Fig. 2. EUS-guided double balloon-occluded gastrojejunostomy bypass (EPASS). (A) A standard upper gastrointestinal endoscope with an overtube is advanced in front of the stenosis causing GOO, and a guidewire is inserted over the stricture beyond the duodenum and jejunum loop. (B) The endoscope is removed, leaving the guidewire and the overtube. Then, a double-balloon tube is perorally inserted over the guidewire. (C) A special double-balloon enteric tube is perorally inserted over the guidewire. (D) Both balloons are filled with saline. (E) After the contrast material is injected to hold the small intestine open, an EUS endoscope is advanced into the stomach. (F) The target jejunum between the 2 balloons is visualized by EUS. (G) The 1-step procedure (freestyle technique) is carried out using direct electrocautery-enhanced tip delivery system insertion without needle puncture. The stent is deployed across the GE tract under combined EUS, fluoroscopic, and endoscopic guidance. (H) The lumen of the deployed stent is dilated using a dilating balloon. (I, J) Finally, EPASS is performed. EUS, endoscopic ultrasonography; GOO, gastric outlet obstruction.
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