Clin Endosc.  2020 Jul;53(4):491-496. 10.5946/ce.2019.145.

Endoscopic Self-Expandable Metal Stent Placement for Malignant Afferent Loop Obstruction After Pancreaticoduodenectomy: A Case Series and Review

• Sakai A
• Shiomi H
• Iemoto T
• Nakano R
• Ikegawa T
• Kobayashi T
• Masuda A
• Kodama Y

• KMID: 2504955
• DOI: http://doi.org/10.5946/ce.2019.145

Abstract

In this study, we assessed a series of our cases in which endoscopic self-expandable metal stents (SEMSs) were used to treat malignant afferent loop obstruction (ALO) that arose after pancreaticoduodenectomy (PD). We retrospectively examined the records of 7 patients who underwent endoscopic SEMS placement for malignant ALO following PD. Clinical success was achieved in all cases. The median procedure time was 30 min (range, 15–50 min). There were no cases of stent occlusion, and no procedure-related adverse events were encountered. All patients died of their primary disease, and the median overall survival period was 155 days (range, 96–374 days). A re-intervention involving endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting was performed for obstructive jaundice and acute cholangitis in 1 case. In conclusion, endoscopic SEMS placement may be an effective and safe treatment for malignant ALO that arises after PD.

Keyword

Endoscopic self-expandable metal stent; Endoscopic ultrasound-guided hepaticogastrostomy combined with antegrade stenting; Malignant afferent loop obstruction

Figure

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  Fig. 1. (A) A computed tomography scan revealed marked distention of the afferent loop, which was suggestive of bowel obstruction caused by a recurrent tumor. (B) An endoscope was inserted into the afferent loop. A neoplastic stenotic lesion blocked further passage of the endoscope. (C) A nasojejunal tube was placed over a guidewire to decompress the dilated afferent loop. (D) A self-expandable metal stent was inserted using the standard through-the-scope technique.

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  Fig. 2. (A) Case 2 presented with obstructive jaundice due to invasive cancer involving a bilioenteric anastomosis after self-expandable metal stent (SEMS) insertion. (B) Endoscopic ultrasound-guided biliary drainage was selected. An echoendoscope was advanced into the stomach, and a 19-gauge fine needle aspiration needle was advanced into a left-sided intrahepatic bile duct (B3). Cholangiography showed stenosis of the bilioenteric anastomosis, and a guidewire was advanced through the stenotic lesion and into the afferent loop. (C) An uncovered SEMS was placed across the stenotic lesion, and a plastic stent was placed through the fistula between the gastric body and the intrahepatic bile duct.

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