One-step, exchange-free, single-balloon-assisted endoscopic ultrasound-guided gastroenterostomy with lumen-apposing metal stent in malignant gastric outlet obstruction.

An 81-year-old woman with malignant gastric outlet obstruction due to pancreatic adenocarcinoma (▶Fig. 1 a) was referred to our institute for endoscopic ultrasound (EUS)-guided gastroenterostomy. Under general anesthesia, a 0035-inch guidewire (Navigator; Olympus Medical Systems, Center Valley, Pennsylvania, USA) was inserted through the duodenal stenosis (▶Fig. 2 a) deep into the small bowel using a standard gastroscope under fluoroscopic assistance (▶Fig. 2b). A 20-mm balloon dilator (CRE balloon; Boston Scientific, Marlborough, Massachusetts, USA) was then inserted over the wire across the obstruction and filled with contrast fluid (▶Fig. 2 c). A therapeutic linear echoendoscope (GF-UC140P; Olympus Medical Systems) was used to locate the balloon in a small-bowel loop adjacent to the gastric wall (▶Fig. 3 a, b). The jejunal loop was accessed directly from the stomach with a 15-mm diameter lumen-apposing metal stent (LAMS) contained within an electrocautery-enhanced delivery system (Hot AXIOS; Boston Scientific) (▶Fig. 3 c), avoiding the multiple accessory exchanges previously described with other techniques [1–3]. In fact, there was no need for a fine-needle aspiration needle, guidewire, or tract dilation, and the stent was released in a single-step, exchange-free fashion (▶Video1). During the procedure, the small-bowel loop was kept in close apposition to the gastric wall by pulling on the inflated balloon, which was firmly anchored within the bowel loop. The Trendelenburg position of the patient further helped to obtain “gravity countertraction” to puncture. Direct access into the jejunal loop was performed by aiming the electrocautery tip of the delivery system slightly distally to the balloon in order to avoid any eventual entrapment of the distal flange of the stent inside a popped balloon. As a result, the balloon remained intact and the LAMS was successfully released (▶Fig. 4 a, b). After deployment of the AXIOS stent, the lumen of the stent was balloon-(over)dilated up to 18mm (▶Fig. 5 a). A through-the-stent contrastography revealed no leak of contrast fluid at the end of the procedure (▶Fig. 5b). The patient resumed an oral diet the day after the procedure, after a follow-up computed tomography scan confirmed the correct position of the stent (▶Fig. 1b).