EUS-guided Gastrojejunostomy Research Articles

2187 Successful EUS-Guided Gastrojejunostomy in Altered Anatomy After Failed Surgical Management

INTRODUCTION: Endoscopic ultrasound (EUS) guided gastrojejunostomy is a recognized technique for relief of benign and malignant gastric outlet obstruction (GOO). This technique creates a fistulous tract between the stomach and the jejunum via placement of a lumen apposing metal stent. It has been shown to be technically and clinically successful in many patients with GOO, however its feasibility in the setting of altered postsurgical anatomy is less clear. CASE DESCRIPTION/METHODS: We present a 70-year-old female who underwent a laparoscopic cholecystectomy complicated by bile leak and duodenal perforation requiring a Roux-en-Y gastrojejunostomy. In the following year she developed GOO related to stenosis at the GJ anastomosis. Endoscopic placement of an esophageal covered metal stent across the anastomosis did not provide long term resolution of GOO and was followed by a second surgical revision of her gastrojejunostomy. Unfortunately, she continued to have significant nausea and recurrent vomiting. Repeat EGD and upper GI series showed persistent GOO at the level of the anastomosis. Therefore, a decision was made to attempt EUS guided gastrojejunostomy. A gastroscope was advanced past the anastomosis and a guide wire was placed into the jejunum. Next, a 20 mm balloon catheter was advanced over the wire to the proximal jejunum using fluoroscopic guidance. An EUS echoendoscope was then inserted sideways to the balloon and used to identify the distended proximal jejunum in close proximity to the gastric wall. The jejunum was punctured under EUS guidance with a 19-gauge needle. A 0.025" guidewire was advanced through the needle under fluoroscopy into the proximal jejunum. A 15 mm × 10 mm AXIOS stent was advanced over the wire, and successfully deployed with the flanges in close approximation to the walls of the proximal jejunum and stomach. (Image 1). Upper GI series showed no evidence of leak and adequate gastric emptying across the gastrojejunal stent. The patient was discharged two days later on a low residue diet. Repeat EGD and upper GI series six weeks later showed no signs of GOO with a patent AXIOS stent (Image 2). At 6 month follow-up the patient continues to have complete resolution of nausea and vomiting. DISCUSSION: EUS guided gastrojejunostomy using lumen apposing covered metal stents can be a safe and effective option for management of GOO in patients with altered anatomy. However, there still remains need for long term follow up to determine the durability of such novel endoscopic interventions.

Non-Malignant Gastric Outlet Obstruction: Therapy With Endoscopic Ultrasound Guided Gastrojejunonostomy

We describe here an 82 year-old male with past medical history of coronary artery disease, sick sinus syndrome s/p permanent pacemaker insertion who presents with a three day history of nausea and vomiting. A CT scan was obtained in the emergency department that showed a markedly distended abdomen. Although no discrete mass was seen, findings were concerning for a gastric outlet obstruction (GOO) (Figure 1). The patient was made NPO and a nasogastric tube was placed for decompression. Of note, the patient was hospitalized at an outside facility 1 month prior due to a severe gastro-intestinal hemorrhage. An endoscopy performed at that time revealed that a ulcerated mucosa encompassing two-thirds of the second portion of the duodenum.2130_A Figure 1 No Caption available.A repeat EGD was performed at our facility revealing a benign appearing high grade stricture in the duodenal bulb at the base of a healing ulcer. Stone-like accretions were found in the pylorus and duodenal bulb which were noted to intermittently occlude the stricture (Figure 2). Biopsies were taken which were negative for malignancy.2130_B Figure 2 No Caption available.The decision was made to proceed with EUS-guided gastrojejunostomy (EUS-GJ). Sonographic examination of the stricture did not reveal an obvious mass. A stone-extraction balloon over a wire was advanced thorough the duodenal stricture into the jejunum. Sterile water was used to dilate the jejunal limb. The linear echoendoscope advanced to the stomach and the jejunal limb was identified. A 19G FNA needle was used to puncture into the jejunum and a second wire was advanced into this limb. Under endoscopic, fluoroscopic and sonographic guidance a 15mm lumen-apposing metal stent (LAMS) was successfully deployed, creating a gastrojejunostomy (Figure 3).2130_C Figure 3 No Caption available.Post-procedure day one patient tolerated a soft diet and was discharged after a 48 hour observation periord. At outpatient follow-up, six weeks after presentation, the patient has done well without significant complications. EUS-GJ are not common-place, however their utility in the treatment of malignant as well as benign gastric outlet obstruction has been demonstrated in international prospective trials. Here we demonstrate that EUS-GJ can be a reliable intervention in patients with GOO. In the future we hope for a comparison study between LAMS, enteral stents and surgical gastrojejunostomies.

EUS-guided gastrojejunostomy with an esophageal fully covered self-expanding metal stent for the management of benign afferent loop obstruction.

EUS-guided gastrojejunostomy with an esophageal fully covered self-expanding metal stent for the management of benign afferent loop obstruction.

68 EUS-GUIDED GASTROJEJUNOSTOMY WITH LUMEN APPOSING METAL STENT VERSUS ENTERAL STENT PLACEMENT FOR PALLIATION OF MALIGNANT GASTRIC OUTLET OBSTRUCTION

Enteral stent placement is commonly performed for palliation of obstructive symptoms caused by malignant gastric outlet obstruction (GOO). EUS-guided gastrojejunostomy (EUS-GJ) with placement of a lumen-apposing metal stent (LAMS) is a novel procedure that may offer long lasting patency with fewer incidence of stent failure, however there is limited data comparing EUS-GJ to enteral stent placement. To compare clinical outcomes and adverse events between EUS-GJ and enteral stent placement in the endoscopic palliation of malignant GOO. A prospectively collected university health care system registry was queried for LAMS, enteral stents, and GOO, and a retrospective analysis was performed. Patients who underwent EUS-GJ and enteral stent placement for the palliation of malignant GOO from 2014-2017 were included. Patients with benign GOO, gastroparesis, or surgically altered anatomy were excluded. Demographics, procedural and technical characteristics, and relevant clinical outcomes were recorded. Adverse events were assessed. Characteristics and clinical outcomes were compared using Fisher’s exact test and Student’s t test when appropriate. A total of 100 consecutive patients who underwent endoscopic palliation of malignant GOO during the study period were analyzed, of which 78 patients underwent enteral stent placement, and and 22 patients underwent EUS-GJ. Mean age was 65.9 ± 11.9 years, and 44.0% of patients were female. A total of 121 stents were placed, including 24 LAMS in the EUS-GJ group and 97 uncovered self expanding metal stents in the enteral stent group. When comparing EUS-GJ and enteral stent cases, technical success was achieved in 100% in both groups, however higher clinical success was attained in the EUS-GJ group compared to enteral stent group (91.7% vs 69.1%, p = 0.036). Mean length of hospital stay following stent placement was similar between the two groups (p = 0.821). The rate of stent failure requiring repeat intervention was significantly higher in the enteral stent group (31.6% vs 8.0%, p = 0.021). The enteral stent group had greater number of adverse events (40.2% vs 20.8%, p = 0.098) and incidence of stent ingrowth (16.5% vs 4.2%, p = 0.189), however this did not reach statistical significance. Misdeployment resulting in perforation occurred in two cases of EUS-GJ, however both cases were managed endoscopically with subsequent successful LAMS deployment in the same session, and neither case required surgery. When compared to enteral stent placement, EUS-GJ has higher rate of initial clinical success and lower rate of stent failure requiring repeat intervention. EUS-GJ should be offered as a minimally invasive alternative for selected patients with malignant GOO in centers with extensive experience.Tabled 1Table 1. Clinical OutcomesEUS-GJ (n, %)Enteral Stent (n, %)p valuePatients22 (22.0)78 (78.0)---Stents Placed24 (19.8)97 (80.2)---Technical Success24 (100.0)97 (100.0)1.000Clinical Success22 (91.7)67 (69.1)0.036Length of Hospital Stay Following Stent Placement (± SD, days)7.4 (9.1)7.9 (8.2)0.821Stent Failure Requiring Re-Intervention2 (8.0)31 (31.6)0.021Time to Re-Intervention (± SD, days)128 (157.0)99.2 (166.5)0.812Total Adverse Events5 (20.8)39 (40.2)0.098Stent Ingrowth1 (4.2)16 (16.5)0.189Stent Obstruction (not including ingrowth)0 (0.0)7 (7.2)0.342Stent Migration0 (0.0)2 (2.1)1.000Inadequate Stent Length0 (0.0)2 (2.1)1.000Bleeding0 (0.0)1 (1.0)1.000Biliary Obstruction0 (0.0)2 (2.1)1.000PEG Placement1 (4.2)5 (5.2)1.000Conversion to EUS-GJ (enteral stent only)---1 (1.0)---LAMS Mesh Erosion (EUS-GJ only)1 (4.2)------LAMS Misdeployment (EUS-GJ only)2 (8.3)------Death Within 30 Days0 (0.0)3 (3.1)1.000Abbreviations: EUS = endoscopic ultrasound GJ = gastrojejunostomy LAMS = lumen apposing metal stent SD = standard deviation Open table in a new tab

1107 Two Cases of Afferent Loop Syndrome Treated by Eus-Guided Gastrojejunostomy With Lumen-Apposing Metal Stent Incorporated in an Electrocautery-Enhanced Delivery System

1107 Two Cases of Afferent Loop Syndrome Treated by Eus-Guided Gastrojejunostomy With Lumen-Apposing Metal Stent Incorporated in an Electrocautery-Enhanced Delivery System

Interventional endoscopic ultrasonography: Where are we headed?

Endoscopic ultrasonography (EUS) is an essential endoscopic tool within the diagnostic and therapeutic armamentarium of gastrointestinal and hepatic diseases. EUS-guided tissue acquisition will develop towards facilitating personalized treatment by obtaining large representative tissue specimens for elaborate immunohistochemical and biomolecular typing of the tumor. Intratumoral or intravascular delivery of drugs potentially offers many advantages over systemic injection. Intratumoral application of radiofrequency ablation and photodynamic therapy show promise but need to be explored further. Appositioning and connecting luminal structures within the gastrointestinal tract using fully covered expandable lumen-apposing stents will expand its indication far beyond the drainage of (infected) fluid collections and EUS-guided gastrojejunostomy is a particularly exciting development that could have significant impact on the management of gastric outlet obstruction.

Percutaneously assisted EUS-guided gastrojejunostomy for the treatment of afferent limb syndrome.

Percutaneously assisted EUS-guided gastrojejunostomy for the treatment of afferent limb syndrome.

Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction

Surgical gastrojejunostomy (GJ), which has been the standard palliative treatment for malignant gastric outlet obstruction (MGOO), is associated with good functional outcome and the long-term relief of symptoms. Endoscopic placement...

EUS-guided gastrojejunostomy for management of complete gastric outlet obstruction

EUS-guided gastrojejunostomy for management of complete gastric outlet obstruction

895 EUS-Guided Gastrojejunostomy for Management of Complete Gastric Outlet Obstruction

An 86 yr old female presents for management of gastric outlet obstruction (GOO) secondary to locally advanced pancreatic adenocarcinoma. An enteral stent was not possible as a guidewire was unable to pass through the stricture. After a multidiscliplinary meeting, the decision was made to proceed with EUS-guided gastrojejunostomy (EUS-GJ) and lumen opposing stent insertion. EUS-GJ offers the advantage of traditional endoscopic stenting in terms of its minimally-invasive nature while avoiding short patency rates due to recurrent stent obstruction by tumor ingrowth. The advent of lumen opposing metallic stents has made EUS-GJ possible by facilitating apposition of the small bowel to the gastric wall for creation of a gastroenteric anastomosis. These anastomotic stents are fully-covered and are bi-flanged to prevent migration and leakage. Various techniques can be used to create a EUS-GJ and include balloon-assisted and direct access. The balloon-assisted technique aids the operator by providing a target (fluid filled biliary retrieval balloon placed over a stiff guidewire) for transgastric puncture. In this patient, as their was complete duodenal obstruction, only the direct access technique was available. The objectives of this video are to demonstrate a technique of EUS-guided gastrojejunostomy using a lumen opposing metallic stent.

EUS-guided gastrojejunostomy after failed enteral stenting

EUS-guided gastrojejunostomy after failed enteral stenting

Transenteric anastomosis with lumen-apposing metal stent as a conduit for iterative endotherapy of malignant biliary obstruction in altered anatomy

EUS-guided transenteric anastomosis was performed in a patient with Roux-en-Y anatomy with recurrent malignancy to allow endoscopic access for biliary drainage. Procedural steps were tested in a porcine model of EUS-guided gastrojejunostomy by using lumen-apposing metal stents (LAMSs).

Novel EUS-guided gastrojejunostomy technique using a new double-balloon enteric tube and lumen-apposing metal stent (with videos)

Surgical gastrojejunostomy is associated with relatively high morbidity and mortality rates. However, current experimental EUS-guided gastrojejunostomy information is limited. To evaluate a novel EUS-guided gastrojejunostomy technique using a new enteric balloon and lumen-apposing metal stent. Animal experiment. Animal laboratory at a referral center. In 5 pigs, gastrojejunostomies were created under EUS guidance. Fully covered lumen-apposing stents were placed between the stomach and the jejunum. Technical success and adverse events of EUS-guided gastrojejunostomy. All stents, with 1 exception, were successfully deployed without any adverse events. The mean time to stent placement was 44.2 minutes (range 28-64 minutes). All animals showed normal eating behavior without signs of infection for 1 month after the procedure. Endoscopic imaging of the stomach site showed the stent to be patent and stable, without dislodgment, in all of the pigs. Necropsy showed complete adhesion between the stomach and the jejunum wall. Pilot study. Creation of an EUS-guided gastrojejunostomy by using a novel enteric balloon and metal stent appears to be promising as a minimally invasive treatment.

Sa1429 EUS-Guided Gastrojejunostomy Using Novel Tools Designed for Translumenal Therapy

Gastric outlet obstruction is frequently caused by advanced gastric, duodenal, and pancreatic malignancies. Surgical gastroenterostomy is associated with appreciable morbidity and mortality. An alternative non-surgical approach is the creation of a gastrojejunostomy under EUS-guidance. Purpose: Porcine evaluation of EUS-guided gastrojejunostomy using three novel tools designed for translumenal therapy.