2187 Successful EUS-Guided Gastrojejunostomy in Altered Anatomy After Failed Surgical Management

Abstract

INTRODUCTION: Endoscopic ultrasound (EUS) guided gastrojejunostomy is a recognized technique for relief of benign and malignant gastric outlet obstruction (GOO). This technique creates a fistulous tract between the stomach and the jejunum via placement of a lumen apposing metal stent. It has been shown to be technically and clinically successful in many patients with GOO, however its feasibility in the setting of altered postsurgical anatomy is less clear. CASE DESCRIPTION/METHODS: We present a 70-year-old female who underwent a laparoscopic cholecystectomy complicated by bile leak and duodenal perforation requiring a Roux-en-Y gastrojejunostomy. In the following year she developed GOO related to stenosis at the GJ anastomosis. Endoscopic placement of an esophageal covered metal stent across the anastomosis did not provide long term resolution of GOO and was followed by a second surgical revision of her gastrojejunostomy. Unfortunately, she continued to have significant nausea and recurrent vomiting. Repeat EGD and upper GI series showed persistent GOO at the level of the anastomosis. Therefore, a decision was made to attempt EUS guided gastrojejunostomy. A gastroscope was advanced past the anastomosis and a guide wire was placed into the jejunum. Next, a 20 mm balloon catheter was advanced over the wire to the proximal jejunum using fluoroscopic guidance. An EUS echoendoscope was then inserted sideways to the balloon and used to identify the distended proximal jejunum in close proximity to the gastric wall. The jejunum was punctured under EUS guidance with a 19-gauge needle. A 0.025" guidewire was advanced through the needle under fluoroscopy into the proximal jejunum. A 15 mm × 10 mm AXIOS stent was advanced over the wire, and successfully deployed with the flanges in close approximation to the walls of the proximal jejunum and stomach. (Image 1). Upper GI series showed no evidence of leak and adequate gastric emptying across the gastrojejunal stent. The patient was discharged two days later on a low residue diet. Repeat EGD and upper GI series six weeks later showed no signs of GOO with a patent AXIOS stent (Image 2). At 6 month follow-up the patient continues to have complete resolution of nausea and vomiting. DISCUSSION: EUS guided gastrojejunostomy using lumen apposing covered metal stents can be a safe and effective option for management of GOO in patients with altered anatomy. However, there still remains need for long term follow up to determine the durability of such novel endoscopic interventions.