Endoscopic ultrasound-guided jejuno-jejunal anastomosis for malignant outlet obstruction after total gastrectomy

Endoscopic ultrasound (EUS)-guided gastrointestinal anastomosis with a lumen-apposing metal stent (LAMS) is an effective alternative to intraluminal stenting for upper gastrointestinal obstruction [1] [2]. Recently, EUS-guided jejuno-jejunal anastomosis (EUS-JJA) has been reported for adhesive obstruction after gastric bypass and afferent loop syndrome [3] [4] [5].

A 75-year-old man presented with progressive epigastric pain and weight loss due to advanced malignancy after a previous total gastrectomy. Peritoneal recurrence had been diagnosed 2 years after the gastrectomy, and he had received chemotherapy, achieving stable disease for more than 3 years. On this presentation, as celiac trunk infiltration had been found on a recent computed tomography (CT) scan, it was agreed after multidisciplinary discussion that EUS-guided celiac plexus neurolysis should be performed; however, this failed to provide pain relief. At the time of EUS, a tight jejunal stenosis was observed 8 cm below the esophagojejunal anastomosis ([Fig. 1]).

Fig. 1 Radiographic image following oral contrast showing a normal esophagojejunal anastomosis after total gastrectomy, with a dilated jejunal limb due to malignant obstruction.

Given the persistence of symptoms, together with vomiting, the patient underwent EUS-JJA 2 weeks later, after receiving a detailed explanation of the off-label use of the LAMS. A nasobiliary tube was advanced through the stricture and used to fill the jejunal limbs with a methylene blue–saline solution to look for an adequate operative window. A 19-gauge needle was then inserted into the target loop to check for methylene blue aspiration and to inject contrast. A 20 × 10-mm electrocautery-enhanced LAMS (Hot-AXIOS; Boston Scientific, Natick, Massachusetts, USA) was inserted “free-hand” and then dilated up to 18 mm ([Fig. 2] and [Fig. 3 a, b]). A pediatric gastroscope was finally advanced through the LAMS to assess the post-anastomotic jejunal limb ([Fig. 3 c])

Fig. 2 Endoscopic ultrasound image (inset: radiographic image) showing the deployment of the distal lumen-apposing metal stent (LAMS) flange.

Fig. 3 Endoscopic images showing: a the released lumen-apposing metal stent (LAMS) adjacent to the nasobiliary tube that had been placed through the stricture (inset: radiographic image); b the endoscopic ultrasound-guided jejuno-jejunal anastomosis after dilation; c the jejunal limb viewed through the LAMS using a pediatric gastroscope.

On the first postoperative day, a contrast study showed restoration of bowel transit ([Video 1]) and oral feeding was resumed. The patient tolerated the procedure well and returned home 5 days later. He maintained adequate oral feeding and regained 2 kg of weight during the following 2 weeks, allowing chemotherapy to be restarted. Interestingly, he experienced significant improvement in pain control too.

Video 1 Follow-up radiographic image 24 hours after the procedure showing normal passage of oral contrast medium through the jejuno-jejunal anastomosis, thereby confirming restored bowel transit.

EUS-JJA seems an effective treatment for malignant jejunal outlet obstruction.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Fusaroli P, Jenssen C, Hocke M. et al. EFSUMB Guidelines on Interventional Ultrasound (INVUS), Part V. EFSUMB Leitlinien Interventioneller Ultraschall (INVUS), Teil V. Ultraschall Med 2016; 37: 77-99
• 2 Antonelli G, Kovacevic B, Karsensten JG. et al. Endoscopic ultrasound-guided gastro-enteric anastomosis: A systematic review and meta-analysis. Dig Liver Dis 2020; DOI: 10.1016/j.dld.2020.04.021.
• 3 Dioscoridi L, Forti E, Pugliese F. et al. Buried lumen-apposing metal stent after gastrojejunal bypass. Endoscopy 2020; 52: E134-E135
• 4 Mutignani M, Forti E, Larghi A. et al. Endoscopic entero-enteral bypass: an effective new approach to the treatment of postsurgical complications of hepaticojejunostomy. Endoscopy 2019; 51: 1146-1150
• 5 Majmudar K, Wagh MS. EUS-guided jejuno-jejunostomy with lumen-apposing metal stent for complete jejunal obstruction after gastric bypass. Gastrointest Endosc 2016; 84: 853-854

Publication History

Article published online:
23 September 2020