EUS-Guided jejunojejunostomy using a novel dilator for malignant afferent loop obstruction (with video).

Malignant afferent loop obstruction (MALO) can cause cholangitis or pancreatitis due to blind loop dilatation. Malignant afferent loop obstruction is traditionally treated by surgery, percutaneous drainage, or self-expandable metal stent (SEMS) deployment under enteroscopic guidance. EUS–guided drainage has recently been attempted forMALOusing a lumen-apposingmetal stent (LAMS). Although a LAMS has clinical impact, the diameter of the target lesionmust be large enough to enable deployment of the distal flange of the LAMS. In contrast, conventional SEMS is easily deployed but requires intestinal wall dilatation before insertion of the stent delivery system. If force is used while attempting EUS-guided drainage for MALO, the afferent loop can be pushed away from the echoendoscope, after which it may be difficult to insert the device. A novel drill dilator has recently become available in Japan (Tornus ES; Asahi Intecc, Aichi, Japan) [Figure 1A]. Using this device, the tract is dilated using a clockwise rotationwithout needing