Endoscopic Gastrojejunostomy: An Evolving Approach for the Treatment of Gastric Outlet Obstruction

Abstract

Gastric outlet obstruction (GOO) can occur due to variety of etiologies, both malignant and benign. The treatment of GOO has evolved over the years, based on etiology, from surgical to an ever-growing choice of endoscopic therapies. We present an 81-year-old man with a history of stage 3 pancreatic adenocarcinoma being treated with a combination of chemotherapy and radiation therapy. He developed biliary obstruction, for which a biliary metal stent was placed 11 months prior to his admission. He presented with two weeks of post prandial nausea and emesis and a resultant intolerance for solid food and thick liquids. He was doing well with good functional status prior to these symptoms. The patient underwent EGD which revealed a severe stenosis at the second portion of the duodenum in the region of the biliary stent with a large ulcer in the area as well. Due to the presence of the large ulcer and a desire to maintain access to the biliary tree the option of a gastrojejunostomy (GJ) was offered. First a long catheter was placed over a wire and left in the distal duodenum to allow for distension with a methylene blue/contrast solution as needed. Using a linear array echoendoscope the distended bowel loop was identified and punctured with a 22 gauge FNA needle and blue fluid was aspirated to confirm position. Using a cautery-enhanced LAMS system a GJ was successfully created with a 15 mm LAMS at the greater curvature of the stomach. The lumen of the stent was then dilated to 15 mm with a balloon. The patient was able to tolerate clear liquids well and was discharged the next day. While a surgical GJ is the preferred management of GOO it is associated with a high rate of complications. Enteral stenting has proven to be an effective alternative, however stent obstruction can occur in about 18% of cases with reported patency rates as low as 57% at 6 months in one series. In patients with biliary metal stents, the subsequent placement of a duodenal stent has been shown to be a risk factor for biliary stent dysfunction. Recent data has demonstrated the feasibility and short-term efficacy of EUS-GJ and offers an intriguing alternative to current options. Potential advantages may prove to be maintained access to the biliary tree and perhaps longer clinical success. While more prospective data is needed regarding the long term efficacy and safety of the technique, it may be a reasonable alternative in certain clinical scenarios.Figure: EUS view of distended loop of small intestine in close proximity to the gastric wall.Figure: Endoscopic view of loop of small intestine through LAMS.Figure: Fluoroscopic image of deployed LAMS forming a gastrojejunostomy.