Reverse endoscopic ultrasound-guided neogastrojejunostomy

Endoscopic ultrasound (EUS)-guided gastrojejunostomy (GJ) has emerged as an alternative to surgery with high clinical success rates. Here, we describe a case of EUS-guided GJ used to manage an outlet obstruction from a hiatal hernia in the setting of a colonic interposition.

A 71-year-old woman with previous total gastrectomy with a colonic interposition graft (neostomach) presented with postprandial regurgitation. The colojejunal anastomosis appeared to have benign stenosis, but stenting led to stent migration. It was then suspected that the obstruction was attributable to extrinsic compression from a hiatal hernia. An EUS-guided neo-GJ was performed to bypass the obstruction. A lumen-apposing metal stent (LAMS) was advanced across the neostomach, but there was misdeployment of the distal flange into the peritoneum.

The LAMS was removed and the perforation closed. The neo-GJ was reattempted in reverse fashion. A LAMS was advanced transjejunally into the neostomach. The result of an oral contrast study confirmed stent patency. The patient had no recurrent symptoms at 6-month follow-up.

Misdeployment of a LAMS into the peritoneum is the most common stent-related adverse event in this type of procedure. A reverse approach allows the use of a less-mobile target to decrease the chances of the target being displaced.