Therapeutic Endoscopic Intervention for Management of Gastric Outlet Obstruction Resulting from Stenosed Gastro-jejunal Anastamosis after Whipple Procedure

Abstract

Purpose: Stenosis of the gastrojejunostomy after Whipple procedure is a known complication, which usually occurs as an intermediate or late event. This could lead to gastric outlet obstruction (GOO), which may need surgery for correction. This has been described mostly in patients with cancer and having ingrowth of the tumor. However, we describe a case where it occurred as an early complication and was successfully managed by a relatively uncommon endoscopic technique. Our patient is a 53-year-old male, who has a history of chronic pancreatitis (CP) with suspicious lesions on his pancreas on EUS. FNAC/biopsies showed features of chronic pancreatitis and atypical cytology. He has a history of alcohol abuse for about 10 years and quit about 18 months ago, when he started having symptoms of pancreatitis. He has a 18-pack-year history of smoking. An elective pancreaticoduodenectomy was done as he had persistent pain and due to the suspicion of malignancy because of the atypical cytology. Surgical biopsies showed no evidence of malignancy. He tolerated the surgery well but in the early post-operative period, he developed nausea, vomiting, diffuse abdominal pain and abdominal distension. NG tube suctioning yielded food and gastric contents. The patient was taken up for endoscopy and was found to have GOO, with severe stenosis of the G-J anastomosis, which was not even visualized. A repeat endoscopy was performed under fluoroscopic guidance and dye was injected into the stomach. Extensive probing was carried out to identify the GJ junction, with the help of fluoroscopy and endoscopy. We were able to identify and insert a guide wire through the G-J anastomosis, which was occluded, secondary to stenosis and edema. We used a 18 mm x 12 cm Evolution fully covered controlled-release stent with a 23-mm flange under fluoroscopic guidance to open up the stenosed G-J junction. Soon after this, flow was established from the stomach into the jejunal limb and we were able to pass the endoscope through this. In the subsequent days, the patient was able to tolerate PO intake and had resolution of his symptoms of GOO. About a week later, he returned with similar symptoms and was found to have GOO again. Endoscopy showed migration of the duodenal stent into the stomach. We were able to retrieve the stent and deploy a new one, and this time, we used clips to secure their position. This again resulted in resolution of his symptoms and 2 weeks after the procedure, the patient is still asymptomatic. We emphasize the importance of endoscopy and also want to share the experience with this relatively uncommon intervention for GOO resulting from stenosis due to edema of the G-J junction.