S2361 Endoscopic Ultrasound-Guided Gastrojejunostomy for the Treatment of Benign Gastric Outlet Obstruction

Abstract

INTRODUCTION: We present a case of a successful endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) for the treatment of benign gastric outlet obstruction (GOO). CASE DESCRIPTION/METHODS: A 37 year-old obese (BMI 80) female with history of an open cholecystectomy presented with nausea and vomiting. Imaging demonstrated a GOO with an obstructive lesion seen at the site of her prior cholecystectomy. An EUS with fine-needle aspiration demonstrated chronic inflammatory changes without evidence of malignancy, and she was discharged with a percutaneous gastrojejunostomy (PEG-J) tube. The patient required frequent PEG-J revisions complicated by the location of the PEG insertion coupled with a deformed pylorus. In order to overcome the anatomy, an ultra-slim bronchoscope was instead used to serve as a rigid steering catheter to advance the wire into the distal small bowel. Unfortunately, despite a longer J-tube, she returned shortly after with a dislodged PEG-J tube, and EUS-GJ was performed given the extensive attempts of revisions. The upper endoscope was advanced under fluoroscopic guidance, and contrast was injected defining the stricture. Water with methylene blue was infused to distend the small bowel. The upper endoscope was exchanged for a linear echoendoscope after which a 19-gauge needle was used to puncture the small bowel from stomach, and methylene blue was aspirated confirming location. An electrocautery-enhanced lumen apposing metal stent (LAMS) was deployed resulting in successful creation of a gastrojejunostomy. The lumen of the LAMS was then dilated with a balloon dilator under fluoroscopic guidance. The stent was then secured in place with the OverStitch device. The patient’s PEG-J was removed and her gastrocutaneous fistula closed using an over the scope clip. The patient tolerated a regular diet without any complications and was discharged. DISCUSSION: Our case highlights the use of bronchoscope to navigate deformed sites that would otherwise be difficult with a flexible angiocatheter. Secondly, it highlights the emergence of EUS-GJ as an innovative alternative to surgical gastrojejunostomy and enteral stenting in benign or malignant GOO. Studies suggests EUS-GJ to be superior to the conventional therapy as it is less invasive and provides lower GOO recurrence and reintervention rates. The EUS-GJ in our patient was technically successful and allowed for resumption of an oral diet, and it signifies EUS-GJ is an effective and potentially safe alternative to conventional treatments of GOO.Figure 1.: Fluoscopic images of navigating through the site of gastric outlet obstruction.Figure 2.: Needle puncture of jejunum under echosonography.Figure 3.: Post-LAMS deployment in gastric body.