Background

Endoscopic resection of circumferential duodenal adenomas carries high stricture risk. We report prophylactic EUS-guided gastroenterostomy (EUS-GE) using a lumen-apposing metal stent (LAMS) performed during circumferential ampullectomy to maintain oral intake throughout the anticipated stricture formation and resolution phase.

Case

A 53-year-old woman presented with dyspepsia. Endoscopy revealed a 50mm circumferential non-granular laterally spreading duodenal lesion involving the ampulla (Paris 0-IIa+Is, JNET 2A). MRCP and CT excluded intraductal extension and metastases. Piecemeal EMR with en bloc ampullectomy was performed. Biliary (8×60mm fully-covered metal stent) and pancreatic (7Fr×5cm plastic) stents were placed. Given near-certain post-resection stricture, prophylactic EUS-GE was performed during the same session: a 20×10mm LAMS was deployed between the gastric antrum and jejunum under EUS and fluoroscopic guidance. This approach was chosen to reduce procedure burden and ensure uninterrupted oral intake during stricture management. Intraprocedural bleeding was controlled with soft coagulation and hemostatic gel. Mild post-ERCP pancreatitis resolved conservatively.

Outcome

Histology confirmed tubulovillous adenoma with focal high-grade dysplasia. Over 22 months, the patient required seven balloon dilations (6–15mm) for duodenal stricture but maintained oral intake throughout via the gastroenterostomy. Two small residual adenoma foci were treated with cold snare polypectomy. No recurrence at last follow-up.

Conclusion

Prophylactic EUS-GE during high-risk circumferential duodenal resection maintains quality of life by preserving oral intake during stricture management, reduces overall procedure burden, and avoids pancreaticoduodenectomy.