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DOI: 10.1055/a-1221-5183
Endoscopic ultrasound guided gastroenterostomy for efferent jeunal loop obstruction in a patient with previous pancreaticoduodenectomy and ascites
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A 68-year-old man, who underwent pylorus-preserving pancreato-duodenectomy(PPPD) for pancreatic adenocarcinoma, after 12 months presented with symptoms of gastric outlet obstruction(GOO). Computed tomography(CT) scan showed tumor recurrence at the efferent jejunal loop(EJL), determining stomach dilation, peritoneal carcinomatosis and ascites ([Fig. 1]). The case was discussed at our multidisciplinary meeting: due to advanced stage of disease and patient’s comorbidities, a palliative approach by endoscopic ultrasound guided gastroenterostomy(EUS-GE) was planned.
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An upper GI endoscope was advanced till the EJL strictures and a 7.5 Fr oro-jejunal catheter was placed across the stricture over a wire, for injecting normal saline mixed with contrast and methylene blue in order to optimize small bowel distension. Under EUS and fluoroscopy guidance a small bowel loop close to the stomach within ascitic fluid was identified and punctured with a 19-gauge needle ([Fig. 2], [Video 1]). Aspiration of blue fluid confirmed the correct location and a 0.035-inch guidewire was advanced through the needle into the efferent limb. A 15 × 10 mm electrocautery enhanced lumen apposing metal stent (EC-LAMS) (Hot-Axios, Boston Scientific Corp, Marlborough, Mass, USA) was placed on the guidewire and the blue fluid coming through the stent confirmed the correct enterogastric deployment([Fig. 3–4]).
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Video 1 Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) to manage malignant gastric outlet obstruction in a pylorus-preserving pancreaticoduodenectomy (PPPD) reconstruction for tumor recurrence at the efferent limb.
Qualität:
![](https://www.thieme-connect.de/media/10.1055-s-00025476/202010/thumbnails/10-1055-a-1221-5183-i1998ei3.jpg)
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Post-procedural course was uneventful. A progressive oral re-intake was administered and a full solid diet was possible three days after the procedure. Patient died 2 months later, due to disease’s progression, without evidence of GOO symptoms recurrence.
After curative surgery for pancreatic cancer up to 60 % of patients develop local and systemic recurrence within the first 12 months [1]. In some cases, recurrence at gastro-jejunal anastomosis or peritoneal carcinomatosis determines GOO. Historically, EJL obstruction has been treated with open surgical gastrojejunostomy or enteral stents. EUS-GE using LAMS has been demonstrated as an effective and safe procedure in the management of GOO for duodenal obstruction with high technical and clinical success rate [2] [3] [4]. Recently a case of EUS-guided drainage with LAMS of an obstructed afferent loop has been published with promising results [5]. Our report firstly demonstrated that palliation of GOO by EUS-GE can be proposed as an effective alternative approach even in patients with previous PPPD with EJL obstruction.
Publikationsverlauf
Artikel online veröffentlicht:
22. September 2020
© 2020. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commecial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
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