Direct Eus Guided Gastro - Jejunostomy Using A Combined Cautery/Stent Device

Endoscopic anastomotic stent devices are demonstrating their use as inventive tools for palliative gastro - enterostomy (GE) in cases of malignant duodenal stenosis unsuitable for surgery. We demonstrate the case of a female patient (83 years) with progressive retention symptoms due to pancreatic head cancer with duodenal stenosis. A surgical GE was refused by the patient. A jejunal small bowel segment suitable for EUS guided anastomosis was identified by water filling the poststenotic intestinal lumen. The target lumen for EUS puncture was additionally enlarged by i.v. application of Buscopane. Transgastric EUS guided puncture was performed using a 19 gauge needle. After intraluminal placement of a guidewire, a stent device carrying an 15/10mm, fully covered metall stent with integrated cautery was advanced in the jejunal lumen. After deployment of the stent, endoscopic and fluoroscopic pictures confirmed a malposition of the jejunal stent flange into the peritoneum, while the gastric flange was in place. The stent was removed and the transgastric puncture site was successfully closed with clips. In a second attempt, after repeating the water enlargement and Buscopane application, a suitable part of the jejunum was directly punctured with the cautery stent delivery system in order to avoid a dislocation of the small bowel by the guide wire. The stent was successfully deployed and created a completely functional GE after additional balloon dilatation. The patient fully recovered from the procedure. A direct EUS guided puncture of water enlarged intestinal lumen using a cautery bearing stent device is a feasible alternative for save deployment of fully covered metal stents for gastrointestinal anastomoses.