V4 - Bridging the Gap: Successful Endoscopic Ultrasound-Guided Gastrojejunostomy with a Lumen-Apposing Metal Stent Placement in the Setting of Malignant Ascites

Introduction: In the context of gastric outlet obstruction (GOO), performing endoscopic ultrasound-guided gastro-jejunostomy (EUS-GJ) can be challenging in patients with significant ascites. This case report presents a novel technique to reduce the gap between the jejunum and stomach, facilitating lumen-apposing metal stent (LAMS) placement.


Case Description/Methods: A 70-year-old female with a history of breast cancer and advanced metastatic ovarian cancer presented with symptoms of persistent nausea, vomiting, and early satiety. Imaging revealed gastric outlet obstruction caused by peritoneal carcinomatosis. Initially, the patient received medical management, but due to high surgical risk, she opted for an EUS-GJ with LAMS placement. During the procedure, a duodenal stricture was identified that could not be bypassed with a regular gastroscope. However, a smaller neonatal endoscope was successfully used. A wire was inserted into the duodenum with the aid of an adult gastroscope, and a nasobiliary drain was placed across the stricture. Contrast and methylene blue were used to confirm the drain's location and distend the small bowel.The adult gastroscope was then replaced with a linear echoendoscope, allowing for visualization of a safe passage from the stomach to the small bowel. A fine needle aspiration (FNA) needle was used to puncture the stomach and reach the distended small bowel, confirmed by fluoroscopy. However, the presence of more than 4 cm of ascites posed a challenge as the gap between the gastric and jejunal walls was too wide for LAMS placement.To overcome this, a long guidewire was inserted through the previous puncture, reducing the distance between the luminal walls. The guidewire was advanced into the small bowel and captured with a mini snare using the neonatal scope. By pulling the distal end of the guidewire through the patient's mouth, both ends were accessible. With controlled manipulation, the luminal walls were brought closer together, allowing for the placement of a 20mm x 10mm LAMS under endoscopic ultrasound guidance. Correct positioning was confirmed by the drainage of methylene blue through the stent, and the distal small bowel was visualized.The day after the procedure, the patient tolerated a pureed diet without significant symptoms.


Discussion: This case report focuses on the difficulties presented by malignant ascites during EUS-GJ procedures. The study describes a successful technique that reduced the gap between the jejunum and stomach, enabling LAMS placement.