EUS-guided gastro-gastrostomy combined with exclusion gastro-jejunostomy as a treatment for occlusion syndrome due to pancreatic cancer in a patient with a Roux-en-y gastric bypass

A 69-year-old patient with a Roux-en-Y gastric bypass was admitted for abdominal pain and persistent nausea without vomiting. A CT-scan showed significant gastric and duodenal stasis of the excluded stomach without dilation of the rest of the digestive tract, due to a pancreatic tumor.

EUS-guided gastro-gastrostomy was decided to drain the excluded stomach. Ultrasound showed macrodilatation of the excluded stomach up to more than 15 cm. A 20 x 10 mm lumen-apposing metal stent (LAMS) was performed by free-hand technique. Subsequently, almost three liters of biliary fluid were aspirated through the LAMS and a naso-gastric tube was placed.

Daily output of nasogatric-tube was up to 1 liter/day, so new CT scan was performed reporting a pancreatic mass in uncinate process leading to obstructive stenosis of third doudenum. Excluded stomach was currently less dilated thanks to gastro-gastric anastomosis.

Endoscopy was performed through the LAMS to access to excluded duodenum. After aspiration of a large amount of biliary fluid, a normal papilla was identified, proximal to a 5cm-length duodenal stenosis, without attempting to the angle of Treitz. A diverting gastro-jejunostomy between the excluded stomach and jejunum was decided, so a 20 mm x 10 mm LAMS was placed by free-hand technique after position of a nasobiliary catheter. Gastro-gastric LAMS was replaced by two double pigtail plastic stents.

Location of the stenosis at post-papillary level explained the lack of complete clinical improvement after gastro-gastric anastomosis, due to biliary retention and gastric secretions. After complementary gastro-jejuno anastomosis, occlusion was resolved.

Conflicts of Interest

Enrique PEREZ-CUADRADO ROBLES is consultant for Boston Scientific

Publication History

Article published online:
27 March 2025