Endoscopic ultrasound-guided treatment for malignant afferent loop obstruction after Roux-en-Y reconstruction

The usefulness of endoscopic ultrasound (EUS)-guided gastrojejunostomy (EUS-GJ) using a lumen-apposing metal stent (LAMS) has been reported. However, LAMS is not available in many countries and is more expensive than a conventional fully covered self-expandable metal stent (FCSEMS). We treated cases of malignant afferent loop obstruction after Roux-en-Y reconstruction: three patients underwent EUS-guided hepaticoenterostomy (EUS-HES) and one patient underwent EUS-GJ with a conventional biliary FCSEMS, instead of EUS-GJ with a LAMS. In two of the cases, EUS-GJ or EUS-guided jejunojejunostomy was not indicated because the afferent loop was far from the stomach or jejunum, and EUS-HES was performed. In one case, in which both EUS-HES and EUS-GJ were feasible, EUS-HES was performed because of unavailability of LAMS for EUS-GJ in Japan. In another case, EUS-HES was not indicated because of massive ascites around the liver, and thus, EUS-GJ using a 10 mm FCSEMS combined with a 7 Fr large-loop double-pigtail plastic stent was performed. In all four cases, the patients' symptoms improved without any adverse events. Stent occlusion did not occur in three of the four cases until the patients died of advanced cancer progression. EUS-GJ using a 10 mm FCSEMS with a 7 Fr large-loop double-pigtail plastic stent or EUS-HES is likely safe and effective for managing malignant afferent loop obstruction.