Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a treatment option for
afferent loop syndrome [1], with the use of various stents having been reported [2]
[3]
[4]
[5]. However, depending on the site of the stenosis of the afferent loop, fistulization
from the stomach can be difficult. We introduce an entero-enterostomy technique using
a forward-viewing echoendoscope and metal stent for the treatment of afferent loop
syndrome.
A 70-year-old woman presented with a chief complaint of abdominal pain, and computed
tomography (CT) showed afferent loop syndrome due to recurrence of pancreatic cancer
([Fig. 1]). We initially attempted transgastrointestinal stenting of the afferent loop stenosis.
The endoscope was successfully inserted to the site of the stenosis, but insertion
of the guidewire through the stenotic lumen was difficult ([Fig. 2]).
Fig. 1 Computed tomography scan images showing intestinal dilatation and disseminated nodules
(arrow) at the onset of the afferent loop on: a axial image; b coronal image.
Fig. 2 The initial situation, with a sharp intestinal bend and severe stenosis preventing
passage of the guidewire, is shown on: a endoscopic image of the intestinal bend; b a schema illustrating the afferent loop syndrome.
We therefore converted to performing EUS-guided fistulization from the stomach to
the afferent loop; however, intragastric EUS identified the presence of part of the
normal intestinal tract between the stomach and dilated afferent loop ([Fig. 3]). Consequently, we attempted to create a fistula, using a forward-viewing echoendoscope
(TGF-UC260J; Olympus, Tokyo, Japan), from a section of the afferent loop to the dilated
afferent loop ([Video 1]). With this technique, it was possible to identify the dilated afferent loop by
EUS without intervention ([Fig. 4 a]) and it was easily punctured with a 19-gauge needle (EZ shot 3 plus; Olympus) ([Fig. 4 b]). After contrast enhancement had been used to confirm penetration of the intestinal
tract, a 0.025-inch guidewire (M-through; Medico's Hirata, Osaka, Japan) was advanced
into the dilated afferent loop ([Fig. 4 c]). A covered metal stent (Covered BileRush Advance, 10 × 80 mm; Piolax Medical Devices,
Yokohama, Japan), with a 7-Fr delivery shaft, was placed ([Fig. 4 d]). A half-pigtail plastic stent was then placed within the metal stent to prevent
ulceration ([Fig. 4 e, f]). No complications were observed. A repeat CT scan showed improvement in the dilatation
of the afferent loop ([Fig. 5]).
Fig. 3 The afferent loop dilation was confirmed by endoscopic ultrasound (EUS) from the
stomach as shown on: a an EUS image that revealed another segment of normal intestine between the stomach
and the dilated afferent loop; b a radiographic image demonstrating the position of the forward-viewing echoendoscope
during the intragastric scan.
Video 1 Endoscopic stent placement in the afferent loop for malignant stenosis via endoscopic
ultrasound-guided gastroenterostomy was not possible. Endoscopic ultrasound-guided
intra-afferent loop entero-enterostomy is therefore performed using a forward-viewing
echoendoscope and metal stent.
Fig. 4 Images from the endoscopic ultrasound (EUS)-guided intra-afferent loop entero-enterostomy
showing: a radiographically, the position of the forward-viewing echoendoscope within the afferent
loop; b puncture of the dilated afferent loop under EUS guidance using a 19-gauge needle;
c the guidewire being advanced into the dilated afferent loop; d deployment of the fully covered metal stent into the afferent loop; e an endoscopic image of the inside of the afferent loop immediately after stent placement;
f a radiographic image of the final stent placement with a notch (arrow) clearly evident.
Fig. 5 The outcome following the endoscopic ultrasound (EUS)-guided entero-enterostomy is
shown on: a a computed tomography curved multiplanar reconstruction of the metal stent, with
an improvement in the dilation of the afferent loop (arrow); b a schema illustrating procedure completion.
This is the first report of this EUS-guided entero-enterostomy technique, which may
be a new option for difficult intragastric puncture during EUS-GE.
Endoscopy_UCTN_Code_TTT_1AS_2AG FB
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online. Processing charges apply (currently EUR
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