Preservation of EUS-guided gastrojejunostomy LAMS during pancreaticoduodenectomy: a paradigm shift in the surgical management of borderline resectable pancreatic cancer.

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) with lumen-apposing metal stents (LAMS) is increasingly employed for palliation in pancreatic ductal adenocarcinoma (PDAC). We report the first European case in which a EUS-GJ LAMS was preserved and functionally integrated during pancreaticoduodenectomy (PD), supporting the concept that endoscopic bypass can be part of a curative surgical pathway. A 59-year-old male with borderline resectable PDAC and failed ERCP underwent sequential endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) and gastrojejunostomy with LAMS. After completing a full course of neoadjuvant chemotherapy and showing tumor regression, he underwent PD with en bloc portal vein resection. The preexisting LAMS was intraoperatively preserved and incorporated as the definitive gastrojejunostomy. Outcome: The patient had an uneventful recovery. Final pathology confirmed ypT1c N0 M0 R0 PDAC. At 6-month follow-up, he was recurrence-free. EUS-GJ with LAMS can be successfully preserved and integrated during PD, suggesting a potential shift from exclusively palliative use to potentially curative indications. Further investigation in multidisciplinary settings is warranted.