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EUS-directed transenteric ERCP–assisted internalization of a percutaneous biliary drain in Roux-en-Y anatomy
Endoscopic ultrasound–directed transenteric ERCP (EDEE) has recently been described as a safe, effective procedure to obtain biliary access in patients with Roux-en-Y anatomy.1,2 Here, we present a video case report of EDEE-assisted biliary drain internalization in a patient with prior liver transplant and Roux-en-Y hepaticojejunostomy (HJ), presenting with HJ anastomotic stricture (Video 1, available online at www.giejournal.org ).EUS-guided gastrojejunostomy for management of malignant gastric outlet obstruction in a patient with Roux-en-Y anatomy
Gastric outlet obstruction is a complication of advanced gastrointestinal malignancies and contributes significantly to patient morbidity. Surgical gastrojejunostomy (GJ) and enteral stenting have been traditionally employed for management in these patients. Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting and surgical GJ. We present a case of EUS-GJ performed in a patient with Roux-en-Y anatomy.EUS-guided stent placement for afferent limb and gastrojejunal obstruction in a patient with pancreatic cancer
Gastric outlet obstruction occurs in 10% to 25% of patients with pancreatic cancer and is a common manifestation of postsurgical recurrence.1 Afferent loop syndrome can occur in patients with recurrence and is defined by distal obstruction and accumulation of bile and pancreatic fluid, causing distension of the afferent loop and recurrent cholangitis.Simultaneous double gastrojejunostomy for afferent and efferent limb syndromes
Afferent and efferent limb syndromes are potential adverse events after partial gastrectomy with a gastrojejunostomy (GJ) reconstruction. Mechanical obstruction of the reconstructed small-bowel loops is often the underlying etiology, and it occurs because of anastomotic narrowing, postsurgical adhesions, and recurrence of the primary disease.1 Afferent limb syndrome usually presents with abdominal pain, bilious vomiting, and cholestasis and may require urgent surgical intervention in the acute setting to prevent bowel necrosis.Cutting the gastric septum between 2 gastrojejunal openings to manage refractory gastrojejunal stenosis in a bariatric surgery patient
A 48-year-old woman who had previously undergone laparoscopic Roux-en-Y gastric bypass presented with unintentional weight loss, oral intolerance, nausea, and vomiting. The patient had a history of chronic gastrojejunostomy (GJ) stenosis managed by surgical GJ revision; however, the revision GJ developed chronic stenosis (Fig. 1). Multiple endoscopic balloon dilations of the revised surgical GJ had been attempted without clinical success. Adjacent to the stenotic surgically revised GJ, we performed EUS-guided GJ creation using a 15-mm lumen-apposing metal stent (Boston Scientific, Marlborough, Mass, USA), which partially relieved the patient’s symptomatic gastric outlet obstruction.Gastric outlet obstruction: when you cannot do an endoscopic gastroenterostomy or enteral stent, try an endoscopic duodenojejunostomy or jejunojejunostomy
Certain situations preclude an endoscopic gastroenterostomy (EUS-GE) or enteral stent placement in gastric outlet obstruction (GOO), leaving patients with the option of a surgical bypass or enteral nutrition beyond the point of obstruction. We present a third option in these situations: an endoscopic duodenojejunostomy (EUS-DJ) or jejunojejunostomy (EUS-JJ).Natural orifice transluminal endoscopic surgery salvage of direct EUS-guided gastrojejunostomy
Lumen-apposing metal stents (LAMSs) can be used for gastrojejunostomy (GJ) under natural orifice transluminal endoscopic surgery (NOTES) or EUS guidance. EUS-GJ requires both LAMS flanges to be properly placed. Proximal flange misplacement during LAMS deployment into the small bowel or the gallbladder has occasionally been salvaged by a bridging tubular SEMS. However, the only 2 reported instances of distal LAMS flange misplacement during EUS-GJ resulted in procedural failure. We report a successful NOTES approach to salvage distal LAMS flange misplacement during EUS-GJ.
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