EUS-Guided Gastrojejunostomy with AXIOS

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Authors:
Andrés Gutiérrez ¹, Subhash Garikipati ², Vivek Kesar ², Paul Yeaton², Klaus Mönkemüller ^{1,2, 3}

1. Universidad de la República, Facultad de Medicina, Escuela de Graduados - Postgrado en Gastroenterología, Unidad Académica Gastroenterología - Prof. Dra. Carolina Olano, Hospital de Clínicas - Dr. Manuel Quintela, Montevideo, Uruguay

2. Department of Gastroenterology, Virginia Tech Carilion School of Medicine, Roanoke, United States

3. Department of Gastroenterology, Ameos Teaching University Hospital (Otto-von Guericke University– Magdeburg), Halberstadt, Germany

Presentation:

A 74-year-old man with metastatic pancreatic adenocarcinoma presented with fatigue, decreased appetite, nausea and vomiting due to occluded duodenal stent. His history was notable for gastric outlet obstruction (GOO) secondary to malignant duodenal stricture, initially managed with placement of a duodenal stent in November 2024. Following progressive disease, he underwent endoscopic biliary stenting for obstructive jaundice in January 2025 and an EUS-guided hepaticogastrostomy in April 2025 due to recurrent biliary obstruction.

Pre-procedural contrast-enhanced abdominal CT imaging demonstrated an infiltrative mass in the pancreatic head causing progressive narrowing of the portosplenic confluence. The stomach as massively dilated and filled with fluid due to GOO (Figure 1 A). Multiple hepatic metastases were present, the largest measuring 3.9 cm. Additionally, biliary dilatation, pneumobilia, small-volume ascites, and a small hiatal hernia were noted. All previously placed stents were stable and appropriately positioned.

On EGD the previously placed self-expanding metal stent (SEMS) was occluded (Figure 1 B). Due to recurrent GOO caused by duodenal stent occlusion, an EUS-guided gastrojejunostomy (EUS-GJ) was performed. This case highlights the crucial steps in performing an EUS-GJ. A linear echoendoscope facilitated recognition of the distal duodenal sweep. In order to achieve a proper gastroenterostomy, the small bowel lumen had to be clearly visible. This was achieved with contrast injection and saline infusion. A biliary guidewire was advanced through the partially obstructed duodenal stent into the duodenum and past the ligament of Treitz (Figure 2 A, B). A nasobiliary drain was advanced over-the-wire into the distal duodenum (Figure 2 C, D, E). The wire was remove and contrast followed saline instilled through the transcystic drain into the jejunum. The duodenum full of saline could be easily visualized with EUS (Figure 3 A). The 20 mm × 10 mm lumen-apposing metal stent (LAMS, AXIOS, Boston Scientific, USA) was then inserted through the stomach wall into the saline filled duodenum. The distal flange inside the duodenum was deployed first and pulled proximally (Figure 3 C). Then proceeded to deploy the proximal flange inside the stomach, fully releasing the entire stent and thus achieving a gastric-jejunal apposition (Figure 3 D, E). The Axios stent was expanded with a balloon (Figure 3 F). Fluoroscopy confirmed correct positioning with no immediate complications (Figure 3 G).

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