Secondary endoscopic ultrasound-guided gastroenterostomy to solve stent dysfunction and prolong lifetime in malignant gastric outlet obstruction

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is effective and safe to relieve gastric outlet obstruction (GOO) ¹ . Long-term stent dysfunction, including stent occlusion, migration, and delamination, could be resolved by food disimpaction, stent exchanges, or an overlapping stent ^{2 3 4} . Here, we report a patient with pancreatic ductal adenocarcinoma (PDAC) who received secondary EUS-GE to solve stent dysfunction 10 months after the index operation.

A 54-year-old male with a history of uncinate process PDAC was admitted due to the recurrence of abdominal distention and vomiting 292 days after his first EUS-GE. The anastomotic lumen-apposing metal stent had maintained patency for 10 months, providing substantial nutrition for anti-tumor therapy and enabling a prolonged survival. This time, abdominal computed tomography demonstrated the recurrence of GOO ( Fig. 1 ). Gastroscopy revealed pills accumulated in the stomach, and erosion, necrosis and stenosis of intestine around the stent ( Fig. 2 ). The distal end of the stent was pointed to the afferent limb. The stent-efferent limb angle was so sharp that the endoscope could hardly pass through. Gastroscopy revealed multiple ulcers in the efferent limb. Radiography showed segmental narrowing of the intestinal lumen ( Fig. 3 ). We postulated this could be attributed to localized inflammatory edema. As the original pathway was passable but not smooth, we applied secondary free-hand EUS-GE elsewhere instead of stent repatency or replacement. A nasobiliary catheter was placed to instill saline solution and methylene blue, facilitating direct puncture with 15-mm × 10-mm cautery-enhanced LAMS (Hot Axios stent; Boston Scientific, USA) under EUS (GF-UCT260; Olympus, Tokyo, Japan) guidance from the upper part of gastric body's posterior wall ( Video 1 , Fig. 4 ). The patient tolerated a liquid diet from postoperative day 3 and gradually resumed a semiliquid diet.

Fig. 1.

Postoperative abdominal computed tomography. a Stomach distention with accumulation of gastric contents. b Initial EUS-GE with lumen-apposing metal stent.

Fig. 2.

Endoscopy revealed erosion, necrosis, and stenosis of intestine around the stent.

Fig. 3.

Radiography showed segmental narrowing of the efferent intestinal lumen.

Fig. 4.

Postoperative radiography demonstrated stent patency after the secondary EUS-GE (thin arrow: contrast agent passed the initial stent but limited to the afferent limb; bold arrow: contrast agent passed the second stent and reached the distal jejunum).

Download video file ^{(51MB, mp4)}

Procedure of two EUS-GE for the patient.

Video 1

We demonstrate the significance of EUS-GE to prolong survival duration in malignancy. We also provide a feasible resolution to prevent stent dysfunction for stent-dependent patients.

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