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Background Endoscopic enteral stenting is the standard of care for gastric outlet obstruction (GOO) despite high risks for stent dysfunction and need for re-intervention. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel technique that has the potential to decrease the risk of stent dysfunction due to tumor tissue in-/over-growth. EUS-GE; however, is technically challenging thereby limiting its widespread use. Aims To describe the use of the EUS-GE technique in the management of a GOO using a widely available vascular balloon catheter in aims to demonstrate a modified, more accessible approach to EUS-GE. Methods A 76-year-old woman with a suspected distal common bile duct (CBD) cholangiocarcinoma presented with GOO due to extrinsic compression of the duodenum from the CBD mass. After discussion with the patient and family, a decision was undertaken to perform EUS-GE. An enteroscope was inserted to the level of the obstruction. An 0.035 inch x 450 cm guidewire was advanced across the obstruction and into the jejunal loops under fluoroscopy. Two vascular balloon catheters with a compliant balloon diameter reaching up to 46mm (Coda balloon; Cook Medical, Bloomington, Indiana, USA) were placed with the balloons set 10 cm apart. The device was advanced distal to the obstruction over the wire using fluoroscopic guidance. The balloons were then inflated, occluding the distal and proximal ends of the small bowel loop closest to the stomach. This segment was then dilated with infusion of saline and contrast and identified using EUS. An electrocautery-enhanced 15-mm LAMS was then inserted forming the GE. Results The patient’s post-procedure course was uncomplicated and she tolerated a stent diet within 24 hours of the procedure with no recurrent obstruction at 3 months follow-up. Conclusions EUS-GE is a promising modality for GOO. The described case demonstrates that a modified approach using widely available vascular balloon catheters can effectively facilitate the technical aspect of this procedure. Further studies are needed to validate this novel technique. Funding Agencies None

A176 DOUBLE-BALLOON ENDOSCOPIC ULTRASOUND-GUIDED GASTROENTEROSTOMY FOR A MALIGNANT GASTRIC OUTLET OBSTRUCTION: SIMPLIFYING A COMPLEX PROCEDURE