S1865 EUS-Guided Gastrojejunostomy Using Lumen-Apposing Metal Stent (LAMS) for Malignant Gastric Outlet Obstruction

Abstract

INTRODUCTION: Endoscopic ultrasound guided gastrojejunostomy (EUS-GJ) is a novel endoscopic technique as a treatment for benign or malignant gastric and duodenal stricture with gastric outlet obstruction (GOO). EUS-GJ is performed in non-surgical candidates due to its less invasive approach. EUS-GJ involves creating a fistulous tract to access to the jejunum from the stomach using a lumen-apposing metal stent (LAMS) (AXIOS™, Boston Scientific Corp., Marlborough, MA, USA). Thus, creating a gastrojejunal bypass endoscopically. CASE DESCRIPTION/METHODS: An elderly patient presented with nausea, vomiting and inability to tolerate oral intake. The upper-endoscopic examination demonstrated a malignant stricture in the first portion of the duodenum (Figure 1). The risks and benefits of EUS-GJ were discussed with the patient due to poor surgical candidacy. The direct endoscopic ultrasound puncture technique involves advancing the linear endoscope into the stomach. The targeted jejunal loop is identified endosonographically. A 22-gauge needle puncture is used to distend the jejunum and injection of contrast is used to confirm the location before creating the fistulous tract. Then, the creation of a fistulous tract was completed with enhanced electrocautery 20-mm LAMS delivery system utilizing a free hands technique. The Gastrojejunostomy is then created by deploying the distal flange of the LAMS in the jejunum followed by pulling back to the stomach where the proximal flange is deployed. Finally, the balloon is dilated to 20-mm (Figure 2). Follow up abdominal CT visualized resolution of GOO (Figure 3). DISCUSSION: EUS-GJ is a less invasive approach in patients with GOO and contraindication to surgery. EUS-GJ remains a highly technically challenging endoscopic procedure. The data currently shows that a high technical (>90%) and clinical (>80%) success rates with low adverse events rate might be reached by a skilled therapeutic endoscopist with experience in therapeutic EUS. Therefore, EUS-GJ is a safe and efficacious treatment modality for the management of benign and malignant GOO.Figure 1.: Endoscopic view showing malignant stricture in the first portion of the duodenum.Figure 2.: Endoscopic view across the lumen-apposing metal stent showing the anastomotic connection between the stomach and jejunum, effectively bypassing the obstruction.Figure 3.: Computerized tomography abdomen after endoscopic ultrasound guided gastrojejunostomy showing the lumen-apposing metal stent and demonstrating resolution of the gastric outlet obstruction.