Clin Endosc.  2025 Mar;58(2):201-217. 10.5946/ce.2024.206.

Endoscopic ultrasound-guided gastroenterostomy, with focus on technique and practical tips

• Yang CY
• Huang WH
• Cheng HH

• KMID: 2566139
• DOI: http://doi.org/10.5946/ce.2024.206

Abstract

Gastric outlet obstruction (GOO) is a condition characterized by a mechanical obstruction of the stomach or duodenum, caused by either benign or malignant disease. Traditionally, surgical gastrojejunostomy (SGJ) has been the standard treatment for malignant GOO and endoscopic stenting (ES) offers a less invasive option, but it often requires repeat interventions. Recently, endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE), an innovative technique, has been applied as an alternative to SGJ and ES for GOO patients. Direct EUS-GE, device-associated EUS-GE, and EUS-guided double balloon-occluded gastrojejunostomy bypass are the most commonly used techniques with reported technical success rates ranging from 80% to 100%, and clinical success rates between 68% and 100%. Adverse event (AE) rates range from 0% to 28.2% and the stent misdeployment is the most common while other AEs include abdominal pain, bleeding, infection, peritonitis, bowel perforation, gastric leakage, and stent migration. It is clear that EUS-GE may achieve a similar clinical success to SGJ with fewer AEs and a shorter hospital stay. Compared to ES, EUS-GE showed higher clinical success, fewer stent obstructions, and lower reintervention rates.

Keyword

Endosonography; Gastric outlet obstruction; Gastroenterostomy; Interventional ultrasound

Figure

• 

  Fig. 1. (A) Upper gastrointestinal (UGI) series image shows the filling defect (tumor) is noted at the second portion of duodenum (type II gastric outlet obstruction). The direction and pattern of the proximal small intestine are visualized by the contrast media enhancement. (B) A 7-Fr nasobiliary catheter tube is inserted through the guidewire into the proximal jejunum. Saline and contrast media is infused through the nasobiliary drainage tube and the pattern of the small intestine is similar to that visualized by UGI series. (C) Abdominal computed tomography (CT) reveals the proximal jejunum goes to the right side after the small intestine passes through the ligament of Treitz. (D) The direction and pattern of the proximal jejunum is also similar with abdominal CT image.

• 

  Fig. 2. Techniques of endoscopic ultrasound-guided gastroenterostomy (EUS-GE). (A) Direct technique. (B) Rendezvous guidewire technique. (C) Retrograde deployment technique. (D) Balloon-assisted technique. (E) Orojejunal catheter (nasobiliary drain, nasojejunal tube)-assisted technique. (F) Ultraslim endoscope assisted. (G) EUS-guided double balloon-occluded gastrojejunostomy bypass. LAMS, lumen-apposing self-expandable metal stent.

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  Fig. 3. Steps of endoscopic ultrasound (EUS)-guided gastroenterostomy using nasobiliary drain assisted technique. (A) A 0.035-inch guidewire is passed into the proximal jejunum guided by large size of retrieval balloon. (B) Under endoscopic and fluoroscopic guidance, a 7-Fr nasobiliary catheter tube is inserted through the guidewire into the proximal jejunum. (C) Saline and contrast media are infused through the nasobiliary drainage tube to inflate the proximal enteric loops. (D) The saline-distended loops of the proximal small bowel are identified by using EUS. (E) EUS-guided puncture and successful deployment of lumen-apposing metal stents (LAMS). (F) The endoscopic view of the deployed LAMS is confirmed by visualizing blue-dyed water (methylene blue) infused through the nasobiliary drain.

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  Fig. 4. Type I stent misdeployment. (A) A tent-like sign of the bowel wall (arrows) is visualized by endoscopic ultrasound (EUS) and it means that the EUS-guided puncture does not actually penetrate into the lumen of the small intestine. (B) The distal flange of the lumen-apposing metal stent opens in the peritoneum outside the small intestine.

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