LAUSR

RETROPERITONEAL FIBROSIS IS a chronic inflammatory process characterized by fibrosclerosis of retroperitoneal structures. It usually presents with obstructive uropathy. Gastrointestinal involvement as a presentation is unusual. A 70-year-old hypertensive woman presented with abdominal distension and postprandial pain relieved by bilious vomiting for 3 weeks. Contrast enhanced computed tomography (CECT) of the abdomen showed narrowing in the third part of duodenum with distended proximal duodenum and stomach, without any mass lesion (Fig. 1), along with left hydroureteronephrosis due to pelvic-ureteric junction narrowing. Multidisciplinary board discussion decided for minimally invasive endoscopic ultrasonography (EUS)-guided gastric bypass for symptomatic gastric outlet obstruction (GOO), in view of the comorbidities, that were performed using a linear echoendoscope (GF-UCT 180; Olympus, Tokyo, Japan), double-balloon orojejunal tube (EPASS balloon, Tokyo Medical University; Create Medic, Yokohama, Japan), and cautery-enhanced lumen apposing metal stents (LAMS) (20 mm, AXIOS-EC; Boston Scientific, Marlborough, MA, USA). In this procedure, initially a 0.035 angled tip guide wire (Dreamwire High Performance; Boston Scientific) was inserted using an upper gastrointestinal endoscope across the stricture deep inside the proximal small intestine. Then, an EPASS balloon catheter was advanced over the wire, with the proximal balloon beyond the duodenal stricture and distal balloon beyond the duodenojejunal flexure. Both the balloons were inflated with contrast mixed saline (40 cc) to anchor the small bowel. Then, a 20 cm long intervening small bowel segment between the balloons was distended with 150 cc of saline mixed with contrast and indigo carmine. After adequate distension of the lumen, under EUS guidance the AXIOS-EC stent was deployed transmurally between the stomach and jejunum (Fig. 2, Video S1). At follow-up at 6 months, the patient did not report any GOO symptoms and has been tolerating oral feeding well. We conclude that EUS-guided gastroenterostomy is a viable alternative to surgical gastrojejunostomy in patients with benign GOO. Authors declare no conflict of interest for this article. Authors declare no conflict of interest for this article.