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Diameter of surgical versus endoscopic ultrasound-guided gastrojejunostomy: that much wider after all is said and done?
Whereas retrospective literature confirms the comparable clinical success of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) and surgical gastrojejunostomy (SGJ)  , no head-to-head comparison exists of their caliber and long-term patency.
We present one case of a patient receiving both procedures, offering an unusual opportunity for direct comparison ([Video 1]).
Video 1 A patient receiving both an endoscopic ultrasound-guided and a surgical gastrojejunostomy offered an unusual opportunity to compare the diameter of the 2 anastomoses.
A 52-year-old patient was diagnosed with gastric outlet obstruction owing to a duodenal B-cell lymphoma. EUS-GJ was performed using a 20-mm lumen-apposing metal stent (LAMS), followed by 18-mm balloon dilation  ([Fig. 1]).
Upon disease remission with chemotherapy, a blind-ended bulb resulted from scarring of the stenotic duodenal tract. Although the EUS-GJ was wide and patent ([Fig. 2]), erosions were appearing on the jejunal side after 8 months ([Fig. 2 c]) and an SGJ was proposed owing to the uncertainty of long-term patency of the EUS-GJ and a potentially wider caliber of the SGJ.
Following surgery, gastrointestinal follow-through ([Fig. 3]) showed adequate flow through both anastomoses, but EUS-GJ seemed reduced in diameter 13 months after placement. LAMS extraction was planned, revealing significant granulation tissue overgrowth surrounding a stabilized fistula reduced in caliber ([Fig. 3]).
On that occasion, the SGJ caliber was evaluated. Although the surgeon created an almost 5-cm incision, a 20-mm balloon perfectly fitted the final SGJ ([Fig. 4]). Indeed, SGJ requires a linear incision of stomach and jejunal walls and latero-lateral suturing of their inferior and superior margins . This elliptic anastomosis will become round after maturation and scarring, with a smaller final circular diameter compared to the initial linear cut ([Fig. 5]).
Pending randomized data, this case suggests a comparable caliber of SGJ and EUS-GJ for a substantial part of their history, and therefore an assumed larger diameter should not be used as a reason to prefer SGJ. However, it also suggests that long-term LAMS friction may induce inflammatory responses deserving further elucidation, especially when advocating EUS-GJ use in benign disease.
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
Article published online:
17 September 2021
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