We would like to thank Bronswijk et al
1
for their cogent comments and for their series on performing EUS-guided gastroenterostomy.2
We agree that cost efficiency is unquestionably an important part of health care in a world of finite resources and in avoiding waste. The transverse colon is in close proximity to the greater curvature of the stomach. Although this part of the colon is often recognizable by the air in it, it can rarely be fluid-filled and mistaken for the small bowel.
Using a 19-gauge needle puncture to confirm that the duodenum or jejunum is what is being visualized as the intended target for the anastomosis is a simple way to avoid a devastating adverse event in gastrocolostomy, which has unfortunately happened even in expert hands. However, when the nasojejunal tube is visualized in the small bowel or when Doppler flow during rapid infusion allows confirmation of the small bowel, we agree that the needle puncture step can be avoided. For providers starting to perform EUS-guided gastroenterostomy, we recommend a finder needle as a quick (inexpensive) initial step to avoid a devastating adverse event in what is often a fragile patient population.
With regard to deployment of the lumen-apposing metal stent over a guidewire, this is not done with the antegrade EUS-guided gastroenterostomy or “direct” method (the technique most of the authors have been using for several years now). In fact, we believe the guidewire may contribute to misdeployments by pushing the small bowel away while opening the duodenal/jejunal flange. Some providers dilate the lumen-apposing metal stent after deployment. In that case, the same guidewire used to pass the nasojejunal tube can be reused for the balloon dilation. However, most of the authors do not believe it is necessary to dilate the lumen-apposing metal stent, and anecdotally, there may be a slightly higher risk of bleeding with balloon dilation.
Disclosure
Drs Irani, Itoi, Baron, and Khashab are consultants for Boston Scientific. Dr Irani is also a consultant for GORE Medical.
References
- EUS-guided gastroenterostomy: less is more! The wireless EUS-guided gastroenterostomy simplified technique.VideoGIE. 2020; 5: 442
- EUS-guided gastroenterostomy: techniques from East to West.VideoGIE. 2019; 5: 48-50
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- EUS-guided gastroenterostomy: Less is more! The wireless EUS-guided gastroenterostomy simplified techniqueVideoGIEVol. 5Issue 9
- PreviewFor patients with either benign or malignant gastric outlet obstruction, surgical gastroenterostomy, the standard of care for many years, seems to be losing ground to EUS-guided gastroenterostomy.1-3 Various technical approaches to this endoscopic technique have been described, although the direct method, using only a nasojejunal catheter, 19-gauge needle, and lumen-apposing metal stent, has been suggested as the preferred method.4 In the February issue of VideoGIE, Irani et al5 gave their expert overview of 5 different EUS-guided gastroenterostomy techniques in their technical review “EUS-guided gastroenterostomy: techniques from East to West.” Although we completely agree with the authors that superiority of 1 of 5 techniques has not been proven to date, we would like to add a sixth approach, which may also potentially improve cost effectiveness and time efficiency.
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