LAUSR

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposingmetal stent (LAMS) (Hot Axios; Boston Scientific, USA) effectively manages afferent loop syndrome [1, 2]. The LAMS prevents stent migration and fluid leakage. However, because the distance between the flanges of the LAMS is 10mm, if the distance between the afferent limb and the stomach increases beyond this distance, the risk of technical failure and complications increases [3]. Recently, a novel dumbbell-shaped fully covered self-expandable metal stent (FCSEMS) (Bonastent M-Intraductal; Standard SciTech, Seoul, Korea) has become available [4]. Its unique shape, with a diameter in the central saddle portion that is thinner (8mm) than that of the proximal and distal portions (12mm), provides comparable antimigration properties to the LAMS. The length of the central saddle portion is 20mm, longer than that of a LAMS (▶Fig. 1). We performed EUS-GE using a novel dumbbell-shaped FCSEMS for afferent loop syndrome with a long interluminal distance (▶Video 1). A 68-year-old man who had undergone pancreaticoduodenectomy for pancreatic cancer presented with severe abdominal pain. Computed tomography (CT) revealed a dilated afferent limb with ascites, and a diagnosis of afferent loop syndrome with peritonitis was made. Although the distance between the stomach and the afferent limb was 20mm, we elected to perform EUS-GE (▶Fig. 2). Endoscopic enteral stenting risks perforation of the afferent limb owing to increased intestinal pressure during the procedure. The dilated afferent limb was punctured using a 19-G needle from the stomach and contrast medium was injected. A 0.025-inch guidewire was placed into the dilated afferent limb; the needle tract was dilated using a 4-mm ultra-tapered balloon catheter. The novel FCSEMS was deployed, apposing the dilated afferent limb and the gastric walls. A 7-Fr double-pigtail plastic stent was placed across the FCSEMS to prevent SEMS-induced complications, including bleeding and perforation (▶Fig. 3). The patient’s symptoms rapidly improved, and CT revealed shrinkage of the dilated afferent loop (▶Fig. 4). Stent migration did not occur before the patient died. This novel dumbbell-shaped FCSEMS may be helpful in EUS-GE for afferent loop syndrome with long interluminal distance.