Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is an emerging procedure in
the management of gastric outlet obstruction [1]
[2]
[3]
[4]
[5]. One potential application of EUS-GJ is to divert luminal contents away from a luminal
defect in order to minimize infection and/or facilitate healing.
The patient is a 71-year-old man with a history of pancreatic adenocarcinoma and uncovered
metal biliary stent placement 16 months ago who was admitted with cholangitis and
bacteremia (E. coli and Klebsiella) secondary to an occluded biliary stent.
Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated tumor infiltration
of the medial duodenal wall with an associated necrotic debris-filled cavity ([Video 1]). The lateral wall of the indwelling metal stent was clearly visible in the cavity,
consistent with necrosis of the bile duct ([Fig. 1]).
Video 1 Management of cholangitis from a necrotic bile duct with combined fully covered metal
biliary stent and endoscopic ultrasound-guided gastrojejunostomy.
Fig. 1 Necrotic cavity at second portion of duodenum with visible lateral wall of indwelling
biliary stent (arrow); duodenal lumen is visible separately (star).
Cholangiogram demonstrated extravasation of contrast through the stent side holes
into a contained cavity ([Fig. 2]). To prevent further contamination of the biliary tree, a 10-mm × 60-mm fully covered
metal biliary stent (Wallflex; Boston Scientific, Marlborough, Massachusetts, USA)
was placed within the uncovered stent ([Fig. 3]). Repeat cholangiogram confirmed no further extravasation.
Fig. 2 Cholangiogram demonstrating contrast extravasation through the side holes of the
indwelling uncovered metal biliary stent into a contained necrotic cavity.
Fig. 3 Placement of a coaxial fully covered metal biliary stent.
To minimize the risk of further soiling of the necrotic cavity and bile duct, EUS-GJ
was pursued with the goal of diverting luminal contents away from this area. Approximately
250 cc of a dilute methylene blue/saline/contrast solution was infused into the proximal
jejunum. A loop of jejunum adjacent to the gastric wall was identified and a 15-mm × 10-mm
electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific)
was placed ([Fig. 4]).
Fig. 4 Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent.
The patient tolerated the procedure well and was started on a clear liquid diet that
night. He was discharged home 2 days later. At 1 month follow-up, the patient was
eating a full diet and was otherwise doing well.
This case demonstrates a novel use of endoscopic ultrasound-guided gastrojejunostomy
to manage a gastrointestinal luminal defect. Other potential applications may include
management of gastroduodenal fistulas, perforations, and post-operative leaks.
Endoscopy_UCTN_Code_CPL_1AK_2AD
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