the obstructed jejunal loop into the stomach. Fluoroscopy was not performed since
correct placement could be confirmed by EUS and direct view of the jejunal lumen ([Fig. 2 a, b], [Video 2]). Following the procedure, the patient’s symptoms resolved and enteral feeding was
reinstated ([Fig. 3]). No adverse events were observed during a 30-day follow-up period.
Fig. 1 Endoscopic ultrasound (EUS)-guided gastroenterostomy to treat a patient with malignant
obstruction of the afferent loop of a Roux-en-Y anastomosis. a Visualization of the dilated jejunal loop with EUS. b EUS-guided puncture of the jejunum using the Hot Axios stent delivery system.
Endoscopic ultrasound (EUS)-guided gastroenterostomy: puncture of the jejunum.
Fig. 2 a The lumen-apposing stent with the delivery system in the stomach. b The stent is fully deployed.
Deployment of the lumen-apposing stent as seen with gastroscopy. Fluids are flowing
from the jejunal loop into the stomach.
Fig. 3 Computed tomography (CT) scan showing the correctly placed lumen-apposing stent.
Currently, two case series and several case reports have been published describing
different methods such as the double-balloon technique and water infusion [2]
[3]
[4]
[5]. In patients with afferent loop obstruction, direct EUS-guided gastroenterostomy
without the use of fluoroscopy or other adjuncts can safely be performed since the
dilated jejunal loop is filled with fluids, but further research is warranted before
large-scale clinical implementation.
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