Saline with methylene blue-assisted endoscopic ultrasound-guided gastrojejunostomy using a double-flared fully covered metal stent.

Duodenal malignant stenosis can be caused by primary duodenal cancer or pancreatic cancer involving the duodenum [1]. Current treatment options include laparoscopic bypass and palliative duodenal stent placement under endoscopic or radiographic guidance. Both methods have their advantages and disadvantages. Surgical methods will cause greater trauma to patients, while a duodenal stent might remain patent for only a short time (generally 3–6 months), with the risk of tumor ingrowth and/or overgrowth [2]. For these reasons, we may also choose endoscopic ultrasoundguided gastroenterostomy (EUS-GE), with placement of a double-flared, fully covered, metal stent to create an anastomosis and bypass the obstruction. Here, we report a successful EUS-guided gastrojejunostomy (EUS-GJ) in a 65-yearold man who presented to our hospital with malignant duodenal stenosis, causing persistent vomiting and difficulty eating. Computed tomography (CT) showed a low-density 23×17mm mass in the pancreatic head (presumed to be pancreatic cancer), along with distal biliary obstruction, a dilated pancreatic duct, and multiple enlarged pancreatic, hilar, and hepatic lymph nodes (▶Fig. 1 a). The patient had undergone a Roux-en-Y bypass 2 years previously at another hospital. The previous surgery precluded laparoscopic intervention because of abdominal adhesions; we therefore decided to perform EUS-GJ. The patient was placed in a supine position under general anesthesia. The endoscope was advanced to the area of the stenosis, and a guidewire and catheter were inserted across the stenosis, which was too narrow for passage of the endoscope. Angiography showed the distal bowel. Then, the wire was removed and approximately 200mL of saline with methylene blue dye was pumped into the distal small bowel through the catheter E-Videos