A 65-year-old man with a history of peptic ulcer disease status postremote Billroth II gastrojejunostomy in 1970 with known metastatic gastric carcinoma presented in the outpatient setting with several months of abdominal pain, fatigue, weight loss, and poor appetite. His body mass index was 15 kg/m2. This constellation of symptoms resulted in interruption of his chemotherapy regimen. On examination, his abdomen was soft and initially nondistended. He had hyperactive bowel sounds, normal pitch. There was moderate tenderness to palpation over the right upper quadrant and left side, no rebound, and no guarding. The laboratory results revealed anemia hemoglobin 7.7 g/dL, alanine aminotransferase 43 U/L, aspartate aminotransferase 45 U/L, alkaline phosphatase 2006 U/L, TBili 0.5 mg/dL, and albumin 2.5 g/dL. He was admitted to the hospital for management.
Abdominal computed tomography showed Billroth II gastrojejunostomy with high-grade afferent loop obstruction due to enlarging gastric mass with probable extragastric extension into the left upper quadrant and decompressed distal bowel. There was contact without definite invasion of the pancreatic tail and lateral limb of the left adrenal gland. Interval increase in biliary ductal dilatation, worst in the left hepatic lobe with concomitant gallbladder, and pancreatic duct distension were noted all consistent with downstream obstruction (Figure 1). Given his body mass index of 15 and notable deconditioning, he was deemed a priori not to be a surgical candidate for a palliative bypass.
Upper endoscopy showed a circumferential, fungating, and ulcerated friable 4-5 cm mass of malignant appearance involving the anastomosis. The mass caused near-total obstruction of both the pancreatobiliary and efferent limbs (Figure 2). Because of the severity of his obstruction, a pediatric gastroscope was required to pass the tumor. A guidewire was passed into the afferent limb through the pediatric gastroscope after which a second guidewire was passed into the efferent limb (Figure 3). The guidewires were both passed before any stent deployment, given a concern for possible worsening obstruction after the first stent was placed and expanded. The afferent limb guidewire was backloaded through a duodenal stent loaded in a therapeutic gastroscope, and the gastroscope was advanced through the wire. An uncovered metal stent was deployed across the gastric mass into the afferent limb under endoscopic and fluoroscopic guidance. The efferent limb guidewire was then backloaded through a second duodenal stent loaded in the therapeutic gastroscope, and the gastroscope was advanced over the wire. A second uncovered metal stent was deployed across the gastric mass into the efferent limb under endoscopic and fluoroscopic guidance (Figure 4). The afferent limb was deployed first because there was concern that the first stent would obstruct the lumen and ability to place the second stent. In addition, afferent limb obstruction was the most acute pathology, as evident by this patient's presenting symptoms, laboratory tests, and imaging. Using the double guidewire technique was critical in ensuring our ability to properly deploy the second stent. Without a double wire technique, given the degree of obstruction, it would likely not have been possible to introduce a wire down the efferent limb after afferent limb stent deployment. To prevent stent migration, a "kissing-stents" technique was used, and 2 clips were deployed to attach the gastric end of both metal stents (Figure 5).
The patient returned to the floor. After the procedure, he was able to resume a clear liquid diet the first day, followed by a duodenal stent diet. Liver function tests normalized except for alkaline phosphatase, which continued to downtrend slowly ( Table 1). Stents remain patent because of the time of this report, and he was tolerating oral intake.