Endoscopic ultrasound-guided gastrojejunostomy: Novel double catheter technique with video

Abstract

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) can provide durable treatment for gastric outlet obstruction.¹ Technical challenges have limited widespread adoption of the procedure.² Various techniques such as nasojejunal tube or dedicated balloon-assisted technique have been explained in the literature.³ The commonly used technique of nasojejunal catheter-assisted GJ has the limitation of difficulty in correct identification of the desired loop. Multiple small bowel and even colonic loop may get distended with infusion of fluid, and may lead to erroneous puncture of the distal small bowel or colonic loop. We attempted to overcome this difficulty by placing two catheters simultaneously in the jejunum. One catheter placed near the duodenojejunal (DJ) flexure is used to infuse saline for jejunal loop distension and another catheter placed distally acts as a guide to identify the correct proximal jejunal loop. A 64-year-old man with advanced gastric cancer-causing pyloric obstruction underwent EUS-GJ (Video S1). The procedure was performed under general anesthesia with endotracheal intubation in the supine position. Gastroscope (HQ 190; Olympus, Tokyo, Japan) could be negotiated across the pyloric growth and guidewire (Visiglide, G-240-2544S; Olympus) was placed in the jejunum and a catheter (nasobiliary drain, 7F; Devon, Bangalore, India) was placed with the tip at ~50 cm from the DJ flexure. Another guidewire was passed and the catheter was placed with the tip near the DJ flexure, under fluoroscopic guidance (Fig. 1). Linear echoendoscope (GF UCT 180, ME-2 premium plus processer; Olympus) was introduced. Glucagon injection was used for bowel relaxation and a methylene blue-stained normal saline was infused through the proximal catheter and jejunal loop where the distal catheter was identified. A lumen-apposing metal stent (Hot AXIOS Stent and Delivery System, 20 mm ×10 mm; Boston Scientific, Marlborough, MA, USA) was deployed with the freehand puncture technique (Fig. 2). Immediate release of methylene blue-stained fluid through the deployed stent was identified, confirming the position of stent in the bowel lumen. The present technique may overcome the difficulty in identification of the correct bowel loop during EUS-guided gastrojejunostomy.

Authors declare no conflict of interest for this article.