Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Figure 1 Schematic representation of different endoscopic ultrasound-gastrojejunostomy techniques. A: Direct technique; B: Retrograde technique; C: Rendezvous technique; D: Balloon-assisted technique; E: Nasobiliary-assisted technique; F: Endoscopic ultrasound-guided double balloon-occluded gastrojejunostomy bypass. LAMS: Lumen apposing metal stent.

Figure 2 Endoscopic ultrasound-guided gastrojejunostomy using the nasobiliary drain assisted technique. A: Endoscopic view of the severe luminal obstruction in the proximal duodenum secondary to advanced pancreatic cancer; B: A percutaneous transhepatic biliary drain previously placed for jaundice can be identified on fluoroscopy. A therapeutic endoscope was used to advance and coil a 0.035” guidewire across the obstruction in the distal unobstructed bowel under fluoroscopic guidance; C: A nasobiliary catheter drain was then advanced through the channel of the scope over the guidewire across the obstruction. Contrast was injected under fluoroscopy to identify the target jejunal loop for endoscopic ultrasound (EUS)-guided gastrojejunostomy using; D: The target loop is distended with continuous infusion of fluid via the nasobiliary drain assisting with visualization under EUS; E: Successful EUS puncture of the target loop under EUS for lumen-apposing metal stent (LAMS) placement; F: Fluoroscopic image of the LAMS with adequate apposition of the gastric and jejunal lumen; G: Endoscopic view of the LAMS with confirmation of position by the visualization of the blue dyed water (methylene blue) infused through the nasobiliary drain.

Figure 3 Approach to a patient with malignant gastric outlet obstruction syndrome. ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound. ¹Currently possible only in highly specialized centers +avoid in perigastric varices, relative contraindication: massive ascites.