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EUS–guided choledochoduodenostomy using a lumen-apposing metal stent in a patient with preexisting duodenal stent and ascites
Endoscopic retrograde cholangiopancreatography in patients with a pre-existing duodenal stent is technically challenging with a low success rate.1 EUS-guided biliary drainage has emerged as a promising technique for patients with malignant biliary obstruction when conventional ERCP fails. Although combined placement of self-expanding metal biliary and duodenal stents can be performed for patients with simultaneous biliary and duodenal obstruction, reports on transduodenal EUS-guided biliary drainage in patients with an existing duodenal metal stent are limited.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 ).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.Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.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.1Endoscopic revision of gastric bypass using plication technique: an adjustable approach
Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric surgeries worldwide.1 Despite successful weight loss after RYGB, weight regain in subsequent years is common, with nearly one-third of patients returning to their prebypass weight.2,3 Although the cause of weight regain is often multifactorial, one of the anatomic causes is dilation and increased tissue compliance of the gastrojejunal anastomosis (GJA),4 which is likely a larger contributor to weight loss than anastomosis size alone.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 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.1-3EUS-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.Safety of EUS-guided gallbladder drainage using a lumen-apposing metal stent in patients requiring anticoagulation
EUS-guided gallbladder drainage (EUS-GBD) can be used to treat acute cholecystitis in patients with medical comorbidities that prevent definitive operative management. Historically, nonsurgical management of cholecystitis was achieved by way of percutaneous gallbladder drainage.Placing a lumen-apposing metal stent despite ascites: feasibility and safety
Placing a lumen-apposing metal stent (LAMS) through ascites carries serious risks, including death from leakage around the LAMS and failure to create a mature fistula between the 2 lumens. However, sometimes no options exist or are equally dangerous. We present 5 patients who underwent LAMS placement despite ascites in 2 different locations.Extrabiliary applications of fully covered antimigration biliary metal stents
Endoscopic stent placement in luminal GI strictures is not always feasible with traditional stents. For example, standard luminal stent delivery catheters may not successfully traverse severe strictures, and enteral stents may not be suitable for sites in the GI tract that pose significant adverse events if downstream migration were to occur. We demonstrate extrabiliary applications of specialized, fully covered antimigration biliary metal stents.EUS-guided gastrojejunal anastomosis to facilitate endoscopic retrograde cholangiography in a patient with a right lobe liver transplant and Roux-en-Y anatomy
Achieving endoscopic biliary access in the setting of altered GI anatomy poses notable technical challenges. Although percutaneous drainage remains a viable alternative, endoscopic approaches are generally preferred by patients because of improvements in quality of life. Roux-en-Y hepaticojejunostomy (RYHJ) biliary reconstruction during liver transplantation is one such example of altered GI anatomy not generally amenable to biliary interventions using conventional endoscopic techniques. We describe a case demonstrating a successful endoscopic approach to achieve biliary access and treat biliary cast syndrome in a patient with a right lobe liver transplant with RYHJ reconstruction.EUS-guided ileocolonic anastomosis for relief of complete small-bowel obstruction
Small-bowel obstruction (SBO) is typically managed with gastric decompression and intravenous hydration; however, when conservative management fails, operative management is necessary.1 In cases of extrinsic compression from adhesive disease, laparotomy with lysis of adhesions is often required.2 Patients with high-grade obstruction who do not proceed to operative management are at risk for bowel perforation and septic shock from peritonitis.3 However, many patients either fail operative management or are not candidates for surgery because of comorbidities.EUS-guided gastrojejunostomy for benign gastric outlet obstruction in a patient with Whipple anatomy
Although lumen-apposing metal stents (LAMSs) are approved for pancreatic fluid collections, off-label use continues to arise for management of a variety of clinical scenarios. LAMSs have been previously described to facilitate biliary access1 and enteral nutrition via EUS-guided gastroenterostomy in the setting of benign and malignant gastric outlet obstruction (GOO) as an alternative to or step-up therapy from duodenal stent placement.2-5 We describe a case of benign GOO in the setting of Whipple anatomy successfully treated by EUS-guided gastrojejunostomy (GJ) with a LAMS to improve food passage into the efferent limb.EUS-guided transrectal drainage of pelvic fluid collections using electrocautery-enhanced lumen-apposing metal stents: a case series
Pelvic fluid collections (PFCs) are frequent adverse events of abdominal surgery or inflammatory conditions. A percutaneous approach to deep PFCs could be challenging and result in a longer, painful recovery. The transvaginal approach has been considered easy but is limited by the difficulty of leaving a stent in place. The transrectal approach has been described, but issues related to fecal contamination were hypothesized. Data on EUS-guided transrectal drainage (EUS-TRD) with lumen-apposing metal stents (LAMSs) are few and suggest unsatisfactory outcomes.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).EUS-guided cholecystogastrostomy for acute cholecystitis in a patient with an omphalocele
Omphalocele is a congenital abdominal wall defect at the umbilicus, which can contain variable amounts of abdominal organs covered in peritoneum.1 We present a 34-year-old woman with a history of an incompletely repaired omphalocele with recurrent small-bowel obstructions and lung hypoplasia, complicated by chronic respiratory failure requiring nocturnal noninvasive ventilation. She presented with a 5-day history of right upper-quadrant abdominal pain, which was associated with focal abdominal distention and overlying erythema (Fig. 1).EUS-guided gastroenterostomy by use of a lumen-apposing metal stent to facilitate ERCP in a patient with duodenal switch anatomy
Lumen-apposing metal stents (LAMSs) have gained popularity in a variety of clinical scenarios. Whereas LAMSs were initially used to drain pancreatic fluid collections, several off-label uses have been developed, including EUS-guided access to facilitate ERCP in patients with surgically altered anatomy. The duodenal switch procedure is a bariatric surgical procedure that induces weight loss by combining a sleeve gastrectomy with an intestinal bypass. This procedure renders the ampulla nearly inaccessible to conventional endoscopic access.Bilateral metal stent placement: ERCP through EUS-guided gastroenterostomy
A 64-year-old man with a history of gallbladder cancer presented with epigastric pain, nausea, vomiting, and jaundice. He had previously undergone placement of an internal-external biliary tube in the right system and a cholecystostomy tube at an outside hospital. CT showed an extended stomach with a liver mass around the hilum and upstream bile duct dilation, suggestive of gastric outlet obstruction and biliary obstruction (Fig. 1).EUS-guided enterocolostomy for palliation of malignant distal small-bowel obstruction
A 43-year-old man with a history of metastatic poorly differentiated signet ring adenocarcinoma of the colon, with metastases to the omentum and significant peritoneal carcinomatosis, was seen as an inpatient. He had an extensive surgical history, including a left hemicolectomy with colostomy and colostomy reversal, cytoreductive surgery, omentectomy, small-bowel resection, and lysis of adhesions. He also had received heated intraperitoneal chemotherapy in the past. He presented with a recurrent small-bowel obstruction.Multi-bypass with the use of lumen-apposing metal stents to maintain luminal continuity of the GI tract in a patient with altered anatomy
The goal of endoscopic palliative therapies is to provide improvement in quality of life with minimal morbidity and mortality. Surgery has been the primary treatment for malignant obstruction, although surgical morbidity is higher in emergency scenarios. Stent placement is commonly used in malignant and benign GI obstruction with established efficacy and safety.1,2 Lumen-apposing metal stents (LAMSs) represent an evolution in endoscopic stents and are considered a disruptive change in therapeutic endoscopy.Endoscopic gallbladder drainage in high-risk surgical patients
Nonsurgical candidates with acute cholecystitis are traditionally treated by percutaneous transhepatic or transperitoneal gallbladder drainage that achieves clinical response rates ranging from 56% to 100%.1,2 These approaches, however, may be associated with adverse events, including bleeding and postprocedural infections, in up to 65% of cirrhotic patients. In addition, percutaneous tube placemement may result in patient dissatisfaction, discomfort, and risk of tube dislodgment.3 With the advent of novel endoscopic tools and techniques, internal gallbladder drainage has become an alternative for nonsurgical patients with acute cholecystitis.EUS-guided gastrojejunostomy with an esophageal fully covered self-expanding metal stent for the management of benign afferent loop obstruction
A 71-year-old man with a history of ampullary adenocarcinoma (T2N0M0 stage II), who had undergone a pancreaticoduodenectomy (classic Whipple resection) 2 years earlier, presented with acute onset of persistent severe epigastric abdominal pain associated with bilious vomiting. The results of laboratory testing were remarkable for elevated lipase (1183 U/L; reference range 10-80 U/L). The liver biochemical and function test results were within normal limits. A CT scan of the abdomen revealed interstitial edematous pancreatitis and afferent loop dilation with a transition point present (Figs. 1A and B).Pancreatic duct rendezvous with pancreatoscopy through the minor papilla
An 18-year-old woman presented to our hospital with diffuse abdominal pain and visible distention. She reported a history of acute pancreatitis 2 months earlier. Physical examination revealed diffuse abdominal tenderness without rebound and an abdominal fluid wave. CT of the abdomen and pelvis (Figs. 1 and 2) showed a large volume of ascites and marked dilation of the pancreatic duct to 16 mm, with a hypodense filling defect within the pancreatic duct near the head of the pancreas.
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