Endoscopic Ultrasound – Gastrojejunostomy (EUS-GJ)

EUS-GJ is a way of treating the problem of obstruction (blockage) of the stomach or duodenum (the intestine immediately after the stomach), in patients who cannot eat and may suffer with vomiting due to this blockage. This is done by inserting a specialised stent (a short tube) between the stomach and the small bowel (jejunum) to create an opening for food to go through, so bypassing the obstruction. The particular stent used is known as a LAMS (lumen apposing metal stent).

You are under anaesthetic (asleep) for this procedure.

The first step is for us to perform a simple gastroscopy – a procedure in which a standard endoscope (flexible telescope) is passed through your mouth into your stomach. A thin tube is then passed through the obstruction and into the small bowel beyond. X-ray guidance is used to do this. Fluid injected down the tube allows us to assess the blockage and small bowel using another endoscope fitted with an ultrasound (sound wave) device. Using ultrasound to guide us the LAMS can then be placed directly through the stomach wall into the small bowel to create a passage through which fluids and food can pass freely.

Diagram of EUS-GJ

The LAMS we use is a ‘Hot Axios’ stent manufactured by Boston Scientific. This device is CE Marked for certain similar procedures but it is NOT yet CE marked for EUS-GJ (this is pending). CE marking indicates that a product has been assessed by the manufacturer and deemed to meet EU safety, health and environmental protection requirements. However, there is a lot of world-wide experience of using Hot Axios stents for EUS-GJ, and the doctors who use these stents in their practice all agree that the stent is suitable for this purpose. The ESGE (European Society of Gastroenterological Endoscopy) also supports the use of these stents for EUS-GJ.

EUS-GJ helps patients who develop indigestion, vomiting and difficulty eating due to their blockage stopping the stomach emptying as usual.

Another option is the placement of a duodenal stent, which is a metal tube placed through the middle of the blockage using an endoscope to create a tunnel that allows food to pass through. Based on several studies the EUS-GJ procedure has been shown to provide a greater improvement in symptoms and stays open for much longer, but for now the final choice should be personalised, dependent on the cause of the blockage and future treatment options.

Before the EUS-GJ procedure existed, the connection between stomach and intestine could only be made by surgical gastrojejunostomy (an operation which may or may not be ‘keyhole’). Whilst the EUS-GJ procedure will still mean an overnight stay in hospital for observation, it does avoid the need for surgery, abdominal scars, and the risks of invasive surgery.

The general risks include: anaesthesia related risks, (which will be discussed with you by the anaesthetic team), tooth damage, a chest infection, and damage to or a perforation (hole) in the oesophagus, stomach or small bowel caused by the endoscope.

The potential risks specific to the EUS-GJ procedure can occur in up to 10% (one in ten) of patients:

• There is a small risk of bleeding. Your blood tests will be checked to ensure that you are not at increased risk of this. This will be arranged if we do not already have the results. If you take blood thinning tablets, such as warfarin or clopidogrel, then you must let your doctors know and these medicines need to be stopped temporarily before the procedure. This should be discussed with you by the doctor arranging the procedure or at your pre-assessment clinic appointment (this is described below).
  • Rarely, if bleeding continues and is severe, then a blood transfusion or a procedure to stop the bleeding, using X-rays to guide equipment inserted into the groin and through blood vessels to seal the leaking blood vessel may be required.
• There is a small risk that the stent could be put in the wrong place or it could move into the wrong place after initial placement, thus leaving a hole in the stomach or in the intestine. This may require another endoscopy procedure, or urgent surgery for the hole to be fixed.

• You can choose to have a duodenal stent (described above) instead.
• Surgical gastrojejunostomy is an option for some people, but may not be suitable for those who are particularly frail or unwell.
• You may choose to have no treatment for the blockage. A tube passed through your nose into your stomach would help relieve the vomiting and a special feeding solution pumped through a vein could be given if appropriate.

Fasting beforehand – You should not eat anything for 12 hours before the appointment. Do not drink anything for six hours before the procedure. Sometimes you may be asked to be fasted for even longer, which will be explained to you by the doctors arranging the procedure.

Your usual prescription medicines, except those mentioned below, can be taken with a sip of water.

Blood thinners – You will need to have a blood test shortly before your procedure (usually within the previous two weeks). If this test has been performed locally or through your GP it is important that you obtain a copy of the results and bring this with you. If you are attending directly from another hospital then you will not need to do this as the team looking after you will have sent this information to us.

We will need to know about all the medications you take, in particular blood thinners (e.g. clopidogrel, warfarin, heparin), which may need to be stopped or adjusted up to one week before the procedure. If you are attending from another hospital we will liaise with the doctors looking after you regarding this.

If you take clopidogrel or other blood thinners it may be necessary to check with your cardiologist (or other specialist) to be sure that these can be discontinued prior to your procedure.

Please continue to take any other medication (including laxatives).

Diabetes – If you are a diabetic and take insulin, it is important that you continue taking your insulin, but it is suggested that you reduce your dose on the day and night before the procedure. If you are concerned about how to manage this then contact your local Diabetes nurse for advice. Remember to check your blood sugar regularly whilst you are fasting.

If you are taking tablets for your diabetes, please do not take them on the day of the procedure until after the procedure has been done.

Please bring your diabetic tablets or insulin to the hospital with you.

Pre-assessment clinic – If you are attending the appointment from home (not an inpatient transfer from another hospital) then you will be contacted by the anaesthetic team prior to your appointment. This appointment will go through your medical background and medications to be certain it is safe to undergo the anaesthetic for the procedure.

(If you are attending as an inpatient from another hospital this will not take place. The local anaesthetic team may review your case and provide this information directly to the UCLH team)

Admission – You will need to remain as an inpatient overnight following the procedure (either at University College Hospital or returning to your local hospital if you are already an inpatient there) and so you will need to bring an overnight bag if being admitted to University College Hospital.

When you arrive at University College Hospital please come to the 2nd Floor of the Podium and report to the Endoscopy Unit Reception. From there a nurse will take you to ‘Admissions’, check your personal details and check your blood pressure, and you will be asked to change into a hospital gown. Before your EUS-GJ we will discuss the procedure further, as part of the consent process (see below).

Sometimes due to emergencies and other circumstances your appointment may be delayed or postponed. We try our best to see everyone on time but please understand that delays can occur and we ask for your patience in these circumstances.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. The doctor will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment, please do ask to speak with a senior member of staff again.

Some abdominal discomfort and bloating are common. This usually settles after a few hours. The tetam in the Recovery Unit will review you regularly and you can have additional pain killer medication if needed.

You will be kept fasted for 6 to 12 hours after the procedure, during which time you may have some fluids administered through the vein, and then if you manage to drink water without a problem you can build up to clear fluids and then a sloppy diet over two days. In the days after the procedure you can slowly build up the diet and within a week hopefully would be able to manage a more normal diet.

You may be given heparin injections to thin the blood to prevent bloods clots while you are in hospital.

More information on endoscopy procedures can be found on the NHS website or patient.org.uk.

Endoscopy Booking Team (Monday to Friday 09:00-17:00)
Direct line: 020 3456 7022
Switchboard: 08451 555 000 / 020 3456 7890 ext. 67022
E-mail: uclh.endoscopy@nhs.net

Endoscopy Recovery (Monday to Friday 09:00-17:00)
Direct line: 020 3447 3282
Switchboard: 08451 555 000 / 020 3456 7890 ext. 73282

Pancreatobiliary Clinical Nurse Specialist (Monday to Friday 09:00-17:00)
Direct line: 07967 760146 or 07811 785093

On-call Endoscopy Registrar (out of hours emergencies only)
Switchboard: 08451 555 000 / 020 3456 7890

Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London, NW1 2BU
Website: www.uclh.nhs.uk