Clin Endosc.  2018 Sep;51(5):439-449. 10.5946/ce.2018.077.

De-novo Gastrointestinal Anastomosis with Lumen Apposing Metal Stent

• Jain D
• Chhoda A
• Sharma A
• Singhal S

• KMID: 2427717
• DOI: http://doi.org/10.5946/ce.2018.077

Abstract

Gastric outlet obstruction, afferent or efferent limb obstruction, and biliary obstruction among patients with altered anatomy often require surgical intervention which is associated with significant morbidity and mortality. Endoscopic dilation for benign etiologies requires multiple sessions, whereas self-expandable metal stents used for malignant etiologies often fail due to tumor in-growth. Lumen apposing metal stents, placed endoscopically with the intent of creating a de-novo gastrointestinal anastomosis bypassing the site of obstruction, can potentially achieve similar efficacy, with a much lower complication rate. In our study cohort (n=79), the composite technical success rate and clinical success rate was 91.1% (72/79) and 97.2% (70/72), respectively. Five different techniques were used: 43% (34/79) underwent the balloon-assisted method, 27.9% (22/79) underwent endoscopic ultrasound-guided balloon occluded gastro-jejunostomy bypass, 20.3% (16/79) underwent the direct technique, 6.3% (5/79) underwent the hybrid rendezvous technique, and 2.5% (2/79) underwent natural orifice transluminal endoscopic surgery (NOTES)-assisted procedure. All techniques required an echoendoscope except NOTES. In all, 53.2% (42/79) had non-cautery enhanced Axios stent, 44.3% (35/79) had hot Axios stent, and 2.5% (2/79) had Niti-S spaxus stent. Symptom-recurrence was seen in 2.8%, and 6.3% had a complication (bleeding, abdominal pain or peritonitis). All procedures were performed by experts at centers of excellence with adequate surgical back up.

Keyword

De-novo entero-enteric anastomosis; Lumen apposing metal stents; Endosonography

MeSH Terms

Abdominal Pain
Cohort Studies
Endosonography
Extremities
Gastric Outlet Obstruction
Humans
Methods
Mortality
Natural Orifice Endoscopic Surgery
Stents*

Figure

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  Fig. 1. Introduction of the guidewire. (A) Endoscopic view of the duodenal stenosis. (B) Fluoroscopic view of the guidewire introduced through the stenosis of the small bowel. (C) Fluoroscopic view of a 20-mm balloon dilator inflated with contrast fluid within the small bowel (Re-produced with permission from Thieme publishers).

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  Fig. 2. The balloon dilator inside the small bowel loop. (A) Fluoroscopic view of the echoendoscope in the stomach next to the inflated balloon within the adjacent jejunal loop. (B) Echoendoscopic view showing the inflated balloon. (C) Echoendoscope view showing the inflated balloon (*), the tip of the delivery system of the stent (fat arrow) inside the jejunal lumen (**), and the gastric wall (thin arrow) (Re-produced with permission from Thieme publishers).

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  Fig. 3. Deployment of the stent. (A) Echoendoscopic view of the released distal flange of the stent (arrows) into the lumen of the jejunal loop. (B) Fluoroscopic view of the fully released stent (circle) and the intact balloon (Re-produced with permission from Thieme publishers).

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