Endoscopic management of luminal obstruction from duodenal diverticulum, creating duodenal bypass with EUS-guided gastrointestinaloscopy and pyloric suturing. Duodenal diverticulum, an abnormal pouch that protrudes from luminal structure, is asymptomatic in 95% of cases. In rare instances, duodenal diverticulum can cause biliary and duodenal obstruction. Surgical treatment options are focused on either resection of the diverticulum when feasible, or complete duodenal bypass is pursued with either distal gastrectomy with gastrojejunostomy, GJ, or pancreatic duodenectomy with GJ. Complication rates, however, can be as high as 40%. Currently, endoscopic treatment options have not been commonly reported. Endoscopic ultrasound-guided gastrojejunostomy, also known as EUS-GJ, using a lumen-opposing metal stent between the gastric lumen and the distal duodenal or jejunal lumen, has been described as an alternative to surgical gastrojejunostomy. Indications include malignant and benign gastric outlet obstruction, and the procedure carries a technical success rate of greater than 90% and clinical success rate of 85 to 89%, with serious adverse event rates of approximately 5%. While an EUS-GJ can mimic a surgical GJ, complete endoscopic duodenal exclusion has not been well described. Endoscopic suturing has shown to reduce outlets with documented safety and efficacy, such as in the transoral outlet reduction endoscopy procedure, for weight regain after gastric bypass. This technique requires use of endoscopic suturing platforms that allow for full thickness plications. In addition, this team has had prior experience with reduction of the pylors, for treatment of bile reflux in a patient with prior pyloral myotomy. This case will describe the combination of the EUS-GJ and pyloral suturing to create a duodenal bypass in a patient with obstruction secondary to a large duodenal diverticulum. A 78-year-old female patient with a history of peristaltic hernia repair with MASH a few years prior presents with a two-month history of early satiety, postprandial abdominal cramping, and subjective weight loss. Her evaluation included a CT scan that showed multiple large duodenal diverticula with duodenal distension suggesting obstruction. Upper endoscopy confirmed these findings with two large periampullary diverticula and external compression of the lumen caused by the lip of the large diverticulum. Upper gastrointestinal series with small bile follow-through also showed a dominant 9-centimeter diverticula with a delayed contrast passage through the area. Surgical options were considered. However, given the uncertainty of causality to the patient's symptoms as well as the patient's surgical risk and procedural risk, the patient had a multidisciplinary team choose to attempt endoscopic management first. The first step of the procedure was to perform an EUS-GJ. This was done in a well-described method with copious irrigation of at least 500 cc of saline, methylene blue, and contrast through the scope into the proximal jejunum under fluoroscopy. A straight stiff guide wire was inserted into the jejunum, the scope removed, and a nasal biliary drain was passed over the guide wire and left in place to allow for continuous irrigation throughout the whole procedure. The EUS scope was then inserted and used to identify an appropriate loop of small bile endosonographically and fluoroscopically. After confirming appropriate small bile by aspiration of blue fluid through fine needle aspiration, a 20 by 10 millimeter electrocautery-enhanced lumen-opposing metal stand was advanced into the jejunum using a freehand technique. This was followed by deployment of the distilled water followed by deployment of the distilled flange, a position of the jejunum and gastric wall, and finally deployment of the proximal flange forming the gastrojejunostomy. Here we see methylene blue flowing through the lumen-opposing metal stand, further confirming appropriate placement. The contrast is then injected through the scope to ensure passage of the contrast into the small bile without evidence of the leak. The second step of the procedure was then performed using a dual-channel scope mounted with an endoscopic suturing system. This system works by transfer of anchor that serves as a needle through the gastric wall in a purse-string pattern with a single suture. As a final step, the suture is cinched resulting in closure of the pylorus. Contrast was then irrigated towards the pylorus under fluoroscopy and confirmed complete occlusion of the pylorus with passage of contrast from stomach to small bile through the stent. Follow-up upper GI series one week later showed a persistent duodenal bypass. The patient had resolution of her symptoms and gradually resumed the normal diet and gained weight and continues to have improvement of her symptoms at one month follow-up. Combining innovative endoscopic techniques such as EUS-GJ and pylori closure can allow for successful endoscopic alternatives to surgical procedures such as duodenectomy and gastrointestinal bypass for the management of complex conditions such as obstruction caused by duodenal diverticula. Long-term management and results have yet to be determined. Performing these procedures may provide useful predictive information that can help guide more permanent treatment options in the future. Thank you.

endoscopic management

luminal obstruction

duodenal diverticulum

EUS-guided gastrointestinaloscopy

pyloric suturing