Gastrointestinal: Metallic stent for an obstructing jejunal cancer

Abstract

Palliative procedures for obstructing gastrointestinal cancers include bypass surgery and the use of a variety of stents including metallic stents. The latter are now widely used for malignant strictures in the esophagus, stomach, duodenum and colon. However, there are only a small number of reports of the use of metallic stents in the small intestine, particularly in areas distal to the second part of the duodenum. Reasons for this include the long length and looped configuration of the small intestine. In addition, the working channel of most upper gastrointestinal endoscopes is too small for the stent device. Double-balloon endoscopy is a new system of endoscopy that permits visualization of most of the small intestine. In the patient described below, a modification of this technique resulted in the successful placement of a metallic stent for an obstructing jejunal cancer. A 65-year-old woman was admitted to hospital because of recurrent vomiting. Investigations revealed a jejunal cancer with multiple liver metastases. A bypass procedure was recommended but she refused operative treatment. However, she consented to an attempt to treat the obstruction with an endoscopic stent. Using a double-balloon endoscope (EN-450P5: Fujinon, Saitama, Japan), the tumor was identified in the upper jejunum, approximately 30 cm distal to the ligament of Trietz (Fig. 1). Water-soluble contrast material was then injected into the area and showed that the stricture was about 4 cm in length. Thereafter, it was possible to shorten the length between the mouth and the lesion after which a guide-wire was inserted through the endoscope and across the stricture. The endoscope was then removed, leaving the guide-wire in place together with the overtube and its dilated balloon. Using fluoroscopic guidance, a 10 cm metallic stent (Ultraflex: Boston Scientific Corporation, Massachusetts), was inserted over the guide-wire and released across the stricture. After 5 days, double balloon enteroscopy was repeated and confirmed that the stent was in an appropriate position (Fig. 2). The procedure was performed without complication. This technique appears to be suitable for at least some malignant strictures involving the jejunum.