EUS-GUIDED DUODENO-JEJUNOSTOMY (EUS-DJ): A NOVEL ENDOSCOPIC ANASTOMOSIS FOR PALLIATION OF GASTRIC OUTLET OBSTRUCTION (GOO)

Introduction:

We describe EUS-DJ as a novel salvage endoscopic approach in a patient with native GI anatomy in whom attempts at both duodenal SEMS placement and EUS-guided gastroenterostomy were unsuccessful.

Procedure:

A patient with body-tail pancreatic cancer presented with GOO. A tight stricture was identified in the third duodenal portion. Despite multiple attempts, guidewire could not be passed beyond the stricture. In addition, EUS-gastroenterostomy failed because of inability to identify an appropriately dilated small bowel loop through the gastric wall. The echoendoscope was then advanced until the second portion of the duodenum, in the long route, so that the transducer abutted the upper margin of the stricture. A collapsed jejunal loop was identified endosonographically. A 22G needle was first used to puncture the jejunal loop in order achieve initial saline distention, facilitating subsequent puncture with a 19G needle. Through the larger 19G needle, contrast was easily injected for enterography, confirming location within the small bowel and providing additional guidance. Methylene blue was injected immediately before free-hand access across the duodenal and jejunal walls with a cautery-enabled LAMS catheter. Following catheter insertion, a 20-mm diameter LAMS was placed with both distal and proximal flanges released inside the scope channel. No adverse events occurred. The patient was discharged home the following day and tolerates a full diet 3-months later.

Conclusions:

EUS-DJ with LAMS represents a novel palliative option in the treatment of GOO. This approach may be useful in patients with strictures distal to the ampulla, in which wire-guided canalization results difficult. Several tips may facilitate the procedure: graded injection with 22G needle for initial jejunal distension before puncture with a 19G needle; methylene blue injection immediately prior to catheter insertion to provide instant endoscopic confirmation of proper target access upon LAMS deployment; Intra-channel stent release to minimize chances of stent misdeployment.