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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  . Recently, EUS-guided jejuno-jejunal anastomosis (EUS-JJA) has been reported for adhesive obstruction after gastric bypass and afferent loop syndrome   .
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]).
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])
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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23 September 2020 (online)
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