1/9
Some tips for a safer, faster, and easier EUS-gastroenterostomy (EUS-GE)

an interventional EUS procedure used for malignant gastric outlet obstruction

#EUS #AdvancedEndo #GITwitter

(All media posted with permission)

2/9
Patient selection is key
If life expectancy is < 3 months, we believe risks of EUS-GE outweigh benefits choose duodenal stent
If > 3 months, go for EUS-GJ

@BilalMohammadMD @NickMcDonaldMD https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7895656/

3/9
Study pre-procedural imaging carefully
You want to see a distended stomach with D3/D4 coursing immediately inferior to and adjacent to gastric body

In this CT slice, the IR placed GJ tube is a nice guide as to how D3/D4 courses in relation to the stomach

4/9
Place the pigtail of your naso-biliary drain at the ligament of Treitz
This is your ideal puncture site to maximize your window for deep insertion of LAMS catheter (which will minimize AEs)
Connect NB drain to water pump and infuse saline, contrast, and methylene blue

5/9
Use fluoro to guide EUS-scope to ligament of Treitz
On EUS, this is where you will find your best window with a long "runway" to hub your LAMS catheter and ensure complete opening of the distal flange (4.7cm here!)
Continue to infuse fluid up until moment you puncture

6/9
Use a 15mm, not a 20mm LAMS
Anecdotal experience suggests that patients with a 15mm stent do just as well and can tolerate a near regular diet
The outer flange diameter of 24mm vs 29mm gives you a larger margin of error to fully open distal flange in a tight space

7/9
Always puncture freehand, never over a wire
Slow and steady (not like an FNA), let the cautery do the work
Deploy distal flange only when catheter within a thumbs length of being hubbed
Deploy proximal flange in scopebig wheel away unlock catheterpush LAMS out

8/9
Hold your breath, and wait for the methylene blue

Congratulations

9/9
Of course, EUS-GE should only be performed in expert hands where surgical backup is readily available

Anticipate problems and how to troubleshoot. This is a great video by Shayan Irani highlighting various rescue maneuvers ( http://learn.asge.org  2018 DDW Videos)