Endoscopic Ultrasound-Guided Gastrojejunostomy for Efferent Limb Syndrome and Benign Gastric Outlet Obstruction in a Patient with Whipple Anatomy: A Case Report.

Introduction: Lumen-apposing metal stents (LAMSs) have emerged as a versatile tool for managing various gastrointestinal conditions, including postsurgical complications. This case report describes the successful use of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) with LAMS placement to treat efferent limb syndrome (ELS) causing gastric outlet obstruction (GOO) in a patient with altered anatomy after a Whipple procedure. Case Presentation: An 83-year-old female with a history of pancreatic adenocarcinoma status post-Whipple procedure presented with symptoms of GOO 1 year after surgery. Imaging and endoscopy revealed acute angulation at the efferent limb takeoff resulting in mechanical obstruction of the gastrojejunal anastomosis (GJ) without evidence of malignancy. The patient was also found to have ascites concerning for a recurrent pancreatic malignancy. Due to the patient's age and poor surgical candidacy, an EUS-GJ was successfully performed using a 20 × 10 mm cautery-enhanced LAMS bypassing the obstruction in the efferent limb and resulting in immediate symptom relief. The patient gained weight after 1 month of follow-up and remained clinically well with no procedural related complications after a 30-day follow-up. Conclusion: This case highlights the potential of EUS-GJ as an effective, minimally invasive technique for managing complex postsurgical complications in patients with altered anatomy. The technique provided symptom relief while minimizing morbidity and recovery time. In patients with disease progression, EUS-GJ should be considered for the palliation of GOO caused by ELS on a case-by-case basis after discussion between the endoscopists and surgeons.