Utility of a Plumber – HANARO stent in pyloric stenosis after circumferential ESD

Introduction

On endoscopy, a 71-year-old man suffering from chronic, severe atrophic gastropathy, with areas of massive complete intestinal metaplasia presented with a 35-mm stage IIa/b nongranular, laterally sreading tumor ([Fig. 1]). It was narrow band imaging international colorectal endoscopic classification 2 and had a type VI pit pattern and affected 70 % of the circumference of the pylorus and extended through the antrum towards the greater curvature. Biopsies of the lesion showed a tubular adenoma with low-grade dysplasia, which prompted the decision to perform DSE.

Fig. 1 Lesion

Endoscopy

Endoscopic submucosal dissection (ESD) was performed and an en-bloc specimen measuing 52 × 38 × 5 mm was obtained ([Fig. 2]). Histologic examination revealed chronic, moderate atrophic gastropathy with intestinal metaplasia and extensive areas of low- and high-grade intraepithelial neoplasia. The lateral and deep margins were disease-free ([Video 1]).

Fig. 2 Post-ESD image

Video 1 Stenosis after ESD. Stent placement.

At 3 weeks after ESD, the patient presented with symptoms of pyloric stenosis and the diagnosis was confirmed endoscopically by observation of a short, puntiform pyloric stenosis (10 mm) ([Fig. 3]). Three sequential dilations were performed with a CRE balloon up to 18 mm with early restenosis on all occasions and with a progressive weight loss up to 12 kg. Finally, a 16- × 30-mm fully-covered metallic stent (Plumber HANAROSTENT; M.I. Tech, Korea) was placed, which led to clinical resolution of the stenosis at 3-month follow-up and progressive weight gain in the patient. The stent later was removed and the patient’s clinical course was positive.

Fig. 3 Stenosis

Conclusions

Extensive ESD is associated with a high risk of stenosis [1] [2] [3]. At the gastric level, high rates of stenosis are seen in patients who have undergone ESD that affects 75 % or more of the circumference in the cardia or antrum/pylorus [2] [3]. Because of this, prophylactic measures are recommended in these cases [1] [2] [3] [4]. The type of stent described can be useful for treatment of a short stenosis that occurs after circumferential ESD and has failed to respond to conventional techniques such as balloon dilation.

Competing interests

The authors declare that they have no conflict of interest.

• References

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• 2 Sumiyoshi T, Kondo H, Minagawa T. et al. Risk factors and management for gastric stenosis after endoscopic submucosa dissection for gastric epithelial neoplasm. Gastric.Cancer 2017; 20: 690-698
• 3 Yamamoto Y, Kikuchi D, Nagami Y. et al. Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: review of the literature and recommendations from experts. Dig Endosc 2019; 31: 4-20
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Publication History

Article published online:
22 October 2020