Reverse endoscopic ultrasound-guided neogastrojejunostomy

Area of Science:

• Gastroenterology
• Interventional Endoscopy
• Surgical Oncology

Background:

• Endoscopic ultrasound (EUS)-guided gastrojejunostomy (GJ) offers a minimally invasive alternative to surgery for managing upper gastrointestinal obstructions.
• Hiatal hernias can cause outlet obstruction, particularly in patients with prior gastric surgery and reconstructive procedures like colonic interposition.

Purpose of the Study:

• To describe a novel application of EUS-guided GJ for managing outlet obstruction secondary to a hiatal hernia in a patient with a colonic interposition.
• To highlight the utility of a reverse approach for EUS-guided GJ to overcome technical challenges and improve safety.

Main Methods:

• A 71-year-old female with a history of total gastrectomy and colonic interposition presented with symptoms of gastric outlet obstruction.
• Initial attempts at stenting the colojojeunal anastomosis failed due to migration; obstruction was attributed to extrinsic compression from a hiatal hernia.
• EUS-guided neo-GJ was performed, initially with distal flange misdeployment into the peritoneum. The stent was removed, the perforation closed, and a successful reverse approach was utilized.

Main Results:

• The initial attempt at EUS-guided GJ using a lumen-apposing metal stent (LAMS) resulted in distal flange misdeployment into the peritoneum.
• Following stent removal and closure of the perforation, a reverse EUS-guided GJ was successfully performed, with the LAMS advanced transjejunally into the neostomach.
• Oral contrast studies confirmed stent patency, and the patient remained symptom-free at 6-month follow-up.

Conclusions:

• Misdeployment of LAMS into the peritoneum is a known complication in EUS-guided GJ procedures.
• A reverse approach for EUS-guided GJ, targeting a less mobile structure, can mitigate the risk of stent displacement and improve procedural success.
• EUS-guided GJ is a viable option for managing complex outlet obstructions in patients with prior gastric surgery and reconstructive procedures.