Gastric stricture resulting in impairment of gastric emptying may occur after gastric
surgery or laparoscopic surgery [1]
[2]
[3]. In some instances further surgery can be avoided by endoscopic balloon dilation
of the stricture [4]
[5]. We present an unusual case of gastric distortion and stricture after resection
of a gastrointestinal stromal tumor (GIST). Because balloon dilation failed to effectively
relieve the obstruction, endoscopic gastroplasty was performed with good success.
A 54-year-old man presented to our hospital with chronic abdominal distension and
intermittent vomiting. He had undergone wedge resection of a GIST located in the greater
curvature 5 months previously. After resection he began to experience abdominal pain
and vomiting, and a gastric stricture was diagnosed. Endoscopic balloon dilation was
performed, without improvement. He was then transferred to our hospital because of
worsening symptoms. Upper endoscopy revealed gastric distortion and a stricture between
the body and the antrum of the stomach ([Fig. 1 a, b]). Abdominal computed tomography showed thickening of the distal stomach with narrowing
of the lumen. After multidisciplinary team discussion we performed an endoscopic gastroplasty.
Fig. 1 a, b Upper endoscopy revealed gastric distortion and stricture, 5 months after wedge resection
of a gastrointestinal stromal tumor (GIST) in the greater curvature. c Full-thickness incision of the gastric wall on the greater curvature. d A nylon loop was fixed to the distal and proximal edges of the incision to close
it transversely. e Endoscopy showed disappearance of the distortion and stricture after the procedure.
f A widened lumen without distortion is seen 3 months postoperatively.
An endoscope with a transparent cap was inserted into the stomach and the stomach
was washed with sterile saline. The area with the gastric scar (i. e., the greater
curvature) was then marked with a hook knife. The hook knife and an insulated-tip
knife were used to incise the mucosa longitudinally along the markers. Insulated-tip
or hook knives were then used to complete full-thickness incision of the gastric wall
on the greater curvature of the stomach ([Fig. 1c]). Hemostasis was obtained with endoscopic electric coagulation. The incision was
then closed transversely using endoclips and endoloops ([Fig. 1 d]) as follows. First a nylon loop was fixed on the transparent cap attached to the
endoscope, passed to the incision site, and placed into the incision area. A clip
was then used to fix one side to the distal edge of the full-thickness incision and
a second clip was used to further anchor the nylon loop to the proximal edge of the
incision. The nylon loop was then closed thus approximating the distal and proximal
gastric walls to transform the oval-shaped longitudinal incision into a transverse
gastric wall closure. Clips were then used to ensure complete closure of the incision
([Fig. 2], [Video 1]).
Fig. 2 Schematic of the endoscopic gastroplasty procedure and transverse closure method.
Video 1 Endoscopic gastroplasty procedure for postoperative gastric distortion and stenosis.
No significant bleeding or any other complications occurred either during or after
the procedure. After the procedure, the endoscope was able to pass freely through
the widened gastric lumen and the distortion had disappeared ([Fig. 1 e]). No adverse events were noted during the follow-up period. It was found that the
lumen had widened and gastric distortion had disappeared at endoscopy 3 months after
the procedure ([Fig.1 f]).
We successfully performed endoscopic gastroplasty with results similar to those usually
only obtained by surgery. This case suggests that that endoscopic full-thickness longitudinal
incision with transverse gastric wall closure may be a minimally invasive, safe, feasible,
and effective technique for management of patients with benign gastric stricture.
Further validations are needed.
Endoscopy_UCTN_Code_TTT_1AO_2AN
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