S2891 A Case of Endoscopic Ultrasound-Guided Gastrojejunostomy for Gastric Outlet Obstruction in a Patient With a Migrated FCSEMS

Abstract

Introduction: Fully covered self-expandable metal stents (FCSEMS) are often used to resolve benign strictures causing gastric outlet obstruction (GOO). With a short length and anti-migration waist, the TaeWoong Medical FCSEMS is designed to produce radial force against the stricture and greatly reduce stent migration. We report the case of a patient with a retroperitoneal hematoma causing GOO secondary to a duodenal stricture. The FCSEMS placed across the stricture was complicated by stent migration to the stomach, and a gastrojejunostomy (GJ) was performed using a lumen-apposing metal stent (LAMS) and LAMS dilation. Case Description/Methods: A 47-year-old man with no significant history was admitted for GOO secondary to spontaneous non-traumatic hemorrhagic retroperitoneal bleeding. He presented with recurrent episodes of acute epigastric pain radiating to his back, nausea, and vomiting and was found to have pancreatitis with an elevated lipase of 661. Computed tomography (CT) showed a retroperitoneal hematoma surrounding a severely thickened descending and proximal duodenum and the head of the pancreas. Marked distention of the stomach was consistent with GOO. The patient was evaluated by the gastroenterology service, and an esophagogastroduodenoscopy (EGD) revealed a stricture involving the distal D2 and proximal D3 that could not be traversed with the endoscope. An 18 mm x 140mm FCSEMS was placed across the stricture and secured to the antral wall. Three days after discharge, he developed a recurrence of symptoms after advancing his diet to solids. Repeat x-ray and an endoscopic ultrasound (EUS) guided EGD showed the complete migration of the duodenal FCSEMS into the stomach (Panels 1 and 2). The FCSEMS was removed using rat-toothed forceps and an EUS GJ was performed using a 20 mm x 10 mm cautery enhanced LAMS (Panel 3). The patient was able to tolerate both solids and liquids before discharge. Discussion: Despite previously reported benefits of stent anchoring and favorable outcomes of the TaeWoong FCSEMS design, migration occurred. GJ to relieve GOO has emerged as an alternative to refractory cases of endoscopic stenting or surgical GJ, with lower reintervention rates. The use of LAMS to create a GJ successfully mitigated the obstruction in this patient with a complicated hospital course. EUS GJ to relieve obstruction has shown to be promising, and continued research on its safety and efficacy compared to standard therapies (namely FCSEMS) is merited.Figure 1.: 1) X-ray abdomen and pelvis showing the migrated duodenal stent. 2) - Endoscopic view of the migrated FCSEMS in the stomach. 3) - Endoscopic view of the fully deployed LAMS showing the anastomotic connection between the stomach and jejunum, bypassing the duodenal stricture.