Gastrojejunal Billroth II or single Roux-en-Y reconstructions that create a defunctionalized
loop, are usually performed to treat patients with unresectable periampullary tumors
[1]
[2]. The main adverse effect is bile reflux [3]
[4], with irritation of the gastric mucosa, that can generally be controlled with prokinetic
drugs [1]
[2]
[3]
[4]. However, if the symptoms are severe, a redo surgery is the only available option
described in the literature [1]
[2]
[3]
[4].
A 70 year-old man presented with copious vomiting of bile associated with inability
to eat due to severe acute alkaline gastritis. Because of an inoperable pancreatic
head tumor (with liver metastases), the patient had undergone biliojejunal and gastrojejunal
surgical bypasses on a single Roux-en-Y defunctionalized loop 1 month earlier. (The
surgeons had begun to create a Roux-en-Y reconstruction. However during the operation
they had decided to use the biliary loop for the gastrojejunal anastomosis also. Thus
they had created a single isolated Roux-en-Y loop and functionally a Billroth II reconstruction.)
From the earliest postoperative days the patient began to vomit bile increasingly
because of gastroparesis linked to severe acute alkaline injury of the gastric mucosa.
In agreement with the surgeons, we decided to propose a new endoscopic technique to
the patient for palliation of the clinical problem.
First, we placed a 7-Fr nasojejunal tube in the efferent part of the Roux-en-Y loop
under both endoscopic and fluoroscopic view so that we could identify the efferent
loop using endoscopic ultrasound.
Then, we introduced a linear echoendoscope (EG-3870 UTK; Pentax, Hamburg, Germany)
into the afferent part of the loop (containing the biliary anastomosis). After dilating
the efferent part (the portion after the gastrojejunal anastomosis) with physiological
solution, we were able to locate it endosonographically. We failed to perform an endoscopic
enteral bypass with our previously described usual technique (using a cystoenterostome
and a fully covered lumen-apposing metal stent [LAMS], 16 mm × 20 mm) [5] having lost the correct position because of loose intestinal contact caused by ascites.
At the end of this first attempt, we placed some endoclips to close the intestinal
perforation. The following day we used the Hot Axios Stent and Electrocautery Enhanced
Delivery System (Boston Scientific, Marlborough, Massachusetts, USA) to pass from
the afferent to the efferent portion and we created a fixed new bridge between them
using a LAMS (diameter 15 – 24 mm, length 10 mm) ([Video 1]).
Video 1 In a patient with a gastrojejunal bypass and copious vomiting of bile, enteroenteral
stenting was performed to allow bile to flow directly from the afferent to the efferent
portion of the gastrojejunal derivation, thus bypassing the gastrojejunal anastomosis.
The patient had an immediate resolution of symptoms and a prompt improvement in terms
of quality of life with 3 months of follow-up.
This new endoscopic technique was used as a rescue therapy in a patient with low life
expectancy and poor general condition in order to avoid a surgical re-operation. We
have begun to verify this first result with a prospective study in selected patients.
Endoscopy_UCTN_Code_TTT_1AS_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
