Secondary endoscopic ultrasound-guided gastroenterostomy to solve stent dysfunction and prolong lifetime in malignant gastric outlet obstruction

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is effective and safe to relieve gastric outlet obstruction (GOO) [1]. Long-term stent dysfunction, including stent occlusion, migration, and delamination, could be resolved by food disimpaction, stent exchanges, or an overlapping stent [2] [3] [4]. Here, we report a patient with pancreatic ductal adenocarcinoma (PDAC) who received secondary EUS-GE to solve stent dysfunction 10 months after the index operation.

A 54-year-old male with a history of uncinate process PDAC was admitted due to the recurrence of abdominal distention and vomiting 292 days after his first EUS-GE. The anastomotic lumen-apposing metal stent had maintained patency for 10 months, providing substantial nutrition for anti-tumor therapy and enabling a prolonged survival. This time, abdominal computed tomography demonstrated the recurrence of GOO ([Fig. 1]). Gastroscopy revealed pills accumulated in the stomach, and erosion, necrosis and stenosis of intestine around the stent ([Fig. 2]). The distal end of the stent was pointed to the afferent limb. The stent-efferent limb angle was so sharp that the endoscope could hardly pass through. Gastroscopy revealed multiple ulcers in the efferent limb. Radiography showed segmental narrowing of the intestinal lumen ([Fig. 3]). We postulated this could be attributed to localized inflammatory edema. As the original pathway was passable but not smooth, we applied secondary free-hand EUS-GE elsewhere instead of stent repatency or replacement. A nasobiliary catheter was placed to instill saline solution and methylene blue, facilitating direct puncture with 15-mm × 10-mm cautery-enhanced LAMS (Hot Axios stent; Boston Scientific, USA) under EUS (GF-UCT260; Olympus, Tokyo, Japan) guidance from the upper part of gastric body's posterior wall ([Video 1], [Fig. 4]). The patient tolerated a liquid diet from postoperative day 3 and gradually resumed a semiliquid diet.

Fig. 1 Postoperative abdominal computed tomography. a Stomach distention with accumulation of gastric contents. b Initial EUS-GE with lumen-apposing metal stent.

Fig. 2 Endoscopy revealed erosion, necrosis, and stenosis of intestine around the stent.

Fig. 3 Radiography showed segmental narrowing of the efferent intestinal lumen.

Fig. 4 Postoperative radiography demonstrated stent patency after the secondary EUS-GE (thin arrow: contrast agent passed the initial stent but limited to the afferent limb; bold arrow: contrast agent passed the second stent and reached the distal jejunum).

Procedure of two EUS-GE for the patient.Video 1

We demonstrate the significance of EUS-GE to prolong survival duration in malignancy. We also provide a feasible resolution to prevent stent dysfunction for stent-dependent patients.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Bejjani M, Ghandour B, Subtil JC. et al. Clinical and technical outcomes of patients undergoing endoscopic ultrasound-guided gastroenterostomy using 20-mm vs. 15-mm lumen-apposing metal stents. Endoscopy 2021; 54: 680-687
• 2 Trieu JA, Kahlenberg S, Gilman AJ. et al. Long-Term Outcomes of EUS-Guided Gastroenterostomy: A Large, Single-Center Experience. Clin Transl Gastroenterol 2025; 16: e00648
• 3 Bronswijk M, van Wanrooij RLJ, Kunda R. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2022; 54: 310-332
• 4 Kerdsirichairat T, Irani S, Yang J. et al. Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction. Endoscopy. Int Open 2019; 7: E144-E150

Publication History

Article published online:
08 August 2025