LETTERS TO THE EDITOR

 

Derivative anastomotic gastrojejunostomic stenosis resolved with a yo-yo type stent

Estenosis anastomótica de gastroyeyunostomía derivativa resuelta con endoprótesis tipo yo-yo

 

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Key words: Gastrojejunostomy. Strictures after gastric surgery. Malignant gastric outlet obstruction. Enteral stent.

Palabras clave: Gastroyeyunostomía. Estenosis tras cirugía gástrica. Obstrucción tumoral del vaciamiento gástrico. Prótesis enterales.

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Dear Editor,

We present the case of a 54-year-old woman with surgical gastrojejunostomic stenosis resolved by the placement of a coated yo-yo type self-expanding metal stent approved for the drainage of pancreatic pseudo-cysts.

The patient had undergone emergency laparoscopic surgery for digestive obstruction due to duodenal compression caused by the retroperitoneal metastatic adenopathies of disseminated breast cancer.

One month after surgery the patient presented oral intolerance with gastric retention, and digestive endoscopy showed almost complete stenosis of the surgical anastomosis, without data showing tumoral infiltration (Fig. 1A).

Under fluoroscopic and endoscopic monitoring a 16x30 mm self-expanding fully covered Link stent (Niti-S, Taewoong) was put into place, reopening the anastomosis and giving access to the intestinal loop (Fig. 1B).

After 24 hours an oral diet was recommenced, and two months after the implant the efficacy and non-migration of the stent was confirmed (Fig. 1C). The patient died five months after the procedure due to her underlying disease, while digestive transit was maintained at all times.

 

 

 

Discussion

Derivative surgery (gastrojejunostomy) has been the treatment of choice for malignant gastric outlet obstruction before the development of enteral stents (1-3). Surgical by-pass is not risk free, and stenosis of the anastomosis may occur in 3-13 % of cases after gastric surgery. This complication can be treated endoscopically by means of dilation and/or the insertion of a self-expanding metal stent (4,5).

There are endoscopically guided systems for enteral anastomosis to drain benign biliopancreatic pathology, based on the implantation of specific coated metal stents (6). As this type of stent has bilateral flaps around each end and a short body, they are able to make close contact with structural walls, reducing the risk of migration and making them ideal for the creation and maintenance of enteral by-passes. The said fixing systems makes it possible to reduce the size of the stent which is ideal for the resolution of short anastomotic stenosis in which the choice of a conventional longer stent would give rise to greater anatomic distortion and tension along the walls of the digestive tract, with the risk of decubitus and complications over the mid-term. Likewise, its coating aids subsequent removal and reduces aggression on the surface mucosa.

In the case described, as it involved stenosis of a very short surgical anastomosis, similar to the path sought in echoendoscopic procedures, the yo-yo type stent seemed to be the most suitable one from an anatomical point of view, with low risk of migration and the possibility of removal in the future if it became ineffective.

As this procedure was undertaken for palliative reasons, the possibility of removal was not evaluated, and in out-patient follow-up a complete clinical response was observed. As far as we know, no similar cases have been reported, and we believe that this technique could be used more widely to rechannel surgical anastomosis such as the case described here.

 

Adrián Huergo-Fernández, Fernando Fernández-Cadenas, Pedro Amor-Martín, Marta Álvarez-Posadilla,
Ignacio Hevia-Lorenzo, Ana Isabel Milla-Crespo, Ramón Sánchez-Fernández and Faustino Pozo-Fidalgo
Clinical Management Unit of Digestive Diseases. Hospital Álvarez-Buylla. Asturias, Spain

 

References

1. Jeurnink SM, Steyerberg EW, van Hooft JE, van Eijck CH, Schwartz MP, Vleggaar FP, et al; Dutch SUSTENT Study Group. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 2010;71:490-9.         [ Links ]

2. Kim JH, Song HY, Shin JH, Choi E, Kim TW, Jung HY, et al. Metallic stent placement in the palliative treatment of malignant gastroduodenal obstructions: Prospective evaluation of results and factors influencing outcome in 213 patients. Gastrointest Endosc 2007;66:256-64.         [ Links ]

3. García-Cano J, Sánchez-Manjavacas N, Viñuelas Chicano M, Jimeno Ayllón C, Martínez Fernández R, Gómez Ruiz CJ, et al. Palliative management of malignant gastric outlet obstruction with endoscopically inserted self-expanding metal stents. Rev Esp Enferm Dig 2008;100:320-6.         [ Links ]

4. Kim JH, Song HY, Park SW, Yoon CJ, Shin JH, Yook JH, et al. Early symptomatic strictures after gastric surgery: palliation with balloon dilation and stent placement. J Vasc Interv Radiol 2008;19:565-70.         [ Links ]

5. Tol JA, Jansen JM, Donkervoort SC. Anastomotic stenosis after pancreaticoduodenectomy: an endoscopic solution. Gastrointest Endosc 2012;76:1067-8.         [ Links ]

6. Itoi T, Binmoeller KF, Shah J, Sofuni A, Itokawa F, Kurihara T, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012;75:870-6.         [ Links ]