Enteral Stent Placement Using Spiral Enteroscopy for Malignant Mid-jejunal Obstruction
Comments: This is a case of a 47 year-old female with metastatic colon adenocarcinoma who was admitted with intractable nausea and vomiting with per oral intake. Upper GI study abdominal CT scan demonstrated a small bowel obstruction with a transition point in the proximal-mid jejunum.
She was deemed to be a poor operative candidate and the decision was made to attempt an enteroscopy with enteral stent placement.
Using the spiral enteroscopy system, the enteroscope was advanced to the proximal mid-jejunum. There was evidence of tumor invasion of the small bowel at this level with a near complete obstruction of the bowel lumen.
A sphincterotome, modified for use with the enteroscope, was advanced through the working channel. The sphincterotome was advanced beyond the luminal compromise. The outline of the stricture was confirmed with an injection of contract. The guidewire was advanced deep into the jejunum. Then, the sphincterotome was removed, leaving the guidewire in place.
Next, the enteroscope was carefully removed through the overtube while leaving the guidewire and the overtube in place. This step required precise coordination between the two physicians performing the procedure. The removal of the enteroscope was performed under both endoscopic and fluoroscopic guidance to confirm the position of the guidewire.
After the complete removal of the enteroscope and the re-confirming the stability of the guidewire position fluoroscopically, and uncovered 22mm x 90mm metal enteral stent was inserted over the guidewire and through the overtube. As the stent is progressing down the small intestine, you can see the unique outline of the overtube used during spiral enteroscopy.
Under fluoroscopic guidance, the enteral stent was advanced over the guidewire through the small bowel beyond the proximal-mid-jejunal stricture. The exact location of the jejunal stricture was made even more evident by the presence of clips and radio-opaque markers from previous surgical and radiologic interventions.
The enteral stent was deployed under constant fluoroscopic guidance across the site of the obstruction. Once the stent is fully deployed, one can appreciate the tight waist of the stent outlining the malignant stricture.
The enteroscope was reinserted through the length of the overtube and advanced into the jejunum. Note the stability of the position of the overtube used for spiral enteroscopy during the procedure. This stability of the position of the overtube in the small bowel holds promise for increasing the number of potential endoscopic small bowel interventions in the future.
The enteral stent position and patency was confirmed endoscopically.
Finally, the enteroscope and the overtube were removed together as a single unit ant the procedure was completed.
Patient tolerated the procedure well and was able to advance to a regular diet within 36 hours. She was discharged to home 3 days after the enteral stent placement.
Future endoscopic interventions in the small bowel appear full of potential.
The authors would like to acknowledge the ASGE Advanced Fellows Video Editing Scholarship Program for its training and support.
| Contributed by: |
Eun J. Shin, MD Johns Hopkins Medical Center Anne Marie Lennon, MD Johns Hopkins Medical Center Patrik I. Okollo III, MD, MPH Johns Hopkins Medical Center |
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Citation: Shin, EJ & Lennon, AM & Okollo III, PI (Jun 01 2009). Enteral Stent Placement Using Spiral Enteroscopy for Malignant Mid-jejunal Obstruction. The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=867 Times viewed since Feb 2006: 1930 |
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