Written Transcript Case report VideoGIE:
Efferent loop obstruction after gastrectomy is a rare adverse event and less common than afferent loop obstruction. There is no standard therapy. Surgical reintervention, plastic stenting and metal stent placement have been described. This video shows an endoscopic jejuno-jejunostomy using a lumen-apposing self-expandable metal stent to bypass an obstructed/kinked efferent loop after subtotal gastrectomy with Roux-en-Y-reconstruction.
We report on a case of a 58-year-old male patient who had a subtotal gastric resection with roux-en-Y-reconstruction due to gastric adenocarcinoma 9 months earlier. After the procedure he developed persistent abdominal pain and vomiting. Endoscopy revealed kinking of the efferent jejunal loop at site of gastrojejunostomy causing food retention in the remaining parts of the stomach an a dilated blind loop.
This endoscopic view shows the remaining parts of the stomach filled up with food.
This is due to an excessive kinking of the efferent loop which is marked with a white arrow at site of gastrojejunostomy. The kinking is so intense that the efferent loop can only be seen from the stomach if a guidewire is inserted. Oral intake results in filling the blind loop which is shown on the right side of the screen marked with a blue arrow.
For the start of the procedure a guidewire is inserted into the efferent loop. The endoscope is then slowly retracted over the guidewire and pulled out of the patient. The guidewire is left in place. A 20mm dilation balloon is now placed over the guidewire into the efferent loop.
Then an endoscope was inserted into the blind loop and the filled ballon catheter in the efferent loop was visualized on EUS and served as a target for the puncture.
The tip of the stent catheter is now energized and direct access to the efferent loop is made by electrocautery.
In the next step the first flangue of the lumen- apposing stent is deployed and then the catheter is retracted.
After the black catheter sheath is seen by the endoscope the second flangue of the lumen-apposing stent is deployed. The dilation ballon catheter lying in the efferent loop is pushed back by the lumen-apposing stent.
At site of puncturing now signs of perforation are seen. The stent is then intubated and a dilation balloon catheter is inserted.
Under radiographic control, the stent is then dilated up to 15mm.
The endoscopic view now shows a perfect interenteric anastomosis and subsequently the blind loop and the efferent loop is intubated showing that the stent is in place.
Afterward, the endoscope is carefully retracted and pulled out of the patient.
Radiographic control on the following day shows a stent in place.
Application of contrast dye into the stent shows a good outflow.
Symptoms greatly improved after the procedure. There were no acute adverse events and the patient was able to eat. Unfortunately further workup revealed lymph node metastases. The patient then received palliative chemotherapy at our institution. Until his death 4 months later no admission due to symptoms related to the endoscopic anastomosis was necessary.
As a summary, we conclude that treatment of an obstructed efferent loop with a lumen-apposing stent is safe and effective and therefore an alternative to surgery. From the technical standpoint, marking the efferent loop by a filled dilation balloon simplifies EUS-guided puncture.