Endoscopic magnet-assisted gastrojejunostomy to treat symptoms caused by a deformed pylorus

A 42-year-old woman presented with a 5-year history of abdominal distension, abdominal pain, and emesis, which became worse after she began eating a little more. Gastroduodenal barium examination detected a deformed pylorus ([Fig. 1 a]). Subsequently, a gastroduodenoscopy was performed, which revealed that the outlet of her stomach lay on the lesser curvature side of the gastric angulus, with a blind end at the antrum ([Fig. 1 b]). We therefore suggested to the patient that she undergo surgery; however, she declined to undergo such treatment, preferring instead an endoscopic method to treat her problems. In the end, we decided to attempt, with the patient’s informed consent, an endoscopic magnet-assisted gastrojejunostomy ([Video 1]).

Fig. 1 Images from a 42-year-old woman with a history of abdominal distension, abdominal pain, and emesis showing a deformed pylorus: a on barium examination; b on endoscopy.

Video 1 Video showing a deformed pylorus identified in a 42-year-old woman with a history of abdominal distension, abdominal pain, and emesis; the procedure of endoscopic magnet-assisted gastrojejunostomy; and the subsequent dilation and stenting of the fistula to leave an unobstructed channel.

Firstly, two ring-shaped magnets (16-mm diameter) with attached fixing strings were placed in succession into her jejunum and stomach ([Fig. 2 a, b]). After several attempts to adjust their position under fluoroscopic guidance, the two magnets attracted perfectly and were then stabilized by the string ([Fig. 2 c, d]). After 1 week with the magnets in place, a superficial ulcer developed under the compression of the magnets ([Fig. 2 e]). We extracted the magnets after another 2 weeks ([Fig. 2 f]), leaving behind a stenotic fistula. We then used a dilation balloon to enlarge the fistula ([Fig. 3 a, b]) and put in a 16 × 20-mm lumen-apposing metal stent ([Fig. 3 c]). A subsequent endoscopy and barium examination showed that this manually built channel was unobstructed ([Fig. 3 d–f]), with no leakage of barium. During 1 month of follow-up, the patient gained relief of her symptoms, without any complications of the procedure.

Fig. 2 Images of the endoscopic magnet-assisted gastrojejunostomy procedure showing: a, b endoscopic views of the two ring-shaped magnets with attached strings being placed into the jejunum and stomach in succession; c, d the two magnets after perfect attraction had been achieved between them on: c endoscopic view; d radiographic image; e the superficial ulcer that developed under compression from the magnets; f the two magnets following their extraction.

Fig. 3 Images of the creation of the manually built channel showing: a the stenotic fistula being enlarged by balloon dilation; b the appearance of the fistula after dilation; c the lumen-apposing metal stent that was inserted across the dilated fistula; d, e endoscopic appearance 3 weeks later; f an unobstructed channel on barium examination.

With advancements of technology, endoscopic methods, such as magnets, natural orifice transluminal endoscopic surgery (NOTES), and endoscopic ultrasound (EUS)-guided techniques, are able to create a gastrointestinal anastomosis without the requirement for surgery [1]. Moreover, the creation of magnet-assisted gastroenteric anastomoses has been demonstrated to be feasible and safe for malignant gastric outlet obstruction [2]. Our experience indicates that this method may also result in good outcomes for patients with benign anatomic abnormalities.

Endoscopy_UCTN_Code_TTT_1AO_2AN

^* Joint first authors

Publication History

Article published online:
15 November 2021

• References

• 1 Marrache MK, Itani MI, Farha J. et al. Endoscopic gastrointestinal anastomosis: a review of established techniques. Gastrointest Endosc 2021; 93: 34-46
• 2 van Hooft JE, Vleggaar FP, Le Moine O. et al. Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study. Gastrointest Endosc 2010; 72: 530-535