EOS-directed transgastric EOS-guided radiofrequency ablation of a neuroendocrine tumor in the head of the pancreas in a patient with Roux-en-Y gastric bypass anatomy. These are our disclosures. Increasingly, more patients are operated on with gastric bypass for obesity, which causes great challenges to endoscopically access the duodenum. One solution to achieve a short access to the duodenum is with EOS-directed transgastric intervention with a lumen-apostate metallic stent or LAMS. We present a case where this technique was applied in combination with EOS-guided radiofrequency ablation or RFA to treat a neuroendocrine tumor in the head of the pancreas. The patient is a 70-year-old lady who has been operated on with Roux-en-Y gastric bypass for obesity for more than a decade previously. She gradually developed increasingly severe hypoglycemia and increasing weight. On the CT scan, a 14 by 12 by 14 millimeter contrast-enhanced lesion was found in the head of the pancreas, and the biochemical workup indicated an insulinoma. The patient was referred for EOS-FNB. From the gastric pouch, we were able to find the tumor, but did not reach it for adequate sampling. After a multidisciplinary team decision, an EOS-guided gastrostomy was suggested to connect the bypass stomach to the pouch and reestablish the original anatomy in order to reach the head of the pancreas with EOS. From the gastric pouch, we punctured the bypass stomach with a 19-gauge FNA needle and injected contrast and fluid. A O025 angulated tip guide wire was passed through the needle and advanced into the duodenum to confirm the axis. Over the guide wire, a 20 by 10 millimeter hot lamps was deployed to create an anastomosis to the bypass stomach. The lamps was dilated to 18 millimeter. After a week, we performed EOS through the lamps. The insertion of the echoendoscope into the duodenum was easy. The lesion was found in the head of the pancreas. We performed elastosonography, which indicated that the lesion was harder than the surrounding tissue. The lesion was also enhanced with contrast. Biopsies were taken with a 20-gauge FNB needle, showing a WHO G1 urinary gland tumor. In the same session, we performed EOS-guided RFA of the tumor using a 10-millimeter RFA probe to ablate the tumor with three times deliveries of 35 watt. After RFA, the tumor was no longer contrast enhanced. Immediately after RFA, we could see a sharp increase in the serum blood sugar. After two days observation with no signs of complication, the lamps was removed. At three months following up, the gastro-gastric fistula had closed and the anatomy had reverted to Roux-en-Y. The patient started to lose weight and the blood sugar level was normal. A CT scan taken one month after the procedure showed no contrast uptake of the tumor. This case demonstrates that EOS-guided RFA of a pancreatic urinary gland tumor in the head of the pancreas in a patient's Roux-en-Y anatomy with a temporary gastro-gastrostomy is feasible. It also demonstrates the potential new application of EOS-directed transgastric intervention.

Roux-en-Y gastric bypass

EOS-directed transgastric radiofrequency ablation

neuroendocrine tumor

insulinoma

WHO G1 tumor