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Pitfalls in stent deployment during EUS-guided gastrojejunostomy using Hot Axios™ (with videos)

1 Department of Medicine, Division of Gastroenterology, Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
2 Department of Surgery, Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand
3 Department of Surgery, Surgical Endoscopy Unit, Rajavithi Hospital, Bangkok, Thailand

Date of Submission28-Jan-2021
Date of Acceptance06-May-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Nonthalee Pausawasdi,
Department of Medicine, Division of Gastroenterology, Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/EUS-D-21-00041

PMID: 34494586

How to cite this URL:
Pausawasdi N, Rugivarodom M, Swangsri J, Ratanachu-ek T. Pitfalls in stent deployment during EUS-guided gastrojejunostomy using Hot Axios™ (with videos). Endosc Ultrasound [Epub ahead of print] [cited 2021 Oct 16]. Available from: http://www.eusjournal.com/preprintarticle.asp?id=325248

A 71-year-old man with multiple medical problems presented with gastric outlet obstruction due to pyloric stricture from a nonhealing peptic ulcer and a 10-kg weight loss in 3 months. Biopsies of the stricture and abdominal computed tomography scan were negative for malignancy and infectious causes. He underwent series of endoscopic balloon dilation up to 12 mm without adequate response. He could not tolerate a soft or regular diet and refused to undergo surgery. Thus, EUS-guided gastrojejunostomy (EUS-GJ) was undertaken.

A 30 mm custom-made single balloon catheter (7-French) with below injection was inserted into the proximal jejunum under fluoroscopic guidance [Figure 1]. A water solution containing 0.5% methylene blue and contrast media was infused until the distal duodenum, and proximal jejunum was fully distended [Figure 2]. A 10 mm × 20 mm cautery-enhanced HOT AXIOSTM stent was used to puncture the inflated small bowel loop with a free-hand technique. However, we lost the target bowel loop's visualization during the proximal flange deployment and decided to retrieve the stent [Video 1 [Additional file 1]]. Then, the puncture was reattempted using wire guided, and the stent was deployed. After complete stent deployment, peritoneal fat was visualized [Figure 3] and [Video 2 [Additional file 2]], suggesting perforation. Thus, the stent was removed using rat tooth forceps, and the puncture site was closed with through-the-scope clips. The patient was NPO, and intravenous fluid and antibiotics were given. He did well after 48 h of observation and was discharged. The EUS-GJ was repeated 6 weeks later, and the procedure was successful without complications [Figure 4] and [Video 3 [Additional file 3]].
Figure 1: Insertion of a single balloon catheter into the proximal jejunum under fluoroscopy

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Figure 2: EUS image of distended small bowel loop before direct puncture

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Figure 3: Visualization of peritoneal fat after stent deployment

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Figure 4: Successful EUS-guided gastrojejunostomy using HOT AXIOS™

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EUS-GE has emerged as a promising alternative treatment for gastric outlet obstruction. The recent meta-analysis showed that EUS-GE had a 92%–94% technical success and a 90%–91% clinical success.[1],[2],[3] Stent misdeployment is not an unusual pitfall occurring in 9.5% of reported cases.[3] The mobility of the small bowel may result in loss of visualization and subsequent stent misdeployment.[4] Insertion of the guidewire can push the small bowel away, thus increasing the risk of stent misdeployment.[5] Potential causes of pitfalls during stent deployment and rescue maneuvers are proposed in [Table 1].
Table 1: Proposed causes of pitfalls during stent deployment and possible rescue maneuvers

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The authors would like to thank the Zeon Medical Co., Tokyo, Japan, for providing us the custom-made balloon catheter for this procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

Nonthalee Pausawasdi and Thawee Ratanachu-ek are Editorial Board Members of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of these Editors and their research groups.

  References Top

McCarty TR, Garg R, Thompson CC, et al. Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: A systematic review and meta-analysis. Endosc Int Open 2019;7:E1474-82.  Back to cited text no. 1
Iqbal U, Khara HS, Hu Y, et al. EUS-guided gastroenterostomy for the management of gastric outlet obstruction: A systematic review and meta-analysis. Endosc Ultrasound 2020;9:16-23.  Back to cited text no. 2
Hakim S, Khan Z, Shrivastava A, et al. Endoscopic Gastrointestinal Anastomosis Using Lumen-apposing Metal Stent (LAMS) for Benign or Malignant Etiologies: A systematic review and meta-analysis. J Clin Gastroenterol 2020. doi: 10.1097/MCG.0000000000001453. Online ahead of print.  Back to cited text no. 3
Marrache MK, Itani MI, Farha J, et al. Endoscopic gastrointestinal anastomosis: A review of established techniques. Gastrointest Endosc 2021;93:34-46.  Back to cited text no. 4
Chen YI, Kunda R, Storm AC, et al. EUS-guided gastroenterostomy: A multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc 2018;87:1215-21.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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