Endoscopic ultrasound-guided gastrojejunostomy: a novel technique

Endoscopic ultrasound (EUS)-guided gastroenterostomy with placement of a lumen-apposing metal stent has emerged as a novel, minimally invasive therapeutic option for patients with gastric outlet obstruction (GOO) [1] [2] [3]. The most challenging aspect of the procedure is immobilizing the jejunal loop in order to create the fistulous tract and deploy the stent. Several different techniques have been described [1] [2] [3]. We present a novel approach involving the use of a second endoscope that is advanced through a previously placed percutaneous gastrostomy (PEG) site to within the target jejunal lumen in order to provide traction on the wire, and to facilitate fistula creation and stent placement.

A 68-year-old man presented with GOO following surgical resection for pancreatic cancer. Enteral stenting and PEG-jejununostomy tube placement were unsuccessful for palliation. Therefore, EUS-guided gastroenterostomy was performed using a novel rendezvous technique ([Video 1]).

Video 1 Endoscopic ultrasound-guided gastroenterostomy using a novel rendezvous technique.

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The echoendoscope was used to identify and access the jejunum from within the gastric lumen, and a wire was advanced into the targeted jejunal loop. A concurrent small-diameter endoscope was advanced percutaneously through the PEG site and across the malignant obstruction into the jejunum, where the coiled guidewire was visualized and grasped by a pediatric biopsy forceps. This provided traction on the wire, which facilitated transgastric cautery-assisted fistula creation and stent placement with a lumen-apposing metal stent ([Fig. 1]). After stent placement, both endoscopes were removed and the PEG site was closed intragastrically with an over-the-scope clip. At 3-month follow-up, the patient was still able to tolerate a soft diet.

Fig. 1 Endoscopic image of a gastrojejunal lumen-apposing metal stent.

In conclusion, EUS-guided gastroenterostomy using this rendezvous technique was safe and efficacious, and should be considered in patients with GOO who have a previously placed PEG tube.

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• References

• 1 Tyberg A, Perez-Miranda M, Sanchez-Ocana R. et al. Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open 2016; 4: E276-E281
• 2 Itoi T, Ishii K, Ikeuchi N. et al. Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut 2016; 65: 193-195
• 3 Khashab MA, Kumbhari V, Grimm IS. et al. EUS-guided gastroenterostomy: the first U.S. clinical experience (with video). Gastrointest Endosc 2015; 82: 932-938