Simultaneous Afferent and Efferent Stenting of Gastrojejunostomy After Whipple Operation

Abstract

Introduction: Effective palliation of both afferent limb syndrome and gastric outlet obstruction after Whipple operation can be provided with simultaneous enteral stenting with self-expandable metallic stent (SEMS).Figure 1Figure 2Figure 3Case report: A 58-year-old male with a history of pancreatic head adenocarcinoma following neoadjuvant chemotherapy underwent the Whipple operation. He presented 6 months later with failure to thrive, weight loss, nausea, vomiting, abdominal discomfort and jaundice. EGD revealed partial gastric outlet obstruction due to marginal ulceration and edema at the gastrojejunostomy anastomosis, which failed medical therapy with pantoprazole and sucralfate. An elective percutaneous gastrojejunotosmy tube was placed and he was started on tube feeds with an initially good response. His symptoms soon recurred, however, leading to further evaluation. Laboratory findings included leukocytosis, direct hyperbilrubinemia and mild transaminitis. Computed tomography scan showed a massively dilated afferent limb (afferent limb syndrome [Image 1]) with hypodense lesions in the liver but no evidence of peritoneal recurrence. He underwent an exploratory laparotomy and with planned revision of gastrojejunostomy but unfortunately diffuse peritoneal implants were found, precluding anastomotic revision. Subsequently, he underwent simultaneous endoscopic stenting of afferent limb (colonic SEMS [Image 2]) and efferent limb (duodenal SEMS [Image 3]) of the gastrojejunostomy for afferent limb syndrome and gastric outlet obstruction, respectively. He fully recovered, was able to ambulate, visit with family, and tolerate full liquid diet without any nausea, vomiting or abdominal pain. He was discharged 10 days following placement of the stents to home hospice care, where he succumbed to his disease 1 month later. Discussion: Although peritoneal disease has been considered a relative contraindication to stent placement, recent experience suggests that gastrojejunostomy stents are safe and effective in this setting. Yet, very few cases of simultaneous afferent and efferent stenting are reported. SEMS can provide durable symptom relief without the morbidity associated with palliative surgery, and it may provide a better quality of life compared to alternatives. The prognosis after developing anastomotic strictures is usually poor and the median survival is 3.5 months after the procedure. The goals of stent placement are to provide relief from obstructive symptoms, to allow the patient to resume a normal diet, thereby improving quality of life.