Endoscopic ultrasound-guided gastrointestinal anastomosis: Evolving applications in advanced therapeutic endoscopy

Figure 1 A 72-year-old female with locally advanced pancreatic adenocarcinoma presented with symptomatic gastric outlet obstruction and underwent endoscopic ultrasound-guided gastroenterostomy for palliation. A: Upper endoscopy demonstrated a severe, malignant-appearing stricture involving the distal duodenal bulb; B: A nasojejunal tube was advanced into the distal duodenum over a guidewire under fluoroscopic guidance; C: A mixture of contrast and water was infused through the nasojejunal tube to distend the small bowel; D: A distended jejunal loop was identified endosonographically from the stomach; E: A 20-mm lumen-apposing metal stent was deployed to create the gastroenterostomy; F: Endoscopic view confirming adequate deployment of the proximal flange within the gastric lumen.

Figure 2 A 67-year-old female with a history of Roux-en-Y gastric bypass presented with abdominal pain attributed to chronic calcific pancreatitis, endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography was performed to facilitate endoscopic therapy. A: Magnetic resonance imaging demonstrated a pancreatic duct stricture with upstream ductal dilation; B: Endoscopic ultrasound visualization of the excluded (remnant) stomach from the gastric pouch; C: The excluded stomach was distended under endosonographic guidance using a mixture of contrast and water; D: A 20-mm lumen-apposing metal stent was deployed to create a gastrogastric fistula; E: Endoscopic view confirming appropriate deployment of the proximal flange within the gastric pouch; F: A side-viewing duodenoscope was advanced through the stent into the remnant stomach to complete the endoscopic retrograde cholangiopancreatography.

Figure 3 A 62-year-old female with metastatic colon cancer presented with distal small bowel obstruction secondary to peritoneal adhesions. Endoscopic ultrasound-guided enterocolostomy was performed for palliative decompression. A: Contrast-enhanced computed tomography demonstrated diffuse small bowel dilation consistent with distal obstruction; B: Endosonographic visualization of the dilated small bowel loop from the descending colon; C: The target small bowel was accessed using a 19-gauge needle and further distended under endoscopic ultrasound guidance with a mixture of contrast and water; D: A 15-mm lumen-apposing metal stent (LAMS) was deployed to create an enterocolonic fistula; E: Endoscopic view confirming appropriate stent expansion and positioning; F: A double-pigtail plastic stent was placed through the LAMS to maintain patency and reduce the risk of stent occlusion or migration.