Endoscopic-ultrasound guided gastroenterostomy (EUS-GE) has recently emerged as the most optimal endoscopic treatment for malignant gastric outlet obstruction (MGOO) (1-4). EUS-GE, however, is generally used in the palliative setting, rather than in patients pursuing definitive treatment. Recent case reports have reported the use of EUS-GE using a lumen-apposing metal stent (LAMS) as a bridge to pancreaticoduodenectomy where the stents were resected en bloc followed by a surgical gastrojejunostomy (5-6). To our knowledge, we present the first reported case of a patient with duodenal obstruction for whom an EUS-GE was performed in the neoadjuvant setting and the LAMS was left in situ as the definitive anastomosis after surgical resection.
A 56 year-old female presented with MGOO secondary to duodenal adenocarcinoma. EUS-GE was performed. The patient then received neoadjuvant chemotherapy followed by pancreaticoduodenectomy six months later. The area of the cancer was readily visible and palpable. The stent was palpable with a well-connected and well-healed anastomosis. The pancreatic head and neck, duodenum, and pylorus were resected en bloc and sent to pathology. The surgical team then opted to leave the previously constructed anastomosis intact, in part due to the EUS-GE being more cranial in the stomach than a surgical gastrojejunostomy. A Roux-Y limb was created 30-40 cm distally, which was used to perform a pancreaticojejunal anastomosis. Further distally, a hepaticojejunostomy was performed.
Post-operatively, clear fluid diet was initiated on POD 2, diet-as-tolerated on POD 4, and the patient was discharged on POD 8. A follow-up EGD was performed 8 months post EUS-GE confirming a patent stent. In order to reinforce the anastomosis as a permanent solution, we considered performing endoscopic suturing as a stent-free strategy. Unfortunately, however, at 1 year follow-up the patient had recurrence of metastatic disease to the liver and a decision was taken to simply exchange the stent given the guarded prognosis.
Our case supports the hypothesis that EUS-GE is a viable and effective option for managing MGOO as a bridge to pancreaticoduodenectomy. It may enable patients to maintain adequate nutritional status, tolerate neoadjuvant chemotherapy and major surgery. Additionally, this case demonstrates feasibility of using EUS-GE as a definitive anastomotic solution during Whipple surgery, which may decrease surgical time, eliminate the risk for anastomotic leak, and most importantly decrease the risk for delayed gastric emptying, which is reported in as much as 20-40% of patients undergoing pancreaticoduodenectomy (7).