EUS-guided gastroenterostomy: A modified direct water infusion approach using a transhepatic jejunal access (with video).

The direct EUS-guided gastroenterostomy (EUS-GE) technique described for the management of malignant gastric outlet obstruction (GOO) entails injection of fluid/contrast across the obstruction using an endoscope to expand the jejunum and allow for EUS-guided cautery-assisted lumen-apposing metal stent (LAMS) insertion. [1-3] Adequate infusion of the fluid across a high-grade obstruction, however, can be challenging, especially if a guidewire cannot be navigated across. Here, we demonstrate a modified direct EUS‑GE technique using a fluoroscopic‑guided transhepatic approach to infuse fluid in the proximal jejunum and assist the “direct” method in a high-grade stricture that did not allow for adequate fluid infusion via the endoscope [Video 1].