Dear colleagues, thank you for the invitation, I would like to present the case of an unusual complication of endosynographically guided gastroenteroanastomosis. We have no disclosures to present. The case regards 65-year-old female, who was in March 2019 diagnosed with invasive lobular breast carcinoma, with metastasis in bones, lymph nodes, liver, and with ongoing palliative cancer treatment. From December 2020, newly-occurred gastric outlet obstruction symptoms, and the duodenal bulb stenosis was found, caused by external compression by malignant lymphadenopathy. In another hospital, they tried to dilate the stenosis, but it was without any effect. The patient was then referred to our hospital, and on the 23rd of December 2020, the endosynographically guided gastroenteroanastomosis was performed. We use the direct technique when we first advance the therapeutical endoscope. It's not possible to pass it across the stenosis, so we then use a nasobiliary catheter, which is advanced through the working channel, across the area of stenosis, over the guide wire. And then the methylene blue infusion is hooked up to the nasobiliary catheter, and the small intestine is inflated with methylene blue and infusion. We do it under fluoroscopy visualization, and you can see here the scope, and then the catheter. Then we switch to the EUS mode and EUS scope, and we try to localize the dilated proximal jejunum, where the lumen opposing methylene stent is going to be deployed. Again, the fluoroscopy visualization, and then the EUS mode, we switch, and we are going to show the deployment of the lumen opposing methylene stent we use with the electroculture enhanced delivery system of the diameter is of 20 millimeters. Now we are going to see the hyperarchaic signal showing the opening of the distal flange. We position the stent and pull it into a position with the gastric wall. We switch to the endoscopy mode, from where we will see the drainage of methylene blue infusion, and it's just confirming the correct position of the lumen opposing methylene stent. We confirm it also under fluoroscopy visualization, where it's going to be shown the position of the methylene stent forming the gastroenteroendostomosis with the correct position. The whole intervention was technically and clinically successful. Patient was discharged from the hospital the second day after intervention, and she began to eat full rational diet. Three months after this intervention, began to feel nauseous again, so we performed gastroscopy, and as you can see, entering the gastroenteroendostomosis, we see the two small bowel loops, and they are without any signs of obstruction, free to, they are possible to pass through. After that, she was again without any symptoms, but after five months from the intervention, new symptoms occurred, and it was diarrhea and stark rashes vomiting, so in another hospital they performed CT, and there was a suspicion of possible communication between a lumen of stomach and lumen of large intestine through the lumen opposing methylene stent forming gastrocolic fistula. We, as you can see here, we confirm it also with gastroscopy, here is the endoscopy view, and we pass through the methylene stent right into the first large bowel loop, full of stool. The same image we see in the second large bowel loop, and then we are gonna get into the third loop, which is the small bowel loop. The fourth loop we didn't find, it was probably compressed. We decide to extract the methylene stent using snare, and after that we need to close the communication between stomach and the large intestine. Here you can see the communication. We use, we decide to use the over-the-scope system with the clips. We use the twin grasper, we are gonna first take the right side, then the left side, pull it into the cap, and then release the clips. The whole closure was a bit, was a bit tricky, as the surrounding tissue around the communication was fibrotic, it was bleeding, because we were not fully satisfied with the closure, we decide to add at the end, also endoloop, use endoloop, and clips, and you will see the final picture. The whole, because the patient was ongoing at the same time, palliative oncology treatment, the lymphadenopathy resolved, as well as the stenosis, which has regressed, therefore we didn't have to perform a new gastroenteroanostomosis, nor any other therapeutical intervention, and the patient is now continuing with her oncology treatment, and she again has a normal rational diet with passage. In conclusion, endosynographically guided gastroenteroanostomosis is a new and effective method providing minimally invasive alternative for treatment of mainly malignant gastric outlet obstruction. It's associated with numerous complications, including a rare gastrocolic fistula, with a possibility of successful endoscopic therapy, as shown here. Thank you for the attention.

endosynographically guided gastroenteroanastomosis

gastric outlet obstruction

malignant lymphadenopathy

gastrocolic fistula

endoscopic therapy