EUS-guided gastroenterostomy: A modified direct water infusion approach using a transhepatic jejunal access (with video).

The direct EUS-guided gastroenterostomy (EUS-GE) technique described for the management of malignant gastric outlet obstruction (GOO) entails injection of fluid/contrast across the obstruction using an endoscope to expand the jejunum and allow for EUS-guided cautery-assisted lumen-apposing metal stent (LAMS) insertion.[123] Adequate infusion of the fluid across a high-grade obstruction, however, can be challenging, especially if a guidewire cannot be navigated across. Here, we demonstrate a modified direct EUS-GE technique using a fluoroscopic-guided transhepatic approach to infuse fluid in the proximal jejunum and assist the “direct” method in a high-grade stricture that did not allow for adequate fluid infusion via the endoscope [Video 1]. A 51-year-old female with pancreatic cancer presented with GOO, where duodenal stenting was unsuccessful given the inability to traverse the high-grade duodenal stricture with a wire. Using the direct EUS-GE approach, a therapeutic gastroscope was advanced into the duodenum and a total fluid/contrast volume of 500 ml was injected through the endoscope at the level of the obstruction. Due to extreme stricture, minimal amount of fluid could traverse, with most of the injections refluxing back into the stomach and bile duct. Since the biliary system was well opacified on fluoroscopy, interventional radiology was able to puncture one of the intrahepatic biliary ducts under fluoroscopy using a 21-gauge needle. A guidewire was advanced through the biliary system past the obstruction and into the proximal jejunum. Over that same guidewire, a 5 French catheter was advanced, and fluid was injected through the catheter allowing for adequate distension of the proximal jejunum, which was now well visualized under EUS [Figure 1]. A cautery-assisted LAMS 15 mm × 10 mm (Axios, Boston Scientific Inc., USA) was inserted with ease via EUS guidance [Figure 2]. Importantly, given that a small 5 French catheter was used to access the biliary system, there was no need to keep an external drain in the patient postprocedure. The patient did well and was able to tolerate a low residue diet within 48 h.Figure 1: EUS image of the dilated fluid-filled small bowel segmentFigure 2: EUS and fluoroscopic images of the gastroenteric lumen-apposing metal stent with distal flange deploymentThis novel approach using transhepatic jejunal access under fluoroscopy allows to safely optimize the direct method in the setting where the infusion of fluid into the proximal jejunum is not feasible by endoscopy alone. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.