University of South Florida Morsani College of Medicine Tampa, FL, United States
Abid Javed, MD1, Ali Abbas, MD, MPH2 1University of South Florida Morsani College of Medicine, Tampa, FL; 2University of South Florida, Tampa, FL
Introduction: Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen apposing metal stents (LAMS) has recently emerged as a minimally invasive modality for the treatment of gastric outlet obstruction as an alternative for transpyloric duodenal stenting. However, it is often challenging to cross the obstruction with the adult gastroscope and standard wires to irrigate with diluted contrast to provide suitable target for LAMS placement when performing EUS-GE.
Case Description/Methods: A 62 year old male with Gardner syndrome presented with epigastric discomfort, anorexia, and weight loss. A push enteroscopy demonstrated an almost completely obstructing proximal jejunal polyp; biopsies demonstrated adenocarcinoma. The patient was not a surgical candidate due to medical comorbidities and hepatic metastases, so the decision was made to offer EUS-GE using a modified technique to bypass the relatively distal obstruction. Using an adult colonoscope, an ERCP cannula over a 600cm guidewire was passed under fluoroscopic guidance. An 8.5Fr nasobiliary catheter was then passed in its entirety through the scope; an ERCP extraction balloon catheter was then advanced over the wire as a pusher to allow exchanging the scope out while leaving the nasobiliary catheter in place. A linear EUS scope was passed alongside the nasobiliary catheter to the gastric cavity and the nasobiliary catheter was connected to the irrigation pump. 500cc of diluted contrast was injected distal to the obstruction under fluoroscopic and endosonographic guidance to create a suitable target for stent deployment. A LAMS was then deployed freehand and established access to the jejunal lumen distal to the obstruction. Finally, a through-the-scope balloon dilation of the LAMS was performed, followed by removal of the nasobiliary tube and the wire. The final location of the gastrojejunostomy was in the distal stomach along the greater curvature to facilitate drainage by gravity. In the weeks that followed, the patient was able to tolerate mechanical soft diet without further obstructive symptoms.
Discussion: Use of an adult colonoscope and nasobiliary tube in conjunction with a 600cm guidewire and a pusher catheter allows for adequate luminal access for obstructions distal to the ligament of Treitz to perform EUS-guided gastroenterostomy.
Disclosures: Abid Javed indicated no relevant financial relationships. Ali Abbas indicated no relevant financial relationships.
Abid Javed, MD1, Ali Abbas, MD, MPH2. P1754 - EUS-Guided Gastroenterostomy for Proximal Jejunal Obstruction: Technique Modification for Deep Enteric Access, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.