S4168 A Novel Approach to Endoscopic Gastrojejunostomy and Pyloric Exclusion by Suture Traction-Assisted Over-the-Scope Clip

Introduction: Gastrojejunostomy (GJ) with pyloric exclusion (PEX) is traditionally a surgical procedure used to bypass the duodenum in conditions such as perforation. Recently, an endoscopic approach has emerged for nonsurgical candidates. We present a novel endoscopic technique for GJ with PEX. Case Description/Methods: A 66-year-old woman with cholangiocarcinoma, status post covered metallic stent placement in the common bile duct (CBD) 3 months prior, presented in septic shock with Escherichia coli bacteremia. Imaging showed a 7 cm ill-defined gas-containing mass in the porta hepatis around the CBD stent. Once stabilized, upper endoscopy revealed a large, contained duodenal bulb perforation with necrotic debris. Inside the cavity, the CBD stent was in place, with the surrounding duct obliterated by the mass but no bile leak was noted. The stent appeared anchored at hilum and ampulla, acting as a bile conduit. After multidisciplinary discussion, a palliative endoscopic GJ with PEX was pursued. The procedure involved 2 steps. First, GJ was achieved using a 20 × 10 mm lumen-apposing metal stent (LAMS). A CF colonoscope was used to pass a soft-tip biliary wire, followed by a nasobiliary drain for irrigation and small bowel distention using water with 0.1% methylene blue and contrast. Endoscopic and fluoroscopic confirmation of position was followed by endoscopic ultrasound-guided LAMS deployment between the stomach and jejunum. Next, PEX was performed using a novel suture traction–assisted over-the-scope clip (OTSC) technique. Using an endoscopic knife, a 4-quadrant mucotomy with pyloromyotomy was performed to reduce pyloric contraction and lower the risk of clip dislodgement. Full-thickness sutures were placed at 4 quadrants around the pylorus using an OverStitch device and intentionally left untightened. The sutures were externalized, and the scope withdrawn. A dual-channel scope mounted with an OTSC was introduced, and the suture threads were captured into the scope using a snare. By applying traction to the threads, pyloric tissue is drawn into the OTSC cap. Once adequate tissue was captured, the clip was deployed, sealing the pylorus. Subsequent inspection showed no visible opening or bile drainage. Discussion: We demonstrate a successful novel endoscopic technique for pyloric exclusion using OTSC in a palliative setting, enabling enteral feeding in an end-stage cancer patient with duodenal perforation. Further studies are needed to compare outcomes with traditional endoscopic methods. Watch the video: https://tinyurl.com/25ACGS4168