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EUS-guided bowel anastomosis


Key points

  • An anastomosis can be established between the stomach and the jejunum under endoscopic ultrasound (EUS)-guidance in patients with gastric outlet obstruction. A lumen-apposing metal stent (LAMS) can be deployed either directly or via assisted-techniques using fluoroscopic and sonographic guidance. EUS-gastroenterostomy carries a higher technical and clinical success without serious adverse event. While experience is limited, the preliminary data appear promising.

  • Transgastric endoscopic retrograde cholangiopanceratography using a LAMS carries a higher technical success and is more efficient than enteroscopy-ERCP (Endoscopic retrograde cholangiopancreatography) and can be considered as a primary procedure for pancreaticobiliary access in patients with Roux-en-Y gastric bypass if local expertise is available. However, serious adverse events may still occur. The procedure is technically intricate. While experience is limited, the preliminary data appear promising.

EUS-guided gastroenterostomy

There are several malignant and benign diseases that can be treated by endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) ( Table 25.1 ). Traditionally, options for the treatment of gastric outlet obstruction (GOO) include either open or laparoscopic gastrojejunostomy and the endoscopic placement of self-expanding metal stents (SEMS) across the luminal obstruction. Recently, there have been reports of successful creation of gastro-enteric anastomosis being performed under endosonographic guidance using lumen-apposing metal stent (LAMS). The procedure has the potential to offer long-lasting luminal patency without the risk of stent obstruction by tumor ingrowth and avoiding the morbidity of a surgical procedure.

TABLE 25.1
Candidates for Endoscopic Ultrasonography-Guided Gastroenterostomy
Malignant Benign
Gastric cancer Gastric ulcer
Duodenal cancer Duodenal ulcer
Pancreatic cancer Acute pancreatitis
Bile duct cancer Chronic pancreatitis
Gallbladder cancer Postendoscopic therapy (i.e., ESD)
Ampullary cancer Postoperative stenosis (i.e., Billroth I gastrectomy)
Lymph node metastasis Superior mesenteric syndrome
Miscellaneous Miscellaneous
ESD , endoscopic submucosal dissection.

Procedural technique

Currently, six EUS-GE techniques have been reported as follows: (1) antegrade EUS-GE: the traditional/downstream method; (2) antegrade EUS-GE: the rendezvous method; (3) retrograde EUS-GE: enterogastrostomy; (4) EUS-guided balloon-occluded gastrojejunostomy bypass (EPASS); (5) antegrade EUS-GE: the direct method; and (6) wireless EUS-gastroenterostomy simplified technique (WEST).

I. Antegrade EUS-GE: The traditional/downstream method

  • Step 1. An endoscopy is performed to place a guidewire in the proximal jejunum past the obstruction. The endoscope is withdrawn, leaving the guidewire in the jejunum.

  • Step 2. Under fluoroscopic control, a large dilating balloon is advanced over this wire to the jejunum.

  • Step 3. EUS-guided 19-gauge needle puncture of the balloon is performed from the stomach.

  • Step 4. A new guidewire is passed downstream into the jejunum through this 19-gauge needle.

  • Step 5. Over this guidewire, the LAMS is deployed, creating a gastroenterostomy.

II. Antegrade EUS-GE: The rendezvous method

  • Step 1. An endoscopy is performed to place a guidewire in the proximal jejunum past the obstruction. The endoscope is withdrawn, leaving the guidewire in the jejunum.

  • Step 2. Under fluoroscopic control, a large dilating balloon is advanced over this wire to the jejunum.

  • Step 3. EUS-guided 19-gauge needle puncture of the balloon is performed from the stomach.

  • Step 4. Instead of passing a guidewire downstream into the jejunum, the puncturing guidewire is trapped in the dilating balloon that was punctured, or an ERCP extraction balloon and basket, and pulled back through the duodenal obstruction, out of the mouth, securing it.

  • Step 5. The LAMS is then deployed over this guidewire under traction.

III. Retrograde EUS-GE

  • Step 1. An endoscopy is performed to place a guidewire in the proximal jejunum past the obstruction. The endoscope is withdrawn, leaving the guidewire in the jejunum.

  • Step 2. Under fluoroscopic control, a large dilating balloon is advanced over this wire to the jejunum.

  • Step 3. EUS-guided 19-gauge needle puncture of the balloon is performed from the stomach.

  • Step 4. Instead of passing a guidewire downstream into the jejunum, the puncturing guidewire is trapped in the dilating balloon that was punctured, or an ERCP extraction balloon and basket, and pulled back through the duodenal obstruction, out of the mouth, securing it.

  • Step 5. A therapeutic endoscope is now advanced over the guidewire, traversing the obstruction to the point of duodenal/jejunal insertion of the guidewire.

  • Step 6. The LAMS is deployed from the jejunum (gastric flange opens first).

IV. EUS-guided balloon-occluded gastrojejunostomy bypass ( Fig. 25.1 and )

  • Step 1. A standard upper endoscope is advanced in front of duodenal stenosis and a guidewire is advanced as far as possible into the jejunum.

  • Step 2. The endoscope is removed leaving the guidewire in place. An overtube is helpful to facilitate passage of the preinflated balloon catheter to avoid looping in the fornix of the stomach as it to passes through the pyloric-duodenal stenosis.

  • Step 3. A double-balloon tube (Tokyo Medical University type, Create Medic Co., Ltd., Yokohama, Japan) is inserted per orally over the guidewire and the two balloons are placed in the duodenum and jejunum in an area adjacent to the stomach.

  • Step 4. Both balloons are filled with saline and contrast material to anchor the small intestine in place. A sufficient quantity of saline with contrast material is introduced into the space between the two balloons to distend the small bowel lumen.

  • Step 5. An echoendoscope is advanced to the stomach to identify the distended duodenum or jejunum.

  • Step 6. EPASS can then be undertaken by the intra-working channel deployment technique which is performed using direct electrocautery-enhanced tip delivery system insertion without needle puncture.

  • Step 7. Postdilation of SEMS depends on endoscopist preference.

V. Antegrade EUS-GE: The direct method ( )

  • Step 1. The duodenum and jejunum are filled with contrast material and methylene blue.

  • Step 2. EUS-guided needle puncture of the jejunum without need for a dilating balloon is performed.

  • Step 3. Methylene blue is aspirated, confirming the needle is in the jejunum (helps avoid unintentionally puncturing the transverse colon).

  • Step 4. The LAMS is deployed without a guidewire.

VI. Wireless EUS-GE simplified technique ( )

  • Step 1. A 7F nasobiliary catheter or enteral feeding tube is placed through the gastric or duodenal stenosis into the jejunum.

  • Step 2. 9% NaCl is infused in the targeted loop of small bowel.

  • Step 3. Using a combination of fluoroscopy and EUS-guided identification of the catheter, electrocautery-enhanced LAMS is placed and deployed into the dilated jejunal or enteric loop.

  • Step 4. The distal flange then is deployed under endosonographic guidance and the proximal flange is deployed inside the endoscope working channel and subsequently pushed outside the working channel together with a careful endoscope retraction, resulting in deployment of the proximal flange into the gastric lumen (intraworking channel deployment technique).

  • Step 5. Postdilation of SEMS depends on endoscopist preference.

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