Over the past decades, the secondary mechanical obstruction of the upper gastrointestinal
(GI) tract caused by pancreatic head tumors has been treated with a standard surgical
approach. The recent development of minimally invasive techniques like transluminal
interventions guided by endoscopic ultrasound (EUS) has opened up new modalities for
some patients [1]
[2].
A 56-year-old woman had been treated with chemotherapy for pancreatic head adenocarcinoma
with metastases to the lymph nodes. An endoscopic retrograde cholangiopancreatography
(ERCP) with a plastic stent implantation was performed to treat obstructive jaundice.
After finishing therapy, the patient presented with symptoms of gastric outlet obstruction.
Owing to her poor surgical status, she was referred for endoscopic treatment.
The procedure was begun by advancing a guidewire (Hydra Jagwire, .035 inch, 450 cm;
Boston Scientific, Marlborough, Massachusetts, USA) followed by a biliary catheter
(X-Press; Olympus Medical Systems Corp., Tokyo, Japan) through the narrowed duodenal
bulb to the most distal part of the upper jejunum. This step was performed under fluoroscopic
guidance with a standard endoscope (GIF-HQ190; Olympus). To exclude a distal small
intestinal obstruction, a contrast solution (Omnipaque; GE Healthcare, Chicago, Illinois,
USA) was injected behind the Treitz ligament ([Video 1]). After passage confirmation, the small intestine was filled with water at the Treitz
ligament level ([Fig. 1]). This facilitated endosonographic visualization of the optimal site for lumen-apposing
metal stent (LAMS) placement. The gastrojejunostomy was performed by implanting a
15-mm stent (AXIOS, Boston Scientific) ([Fig. 2]).
Video 1 Sequential endoscopic therapy was performed to create an endoscopic ultrasound-guided
gastrojejunal anastomosis, followed by retrograde colonoscope-assisted metal stenting
of the bile duct.
Fig. 1 The small intestine is filled with water at the Treitz ligament level. The lumen
of the small intestine (yellow lines), water in the lumen of the small intestine (red
arrow), and the lumen-apposing metal stent before implantation (green arrow) are visible.
Fig. 2 The gastrojejunostomy was performed by implanting an AXIOS stent. The internal flank
in the lumen of the small intestine (green arrows) is visible.
After 4 weeks, the patient presented with no symptoms of GI obstruction but with worsening
cholestasis requiring ERCP. Plastic stent removal and self-expandable metal stent
implantation were performed through the AXIOS stent lumen using a pediatric colonoscope
(PCF-H190, Olympus) ([Video 1, ]
[Fig. 3]). At the 4-week follow-up, no jaundice or gastrointestinal obstruction was observed.
Fig. 3 a A pediatric colonoscope was advanced through the lumen of the AXIOS stent. b The common bile duct cannulation with visible guidewire. c, d Implantation of self-expandable metal stent.
This case is important for three main reasons. First, we confirmed that EUS-guided
transluminal creation of a gastrojejunal anastomosis is a safe and effective alternative
to surgery. From the technical standpoint, we want to highlight the role of the catheter
in locating the optimal site for stent placement. Also, filling the jejunum with water
is a crucial step for safely performing the gastrojejunostomy because it allows for
easy visibility and puncturing during EUS. Second, placement of a self-expandable
stent with the relevant diameter facilitates performing another required procedure,
in this case ERCP. Finally, we have shown that ERCP can be performed using a forward-viewing
endoscope (pediatric colonoscope), which was advanced orally but reached the papilla
on a retrograde route, i. e., through the newly created endoscopic gastrojejunostomy,
making it in essence a “double retrograde” procedure (“oral retrograde ERCP”).
Endoscopy_UCTN_Code_TTT_1AR_2AK
Endoscopy E-Videos is a free 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.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
