A Case of Gastrojejunostomy: We Thought It Would Be a Sprint but Ended up a Marathon

Abstract

This is a 55 year-old Caucasian female with a history of stage IV gastric adenocarcinoma at pylorus causing gastric outlet obstruction. Her tumor is metastatic to liver, complicated by malignant ascites and peritoneal carcinomatosis. She initially underwent gastro-duodenal stent placement to relieve GOO. Subsequently she developed malignancy associated gastroparesis, and obstruction of her gastro-duodenal stent leading to aspiration pneumonia. Given her malignant ascites, peritoneal carcinomatosis a decision was made to avoid percutaneous jejunal access and we proceeded with endoscopic gastro-jejunostomy. Prior to procedure patient underwent a large volume paracentesis, followed by CT abdomen to rule out any small bowel obstruction. She underwent endotracheal intubation and the procedure was performed under MAC sedation. Initially a standard forward-viewing scope was advanced through the gastro-duodenal stent to the fourth portion of duodenum. A stiff long 0.035 guidewire was advanced toward the jejunum under fluoroscopic guidance. A 20 mm dilation balloon was inserted over the guidewire, and, under fluorocopic and endosonographic guidance, we placed the balloon in the proximal jejunum as close as possible from the tip of the echoendoscope located in the distal stomach. Given the presence of preexisting stent, this location was challenging. With a 19G Sharkcore biopsy EUS needle, we punctured the jejunal balloon crossing the gastric wall, creating a gastroenterostomy. The lumen apposing metal stent (LAMS) was deployed, both flares had a complete opening. An XP scope was inserted and advanced to 4th part of duodenum, to pull the guidewire, with the guidewire out of nose and both ends were secured. On endoscopy, it showed that jejunal flare of LAMS was buried into the edematous jejunal wall. Due to risk of migration secondary to ascites reaccumulation and functional failure of end in the edematous wall, we proceeded to place a covered SEMS on with the guidewire in place, 18 mm X 6 cm Taewoog, was successfully deployed thourgh the LAMS lumen. Due to positioning of guidewire, it was technically difficult to guide SEMS towards jeujunal side, as guidewire was coming out of stomach the natural tendency of the stent was to go in that direction. With repeated maneuverings we were able to position the stent appropriately. Both ends of SEMS were located in a good position finally. Final contrast injection showed stent patency without leak. Watch the video: https://goo.gl/Juc3Ay