Login to your account
Don’t have an account?
Create a Free AccountProcedures - Stent placement
EUS-guided gastroenterostomy for proximal jejunal obstruction: technique modification for more distal upper GI tract obstruction
EUS-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stents (LAMSs) has emerged as a safe, minimally invasive modality for the treatment of gastric outlet obstruction (GOO).1 Several techniques have been described, including anterograde, retrograde, and balloon-assisted approaches.1-3 The “direct” anterograde method of EUS-GE using a nasobiliary catheter to instill contrast material within the target jejunal loop distal to the obstruction uses fewer steps than other approaches and does not require use of a balloon.EUS-guided jejuno-enterostomy in a patient with total gastrectomy with Roux-en-Y esophagojejunostomy to facilitate cholangioscopy with electrohydraulic lithotripsy
A 67-year-old man with a history of total gastrectomy followed by Roux-en-Y esophagojejunostomy reconstruction in the setting of gastric adenocarcinoma presented with right-upper-quadrant pain and an abnormal liver function test (LFT) (aspartate aminotransferase 389, alanine aminotransferase 273, alkaline phosphatase 297, total bilirubin 8.70). A liver CT scan was consistent with dilation of the intrahepatic and extrahepatic bile ducts (Figs. 1 and 2; Video 1, available online at www.giejournal.org ).Endoscopic management of gastrojejunocolic fistula after endoscopic gastrojejunostomy
Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) is an alternative to endoscopic stent placement alone and surgical gastrojejunostomy for the management of gastric outlet obstruction (GOO). Similar technical and clinical success rates have been shown with EUS-GJ and endoscopic stent placement alone with lower rates of reintervention in the EUS-GJ group.1 When compared to the more invasive surgical GJ, EUS-GJ has shown similar rates of clinical success and lower adverse event rates.2,3 Rare EUS-GJ adverse events include perforation, peritonitis, bleeding, stent misdeployment, and migration.Transpyloric lumen-apposing metal stent for management of persistent post-esophagogastrectomy leak
Anastomotic leaks are an adverse event complication of GI surgery that contribute to increased hospital stays, morbidity, and mortality. Endoscopic therapy via endoscopic closure techniques or covered metal stent placement has increasingly been used for primary therapy of anastomotic leaks.Transjejunal drainage of an infected postsurgical fluid collection using a 6-mm lumen-apposing metal stent
Postsurgical fluid collections (PSFCs) can be a marked source of morbidity for patients, but advances in therapeutic endoscopy have allowed for endoscopic modalities of drainage to become more accessible.1 Prior studies have established the efficacy and safety of lumen-apposing metal stents (LAMSs) in PSFCs.1-4 In the video accompanying this case report (Video 1, available online at www.giejournal.org ), we demonstrate the transjejunal placement of a 6-mm LAMS for drainage of an infected postsurgical fluid collection.EUS-directed transgastric ERCP in Roux-en-Y gastric bypass revision of sleeve gastrectomy
EUS-directed transgastric ERCP (EDGE) is an effective approach for the treatment of biliary adverse events of patients who have undergone Roux-en-Y gastric bypass (RYGB).1 Through deployment of a lumen-apposing metal stent (LAMS) from the gastric pouch into the excluded stomach, EDGE allows access to the bypassed stomach and duodenum in patients who have undergone RYGB (Fig. 1). However, patients who have undergone sleeve gastrectomy (SG) who undergo revision to RYGB have limited working space within both the gastric pouch and excluded stomach (Fig. 2), making therapeutic endoscopic procedures such as EDGE technically challenging.A case of cystic paraduodenal pancreatitis with gastric outlet obstruction: technical pitfalls in EUS-guided gastroenteroanastomosis
Cystic paraduodenal pancreatitis is part of a spectrum of diseases, collectively gathered under the term “paraduodenal pancreatitis,” which involves the area between the duodenum, the pancreatic head, and the common bile duct.1 Although common clinical presentation is constituted by abdominal pain, weight loss, and jaundice, association with gastric outlet obstruction (GOO) has been reported.2 In recent years, the introduction of lumen-apposing metal stents (LAMSs) led to the diffusion of a novel technique to manage GOO.Endoscopic management of recurrent cholangitis following EUS-guided choledochoduodenostomy
A 74-year-old man who previously underwent a Roux-en-Y gastro-jejunostomy for duodenal stenosis due to an inoperable pancreatic adenocarcinoma was admitted at our institution for obstructive jaundice. Considering the duodenal stenosis, biliary drainage via EUS-guided choledochoduodenostomy was performed using a 6 × 8 mm electrocautery-enhanced lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific, Natick, Mass, USA), with subsequent resolution of jaundice (Fig. 1). After 2 months, the patient was readmitted for acute cholangitis: CT scan showed marked dilation of the biliary tracts, with the LAMS in its proper position (Fig. 2).Endoscopic ultrasound-guided ileosigmoidostomy using a lumen-apposing metal stent for palliation of malignant small-bowel obstruction
High-grade malignant small-bowel obstruction (SBO) is typically managed with surgical diversion (ileostomy) or palliative decompression via nasogastric tube or venting gastrostomy. These approaches have a significant impact on quality of life. Endoscopic palliation of malignant luminal obstruction by lumen-apposing metal stent (LAMS) placement is well established for duodenal obstruction. Distal SBO, however, is challenging to manage endoscopically. We present the case of a novel EUS-guided ileosigmoidostomy technique for the palliation of malignant distal SBO.Utilization of an overtube for placement of a lumen-apposing metal stent for removal of a capsule endoscope retained proximal to an ileal stricture
Capsule endoscopy is a noninvasive procedure used to evaluate the small bowel. Capsule retention remains a significant adverse event of capsule endoscopy, and endoscopic capsule extraction may be technically complicated when device-assisted enteroscopy is necessary to reach the retained capsule. The length and limited diameter of enteroscope working channels limit the endoscopic tools available and can make extraction of the capsule difficult. The presence of enteral strictures can also further complicate endoscopic extraction of a retained capsule.Single-session EUS-guided gastroenterostomy and EUS-guided gallbladder drainage in a patient with concomitant gastric outlet obstruction and acalculous cholecystitis
EUS-guided interventions for cholecystitis and gastric outlet obstruction (GOO) are emerging techniques for high-risk surgical patients.1,2 Compared with percutaneous drainage, EUS-guided gallbladder drainage (EUS-GB) has superior clinical and high technical success rates and limited adverse events.3 Similarly, EUS-guided gastroenterostomy (EUS-GE) for GOO has clinical and technical success rates similar to surgical options, with reduced length of stay, hospital costs, and early resumption of oral intake.EUS-guided gallbladder drainage and subsequent peroral endoscopic cholecystolithotomy: A tool to reduce chemotherapy discontinuation in neoplastic patients?
EUS-guided gallbladder drainage (EUS-GBD) is emerging as a valuable treatment for acute cholecystitis (AC) in patients unfit for surgery. When lumen-apposing metal stents are used, large-caliber access to the gallbladder allows for subsequent direct peroral endoscopic cholecystoscopy (POEC) and eventual cholecystolithotomy (CL), offering a potentially “curative” solution for frailer patients. The aim of this series was to evaluate the outcome of these procedures in oncologic patients experiencing AC, with a specific focus on chemotherapy continuity.Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible
Acute cholecystitis and choledocholithiasis in patients with altered anatomy and major contraindications to surgery represent a challenging clinical scenario.1The use of double-pigtailed stents to relieve obstruction of a previous endoscopic gastrojejunal lumen-apposing metal stent
Endoscopic placement of a lumen-apposing metal stent (LAMS) is a novel means of managing patients with malignant gastric outlet obstruction (GOO), particularly those with prohibitive surgical risk factors. However, long-term data on endoscopic gastrojejunal LAMSs are lacking, and mechanical obstruction may still occur from benign processes. In this video (Video 1, available online at www.giejournal.org ), we describe a novel case in which double-pigtail stents were used to manage an obstructed LAMS due to occlusion of the distal flange of the LAMS by the contralateral jejunal wall.Drainage of gastric intramural abscesses using lumen-apposing metal stents
Gastric intramural abscesses are rare and often related to foreign body trauma. Owing to location and general nonresponse to broad-spectrum antimicrobial therapy, endoscopic drainage is often used.EUS-guided cholecystoduodenostomy and ERCP in a patient with surgically altered anatomy with a double-balloon endoluminal interventional platform
EUS and ERCP in patients with surgically altered anatomy can be technically challenging. For Roux-en-Y and diverting gastrojejunostomy, achieving deep advancement into the pancreaticobiliary limb for EUS and EUS-guided interventions can be difficult because of the linear echoendoscope’s oblique viewing nature, a longer fixed nonbending portion, and the relatively sharp and stiff tip.1 For ERCP, there are similar challenges with intubating the surgical anastomosis, navigating the variable length of the afferent jejunal limb, and cannulation.Cardiac septal occluder for closure of persistent gastrogastric fistula
A 53-year-old man with diabetes mellitus and a history of Roux-en-Y gastric bypass had a bile leak after a cholecystectomy in March 2020. He subsequently underwent EUS-directed transgastric ERCP (EDGE) with gastrogastric fistula creation with a lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Marlborough, Mass, USA) followed by placement of a 10F × 10-cm plastic biliary stent in March 2020.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.Management of combined malignant biliary-duodenal obstruction in Roux-en-Y gastric bypass anatomy with EUS-guided gastrogastrostomy, EUS biliary drainage, and duodenal stent placement
ERCP for patients with Roux-en-Y gastric bypass (RYGB) anatomy is technically challenging. EUS-guided gastrogastrostomy facilitates access to the pancreaticobiliary system and enables us to perform additional procedures.1-5 Here, we describe a case of a patient with RYGB anatomy undergoing EUS-guided gastrogastrostomy followed by EUS-guided fine-needle biopsy (EUS-FNB), EUS-guided biliary drainage, and duodenal stent placement.EUS-guided choledochoduodenostomy creation using a biliary fully covered self-expanding metal stent after maldeployment of lumen-apposing metal stent
A 72-year-old man with stage IV renal cell carcinoma presented with obstructive jaundice secondary to a metastasis in the head of the pancreas. CT imaging demonstrated common bile duct dilation up to 15 mm secondary to a 6-cm pancreatic head mass (Fig. 1). ERCP was attempted but failed because of ampullary effacement from malignant invasion. Because the patient was not a surgical candidate, EUS-guided biliary drainage was attempted.EUS-guided gastroenterostomy to treat gastric outlet obstruction in a patient with gastric lymphoma followed by pyloric recanalization using a rendezvous technique
The rendezvous technique was described to salvage a dislodged stent during EUS-guided gastrojejunostomy.1 We describe using this technique to perform endoscopic gastroenterostomy because of the unsafety of traditional methods2 in this case.EUS-guided jejunojejunostomy to facilitate ERCP in a patient with unique Roux-en-Y gastric bypass anatomy
Lumen-apposing metal stents (LAMSs), although initially created for draining pancreatic fluid collections, are frequently used in an “off-label” fashion. They have recently gained popularity as a means to facilitate ERCP in patients with surgically altered GI anatomy. We have previously described using LAMSs to create a temporary gastroenterostomy to facilitate ERCP in a patient with duodenal switch anatomy.1 The present case describes the use of a LAMS to enable ERCP in a patient with a history of vertical sleeve gastrectomy converted to a Roux-en-Y gastric bypass.EUS-guided gastrojejunostomy and hepaticogastrostomy for malignant duodenal and biliary obstruction
Malignancies in the upper abdomen can cause both biliary obstruction and gastric outlet obstruction (GOO), leading to acute illness and significant impairment in quality of life. Surgical intervention is invasive and morbid, especially in the presence of malignant ascites. Recent advances in therapeutic EUS-guided techniques have provided minimally invasive approaches to offer these patients relief and palliation.1-3The use of a rescue stent in the management of lumen-apposing metal stent migration during EUS-directed transgastric ERCP with stent-in-stent technique to remove a forgotten metal biliary stent
Roux-en-Y gastric bypass poses a unique set of challenges during ERCP. Conventional approaches include laparoscopic-assisted ERCP and balloon-assisted enteroscopy. Laparoscopic-assisted ERCP is invasive and requires coordination between a surgeon and gastroenterologist. Balloon-assisted ERCP has a lower procedural success rate (60%-80%),1 and the size of the working channel can limit interventions. EUS-directed transgastric ERCP (EDGE) (Fig. 1)2 allows for a same-day or multistep procedure by creating a gastrogastric fistula, allowing endoscopic access to the biliary tree via the excluded stomach.EUS-guided gastroenterostomy for duodenal obstruction secondary to superior mesenteric artery syndrome
Superior mesenteric artery syndrome (SMAS) is a rare condition in which the superior mesenteric artery (SMA) impinges on the third portion of the duodenum leading to symptoms of gastric outlet obstruction.1 When conservative management fails, surgical intervention may be required. In patients who are not surgical candidates or who decline surgery, EUS-guided gastroenterostomy (EUS-GE) using a cautery-enhanced lumen-apposing metal stent (LAMS) has been reported as a safe and effective option, but there is otherwise a paucity of data on the approach.
Copyright © 2023 Elsevier Inc. except certain content provided by third parties. The content on this site is intended for healthcare professionals.
