EUS-guided Gastrojejunostomy Research Articles

Recurrence of malignant duodenal obstruction following duodenal stenting: successful management through EUS-guided gastrojejunostomy (with videos)

Recurrence of malignant duodenal obstruction following duodenal stenting: successful management through EUS-guided gastrojejunostomy (with videos)

Is endoscopic ultrasound-guided gastroenterostomy better than surgical gastrojejunostomy or duodenal stenting?

Gastrojejunostomy is a critical procedure for managing gastric outlet obstruction. While surgical gastrojejunostomy has traditionally been the standard approach, endoscopic ultrasound (EUS)-guided gastroenterostomy has emerged as a promising endoscopic alternative. This comprehensive review aims to explore the development, techniques, outcomes, and comparative effectiveness of EUS-guided gastroenterostomy in comparison to duodenal stenting and surgical gastrojejunostomy. A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to April 2024. The search included keywords related to EUS-guided gastrojejunostomy, surgical gastrojejunostomy, and duodenal stenting. Studies reporting on technical success, clinical success, complications, recurrence rates, quality of life, and long-term outcomes were included for analysis. The development of EUS-guided gastroenterostomy has evolved significantly over the years, driven by device advancements and improved endoscopic techniques. Comparative studies have shown that the technique offers several advantages, including the ability to create an anastomosis without the need for surgery, reduced invasiveness, shorter hospital stays, and potentially improved patient outcomes as compared to duodenal stenting and surgical gastrojejunostomy. Endoscopic ultrasound-guided gastroenterostomy represents a promising alternative to surgical gastrojejunostomy and duodenal stenting for the management of gastric outlet obstruction. The technique has evolved significantly, offering a less invasive and more effective treatment option.

Buried lumen-apposing metal stent following EUS-guided gastrojejunostomy: a rare adverse event and its management

Buried lumen-apposing metal stent following EUS-guided gastrojejunostomy: a rare adverse event and its management

Treatment Strategies for Gastric Cancer Patients with Gastric Outlet Obstruction

Gastric cancer frequently leads to gastric outlet obstruction (GOO), causing significant symptoms and complications. Surgical bypass and stenting are two representative palliative treatments for GOO by gastric cancer. This study reviews clinical guidelines for malignant GOO treatment, highlighting differences in recommendations based on patient survival expectations and systemic health. A meta-analysis of surgical bypass and stenting in gastric cancer patients revealed no significant difference in technical and clinical success rates between the two treatments. However, stenting allowed faster resumption of oral intake and shorter hospital stays but had higher rates of major complications and reobstruction. Despite these differences, overall survival did not significantly differ between the two groups. Emerging techniques like EUS-guided gastrojejunostomy show promise but require further research and experienced practitioners. Ultimately, treatment should be tailored to patient preferences and the specific benefits and drawbacks of each method to improve quality of life and outcomes.

A156 INCIDENCE OF MALIGNANT GASTRIC OUTLET OBSTRUCTION IN PATIENTS WITH PANCREATIC CANCER UNDERGOING FOLFIRINOX THERAPY

Abstract Background Malignant gastric outlet obstruction is a morbid complication of pancreatic cancer. There is currently a lack of epidemiology data characterizing its incidence and outcomes in patients with unresectable pancreatic head cancer undergoing chemotherapy with leucovorin, fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX). Determining the incidence of MGOO in this context is crucial for developing effective management strategies. Aims We aim to ascertain the incidence of MGOO in patients with pancreatic cancer treated with FOLFIRINOX. Secondary objectives include evaluating the clinical outcomes of MGOO. The primary endpoint was the rate of malignant gastric outlet obstruction, defined as clinical evidence of MGOO confirmed with axial imaging and/or endoscopy. Secondary endpoints included the length of hospitalization for MGOO and the rate of successful endoscopic or surgical management. Methods This was a retrospective, single-center study including patients with pancreatic head cancer treated with FOLFIRINOX between January 1, 2017, and December 31, 2022, who did not undergo surgical resection. Patients were excluded if they had pancreatic cancer located in the neck, body, and/or tail of the pancreas, had predominantly cystic cancer, had an oncological resection, had a prophylactic surgical gastrojejunostomy, or had metastatic cancer to the pancreas. Results Overall, 44 patients with pancreatic head cancer (40.90% female, mean age 59.3 ± 8.5 years) were included. There was no statistically significant difference in tumor staging between MGOO and No-MGOO patients: overall, 6.8% borderline, 40.9% metastatic, and 52.3% locally advanced. The incidence of MGOO in patients with pancreatic head cancer was 36.36%. Patients who never developed MGOO experienced significantly shorter unplanned hospitalizations (mean ± SD: 20.8 ± 18.30 days) compared to those with MGOO (mean ± SD: 50.33 ± 41.22 days; p = 0.0175). The mean number of FOLFIRINOX cycles received was 7.2 (±5.43) for patients without MGOO and 8.1 (±5.81) for patients with MGOO (p = 0.6152). Among patients with MGOO (n=12), management strategies included EUS-guided gastrojejunostomy (43.75%), duodenal stent placement (31.25%), and medical management (25%). Conclusions Our contemporary data suggest a high rate of MGOO (36%) in patients with advanced pancreatic head cancer undergoing FOLFIRINOX treatment. The development of MGOO was associated with longer total hospitalization when compared to patients who never developed MGOO. Our study underscores the significant negative impact of MGOO with further research needed to elucidate better management strategies including better endoscopic or surgical prophylactic measures. Funding Agencies CIHR

Pitfalls of EUS-guided gastrojejunostomy in a patient with history of Roux-en-Y gastric bypass and a frozen abdomen.

Video 1Case of EUS-guided gastrojejunostomy in a patient with a history of Roux-en-Y gastric bypass and a frozen abdomen.

Endoscopic pyloric exclusion—EUS-guided gastrojejunostomy combined with endoscopic suturing and closure of the pylorus: a novel approach to failed surgical repair of a perforated duodenal ulcer

Video 1Endoscopic pyloric exclusion: same-session EUS-guided gastro-jejunostomy combined with endoscopic suturing and closure of the pylorus.

Iatrogenic perforation during lumen-apposing metal stent deployment closed using an over-the-scope stent fixation clip device

Video 1Endoscopic closure of an iatrogenic perforation caused during EUS-guided gastrojejunostomy for malignant gastric outlet obstruction treated with an over-the-scope stent fixation clip device.

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

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.

S1137 Analysis of Off-Label Usage of Lumen Apposing Metal Stents in the GI Tract: A Single Center Experience

Introduction: Lumen apposing metal stents (LAMS) have revolutionized our approach to pancreatic fluid collections (PFCs). In addition to tremendous success in safely and effectively managing PFCs, LAMS have been utilized in other interventions including EUS-guided gallbladder drainage (EUS-GBD), EUS-directed transgastric ERCP (EDGE), EUS-guided transgastric intervention (EDGI), EUS-guided gastrojejunostomy (EUS-GJ), EUS-guided choledochoduodenostomy (EUS-CD), EUS-guided drainage of post-operative collection (EUS-PO) and stricture dilation (SD). There is limited research on the use of LAMS for these off-label indications. We present our experience using LAMS in the management of conditions other than pancreatic fluid collections. Methods: All patients who underwent LAMS placement between March 2015-October 2021 were added to a prospectively maintained database. Collected data including patients’ demographics, procedure details, clinical outcomes, and adverse events was retrospectively reviewed. All patients who underwent LAMS placement for PFCs were excluded from the analysis. Descriptive statistics were used to summarize our findings. Results: A total of 191 patients underwent LAMS placement during the study period. Of these, 65 patients had indications outside of drainage of PFCs. This included EUS-GBD (25), EDGE (6), EDGI (2), EUS-GJ (11), EUS-CD (4), SD (6), EUS-PO (9), and miscellaneous (2) (Table). The average age was 65.7 years (SD 8.6) and 24 were female (36.9%). Technical success was achieved in 63 patients (96.9%). The diameter of LAMS used included 8mm (n=2), 10mm (n=23), 15mm (n=17), and 20mm (n=21). The average procedure time was 39.4 minutes (SD 5.3) and the average duration of LAMS placement was 36.2 days (SD 8.5). Clinical success was achieved in 57/63 patients (90.5%); however, this was much lower for patients who underwent LAMS placement for stricture dilatation (50%). LAMS was left indefinitely in 24 patients (38.1%). Adverse events occurred in six patients (9.2%). Conclusion: LAMS provide an effective and safe modality for securing endoscopic access and allowing interventions outside of PFCs. However, the efficacy of LAMS for managing gastrointestinal strictures remains in question. Table 1. - Summary of usage of LAMS in the GI Tract EUS-GBD (n=25) EDGE (n=6) EDGI (n=2) EUS-GJ (n=11) EUS-CD (n=4) SD (n=6) EUS-PO (n=9) Miscellaneous (n=2) Age, mean, SD 73.64, 12.0 65.8, 8.1 61.0, 9.9 64.5, 13.0 65.3, 17.0 55.2, 11.75 52.0, 18.5 71, 66 Female gender, n, % 6, 24% 5, 83.3% 1, 50% 2, 18% 3, 75% 5, 83% 2, 22.2% 0, 0% Indications, n % Calculous Cholecystitis, 15, 60% Choledocholithiasis (n=4, 66.7%) Pancreatic mass (n=1, 50%) Malignant GOO, 11, 100% Distal malignant biliary obstruction, 4 100% Anastomotic stricture, 4 (67%) Post-operative fluid collections, 9, 100% Liver abscess, 2, 100% Malignant cholecystitis, 5, 20% Acalculous cholecystitis, 2, 8% Benign papillary stenosis (n=2, 33.3%) Pancreatic cyst (n=1, 50%) Pyloric stricture, 2 (33%) Malignant biliary obstruction, 3, 12% Technical success, n, % 23, 92.0% 6, 100% 2, 100% 11, 100% 4, 100% 6, 100% 9, 100% 2, 100% Clinical success, n, % 21/23, 91.3% 6, 100% 2, 100% 11, 100% 4, 100% 3, 50% 8, 88.9% 2, 100% Procedure duration (min), mean, SD 39.5, 21.7 38.7, 20.0 52, 17.0 66, 31.6 24.5, 13.3 18.7, 3.8 27.3, 9.1 28, 7.1 Duration of LAMS placement, mean, SD 47.9, 27.0 30.3, 11.6 28, 0 N/A N/A 68.5, 26.7 47.3, 28.2 39, 5 Adverse events, n, % 4, 18% 0, 0% 1, 50% 0, 0% 0, 0% 1, 16.7% 0, 0% 0, 0% Length of follow-up (days), mean, SD 47.3, 27.9 208.2, 179.1 240, 144.2 46.50, (28.3, 82.8) 143, 119.9 292, 171.2 565.8, 465.1 43.5, 53.0

EUS-guided gastrojejunostomy for management of malignant gastric outlet obstruction in a patient with Roux-en-Y anatomy.

Video 1Endoscopic ultrasound-guided gastrojejunostomy.

A125 A NOVEL TECHNIQUE COMBINING EUS AND SPYGLASS DS SYSTEM GUIDANCE FOR BOTH THE DIAGNOSIS AND MANAGEMENT OF AFFERENT LIMB SYNDROME

BackgroundAfferent limb syndrome is obstruction of a biliary-enteric limb following pancreaticoduodenectomy. In the past, treatment was limited to surgery or insertion of a percutaneous transhepatic biliary drainage tube. A more recent approach to treatment is Endoscopic Ultrasound (EUS)-guided gastrojejunostomy using a lumen apposing metal stent (LAMS). It was first described in two single case reports in 2015 and has been growing in its application. We present a case series of 2 patients where afferent limb syndrome was successfully managed with EUS guided gastrojejunostomy using LAMS.Aims1-To demonstrate a novel technique for diagnosis and management of afferent limb syndrome.MethodsCase # 1- 79 year old female post Whipple’s surgery for ampullary carcinoma, presented two years after surgery with significant nausea and vomiting. CT scan showed obstruction of the afferent loop suspicious for local tumor recurrence. Patient underwent EUS-guided gastrojejunostomy with successful insertion of 20 x 10 mm (AXIOS EC, Boston Scientific) stent.Case # 2-. A 51 year old male with pancreatic CA status post Whipple surgery presented with worsening abdominal pain and nausea. CT scan confirmed afferent limb syndrome. He underwent EUS- guided gastrojejunostomy with successful placement of 10 x 10 mm (AXIOS EC, Boston Scientific).ResultsCase #1: Patient improved dramatically within days and resumed oral diet. Fourteen days later, an upper endoscopy was performed in order to assess the stricture via an anterograde approach. The adult Olympus HQ gastroscope was advanced through the AXIOS stent into the afferent limb to the level of the stenosis where a tight stricture was seen. Multiple biopsies taken and were negative for malignancy. Four weeks later, she continued to tolerate oral diet well with no abdominal pain or discomfort.Case # 2: Patient continued to do well clinically 12 weeks post operation. Follow-up upper endoscopy was performed to determine the etiology of the obstruction but due to a sharp angulation, the gastroscope could not be advanced through the AXIOS stent. As such, we advanced an adult Olympus 1T gastroscope down to the site of the AXIOS stent and then utilized the Spyglass DS system to advanced deep into the afferent limb to the level of the stricture and took multiple biopsies for diagnostic purposes.ConclusionsInterventional endoscopic management of afferent limb syndrome has been evolving in the past few years with EUS guided LAMS gastrojejunostomy becoming a well stablished modality. We have demonstrated this technique with subsequent endoscopic anterograde assessment. In one of these cases, this anterograde assessment was performed using the cholangioscope in conjunction with the gastroscope to overcome unfavorable angulated anatomy which to our knowledge has not been described in the literature previously. Funding AgenciesNone

Morphological study of the gastrointestinal tract around the ligament of Treitz using upper gastrointestinal radiography: Fundamental data for EUS-guided gastrojejunostomy.

We developed EUS-guided double-balloon occluded gastrojejunostomy (EPASS) for gastric drainage tract obstruction. The success of EPASS depends on the proximity of the stomach and the gastrointestinal (GI) tract near the ligament of Treitz. The aim of this study is to clarify the GI anatomy near the ligament of Treitz. One thousand and sixteen cases imaged upper GI radiography using barium were retrospectively evaluated. Morphologically, the GI tract running near the ligament of Treitz was divided in three types: Type I: The 4th portion of the duodenum (D4) approaches the stomach; Type II: D4 does not approach the stomach; Type III: D4 forms a loop to the jejunum. The minimum distance between the stomach and the GI tract near the ligament of Treitz was measured. Based on the morphological classification, 74.6% in the study group was classified in Type I, 22.0% in Type II, and 3.3% in Type III, respectively. The median minimum distance in Type II/III group were significantly longer, compared with the Type I (P<.01). The GI anatomy near the ligament of Treitz was clarified using upper GI radiography. It is divided into three patterns, and one-fourth of cases may have difficulty in EUS-guided gastrojejunostomy.

Clinical management for malignant afferent loop obstruction.

Afferent loop obstruction (ALO) is defined as duodenal or jejunal mechanical obstruction at the proximal anastomosis site of a gastrojejunostomy. With advances in chemotherapy, the incidence of malignant ALO is increasing. Malignant ALO can be complicated by ischemia, gangrenous bowel, pancreatitis, and ascending cholangitis. Moreover, the general condition of patients with recurrent cancer is often poor. Therefore, accurate and rapid diagnosis and minimally invasive treatments are required. However, no review articles on the diagnosis and treatment of malignant ALO have been published. Through literature searching, we reviewed related articles published between 1959 and 2020 in the PubMed database. Herein, we present recent advances in the diagnosis and treatment of malignant ALO and describe future perspectives. Endoscopic transluminal self-expandable metal stent (SEMS) placement is considered the standard treatment for malignant ALO, as this procedure is well established and less invasive. However, with the development of interventional endoscopic ultrasound (EUS) in recent years, the usefulness of EUS-guided gastrojejunostomy has been reported. Moreover, through indirect comparison, this approach has been reported to be superior to transluminal SEMS placement. It is expected that a safer and less invasive treatment method will be established through the continued advancement and innovation of interventional endoscopy techniques.

Personalized Approach to the Role of Endoscopic Ultrasound in the Diagnosis and Management of Pancreaticobiliary Malignancies

Pancreaticobiliary malignancies arise from different areas within the pancreas and biliary tree. Endoscopic ultrasound (EUS) is a well-recognized diagnostic and therapeutic modality in the treatment of pancreaticobiliary diseases, and more specifically, pancreaticobiliary malignancies. Traditionally used for diagnostic purposes, EUS plays a critical role in tissue sampling and cancer staging. The emergence of the new field of interventional EUS has allowed EUS to also play a critical role in therapeutic management. Novel interventional EUS procedures such as EUS-guided gastrojejunostomy (EUS-GE), EUS-guided biliary drainage (EUS-BD), and EUS-guided gallbladder drainage (EUS-GLB) can be utilized to treat complications of pancreaticobiliary malignancies such as gastric outlet obstruction, obstructive jaundice, and cholecystitis. In addition, interventional EUS procedures can be utilized for the palliation of unresectable malignancies both for source control with EUS-radiofrequency ablation (EUS-RFA) and for the treatment of abdominal pain refractory to opioid medications with EUS-guided celiac axis neurolysis. However, patient selection remains a critical component in both diagnostic and therapeutic interventions and must be tailored to individual patient wishes, disease pathology, and overall prognosis.

EUS-guided gastroenterostomy to treat gastric outlet obstruction in a patient with gastric lymphoma followed by pyloric recanalization using a rendezvous technique.

Video 1EUS-guided gastroenterostomy to treat gastric outlet obstruction followed by pyloric recanalization using a rendezvous technique.

Pitfalls in stent deployment during EUS-guided gastrojejunostomy using Hot Axios™ (with videos).

Pitfalls in stent deployment during EUS-guided gastrojejunostomy using Hot Axios™ (with videos).

S2336 Gastric Outlet Obstruction Caused by Groove Pancreatitis Successfully Treated With EUS-Guided Gastrojejunostomy

S2336 Gastric Outlet Obstruction Caused by Groove Pancreatitis Successfully Treated With EUS-Guided Gastrojejunostomy

EUS-guided gastrojejunostomy for benign gastric outlet obstruction in a patient with Whipple anatomy.

EUS-guided gastrojejunostomy for benign gastric outlet obstruction in a patient with Whipple anatomy.

1033 EUS GUIDED GASTROJEJUNOSTOMY (EUS-GJ) USING A NASOBILIARY TUBE (NBT) FOR WATER INFUSION.

EUS-guided gastrojejunostomy (EUS-GJ) with a lumen apposing metal stent (LAMS) is a new, minimally invasive endoscopic approach to treat gastric outlet obstruction (GOO). Clear visualization of the targeted jejunal loop is essential to complete the procedure. Insertion of a dilating balloon catheter or a specialized double balloon enteric tube into the proximal jejunum are the 2 reported techniques to assist identification of the targeted enteric loop for puncture. This study evaluated the technical and clinical outcomes of the use of a naso-biliary tube (NBT) for water distention of the targeted enteric loop to assist EUS-GJ in a large cohort of patients with GOO. A prospectively collected database on patients referred for treatment of GOO or afferent limb syndrome over a 4-year period was retrospectively reviewed. After confirmation of the duodenal stricture, a guidewire was passed into the proximal jejunum. A 7Fr NBT was then advanced over the guidewire under fluoroscopy. The proximal jejunum was infused with water via the NBT using a water pump. The water distended jejunal loop was then identified by EUS and targeted for EUS-GJ creation using a15mm caliber LAMS (“Hot” Axios, Boston Scientific). Clinical success was defined as the ability to tolerate a non-liquid diet post-procedure. The mean follow-up period was 5.7±2.6 months. 45 patients (71.2±1.8yrs; 23M: 22F) underwent EUS-GJ for duodenal strictures causing GOO (n=41; 37 malignancy, 3 inflammatory ulcers, 1 pancreatitis) or for afferent limb syndrome (n=4). In 36/45 (80%) patients, the stricture could not be traversed with a gastroscope, but insertion of the NBT across the stricture was achieved in all cases. Technical success of EUS-GJ was 44/45 (98%) of patients, with no adverse events. Failure in one case was due to LAMS mal-deployment from equipment malfunction. The resultant gastric perforation was immediately closed by endoscopic suturing with uneventful recovery, and EUS-GJ was successfully achieved 2 days later. Overall mean procedural time was 53±3min. Clinical success was achieved in all 4 benign cases (3.5±1.0months follow-up) and 38/41 (93%) malignant cases (6.0±0.7months follow-up). In 3 failed cases, LAMS was upgraded to 20mm calibre (n=2) or a venting PEG was inserted (n=1) to palliate GOO. Of 14 patients who died, 13 (93%) sustained oral intake until death. For the 31 alive patients, EUS-GJ provided good symptom relief in all for 5.4±0.7 months with 1(3%) had LAMS upgraded to 20mm at 6 months due to recurrent GOO symptoms. Use of a NBT to assist EUS-GJ with a 15mm LAMS is associated with high technical success (98%) with no serious adverse events and excellent immediate and intermediate relief of GOO symptoms in both malignant and benign duodenal strictures. Simplicity and low cost are advantages over the balloon assisted methods.