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A novel “balloon/snare apparatus” technique to facilitate easy creation of fistula tract during EUS-guided gastroenterostomy

Published:April 02, 2016DOI:https://doi.org/10.1016/j.gie.2016.03.1493
      EUS-guided gastroenterostomy (EUS-GE) is a novel procedure for the management of gastric outlet obstruction (GOO). During EUS-GE, creation of a fistula tract can be challenging because the small bowel tends to move away from the stomach. We describe a novel method to secure the guidewire, permitting safe creation of a gastroenterostomy fistula. The first patient was a 48-year-old man with a history of chronic calcific pancreatitis complicated by duodenal stricture and GOO. Multiple endoscopic balloon dilations were performed, without durable benefit. The decision was made to perform EUS-guided gastrojejunostomy. The second patient was a 56-year-old man with a history of metastatic pancreatic adenocarcinoma. He presented with GOO resulting from extrinsic compression of the second portion of the duodenum. An attempt to place an enteral stent at another institution was unsuccessful. The patient underwent EUS-guided gastroduodenostomy. The modified balloon/snare may facilitate EUS-GE because strong tension can be applied to both sides on the wire to anchor the small bowel to the gastric wall. This allows easy creation of the gastroduodenostomy fistula, dilation of the fistula tract, and stent deployment, which in turn may decrease the risk of stent misdeployment during EUS-GE (Fig. 1; Video 1, available online at www.giejournal.org).
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      Figure 1A, Fluoroscopic view of the EUS/FNA needle puncturing the balloon in the small intestine. The guidewire is advanced through the needle into the snare-over-balloon device. The snare is closed to capture the guidewire. B, The balloon with wire is removed from the patient. Both sides of the guidewire are held outside the patient. Tension is applied on both ends of the guidewire during creation of the fistula tract to prevent the small bowel moving away from the gastric wall.
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