Temporary EUS-guided gastrojejunostomy for gastric outlet obstruction caused by severe acute pancreatitis (with videos).

Abstract

Gastric outlet obstruction (GOO) due to duodenal stricture after acute pancreatitis occurs in 5.7%, with two peaks, during the early phase or after 4 weeks.[1] Patients may require enteral and parenteral nutrition or surgical therapy when conservative treatment fails.[1] EUS-guided gastrojejunostomy (EUS-GJ) has emerged as an alternative for malignant GOO and a bridge therapy for benign causes,[23] including after acute pancreatitis as an unusual indication.[24] We present the case of a 73-year-old male with a history of severe acute pancreatitis 8 weeks earlier, with percutaneous drainage of 70 mm × 50 mm pancreatic fluid collection. He complained of oral intolerance. A computed tomography scan revealed a large gastric retention with two small pancreatic fluid collections [Figure 1]. Gastroscopy confirmed impassable duodenal inflammatory stenosis leading to severe gastric outlet gastrointestinal edema (GOGE) [Figure 2]. A nasojejunal tube was inserted downstream the jejunum but failed to achieve enteral nutrition so parenteral nutrition was initiated. He was referred to our unit to address GOO. A 0.035 mm guidewire was inserted through the duodenal stenosis downstream the jejunum using a gastroscope. After exchange for linear echoendoscope and distension of jejunum with water and contrast, the gastric wall was punctured and free-hand deployment of a cautery-enhanced 15 mm × 10 mm lumen-apposing metal stent (LAMS) was performed [Video 1]. However, an unplanned procedure event occurred as free perforation due to distal flange misdeployment outside the jejunum [Figure 3]. The LAMS was removed using rat-tooth forceps [Figure 4] and the procedure was repeated without finding the previous puncture site. Hence, a 15 mm × 10 mm LAMS was inserted allowing the EUS-GJ [Video 2]. Oral feeding was tolerated the next day, and the patient was discharged 6 days after uneventfully. A barium-meal radiography performed 54 days after confirmed adequate gastric emptying [Figure 5]. The LAMS was removed 3 months later and the patient underwent cholecystectomy 9 months later. He remained with any GOO symptoms throughout a 12-month follow-up.Figure 1: A computed tomography scan showing a large gastric distension together with a small fluid collection in the pancreatic headFigure 2: Endoscopic view of impassable duodenal inflammatory stenosis due to severe acute pancreatitisFigure 3: Endoscopic view of the misdeployed distal lumen-apposing metal stent flange after the first EUS-guided gastrojejunostomy attempt. Notice that the peritoneum can be observed across the lumen-apposing stentFigure 4: Radiological view of lumen-apposing metal stent removal using a rat-tooth forceps after misdeployment of distal flangeFigure 5: Radiological view of barium meal. An adequate gastric emptying is observed as the first and second image are compared. (a) The arrow indicates the pylorus. Notice that only a small amount of contrast pass to the duodenum with a second and third portion stenosis. The asterisk refers to the EUS-guided gastro-jejunal anastomosis. (b) Also, the lumen-apposing metal stent can be observed in situ in the right imageThis case suggests that temporary EUS-GJ is feasible and safe in some patients with GOGE after acute pancreatitis[3] as an alternative to indefinite LAMS placement.[5] Distal flange misdeployement noted intraprocedurally was successfully managed by immediate LAMS removal and repeat LAMS insertion across a new puncture tract. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic and M.I.Tech. He is also an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research group.