LAUSR

A 70-year-old woman was admitted to our emergency room due to vomiting for 2 days. The patient had a previous diagnosis of bladder neoplasia with pancreatic head metastasis, and 15 days prior to admission she had undergone placement of a duodenal self-expandable metal stent (SEMS) plus endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) because of jaundice and vomiting due to the compression of the proximal descending duodenum and common bile duct (CBD). A computed tomography scan showed gastric outlet obstruction due to SEMSmigration into the third duodenal portion, with the proximal end of the SEMS hitting against the duodenal wall. Because of this complex case we decide to perform an EUS-guided gastrojejunostomy (EUS-GJ) aided by nasobiliary drain (NBD) to target the jejunal loop and avoid puncture of an ileal or colonic loop. Following gastric lavage using a gastroscope, an angle-tip guidewire (Jagwire; Boston Scientific, Marlborough, Massachusetts, USA) was advanced through the neoplastic stricture to the jejunal loops, but, despite several attempts, the guidewire could not be passed through the duodenal mesh of the SEMS. Therefore, the guidewire was advanced into the CDS, through the papilla, to the jejunal loops. A 7-Fr NBD was advanced over the wire into the CBD (▶Fig. 1), and the gastroscope was replaced with a linear echoendoscope (GF-UCT180; Olympus, Hamburg, Germany). The target jejunal loop was then irrigated by the NBD using a mixture of contrast medium, methylene blue, and saline solution with the intention of dilating it as much as possible. After exclusion of interposed vessels using color Doppler, EUS-GJ using a lumen-apposing metal stent (Hot-Spaxus 20×16mm; Taewoong Medical Co., Ltd., Goyang-si, Korea) was performed. The EUS-GJ was performed freehand with intrachannel release of the proximal flange (▶Video 1). The patient restarted an oral diet 24 hours after the procedure and was discharged 2 days post-procedure.