INTRODUCTION
Gastric cancer is a major problem worldwide. It is the second leading cause of cancer
death, affecting approximately 1 million individuals/year [1] and surgical resection remains the only curative treatment option. A patient with
total gastric resection may undergo various reconstructions. The method of choice
for reconstruction after total gastrectomy for gastric carcinoma still remains controversial.[2] Roux-en-Y esophagojejunostomy is the most commonly done procedure in this setting
as it is relatively simple to perform and prevents reflux esophagitis.
Various postoperative complications following Roux-en-Y esophagojejunostomy are described.
We report our experience with stricture at jejunojejunostomy site which was successfully
managed with single balloon enteroscopy.
CASE REPORT
A 40-year-old female patient presented with a history of 4–5 episodes of nonbilious
vomitings per day for 45 days. There was no history of abdominal pain, fever, abdominal
distension or melena. Bowel habits were normal. She underwent laparotomy for gastric
malignancy with total gastrectomy, esophagojejunostomy, and Roux-en-Y anastomosis
1½ year back. Her routine blood investigations showed hemoglobin of 11.2 g%, total
leukocyte count of 9500/mm 3, and platelet count of 2.5 lakhs. Renal function and
liver function tests were with in normal limits.
Barium meal follow through [Figure 1], and upper gastrointestinal endoscopy [Figure 2] showed postesophagojejunostomy status, one blind end loop, and the other loop showed
prominent folds with dilatation. Proximal small bowel loops were dilated. Contrast-enhanced
computed tomography abdomen showed short segment asymmetrical wall thickening of proximal
jejunal loop with luminal compromise and dilatation of proximal portion of jejunal
loop.
Figure 1: Barium meal follow through showing dilated esophagus and proximal bowel loops
Figure 2: Esophagojejunal anastomotic site
Single balloon enteroscopy (Olympus, SIF-Q180) was done for this patient, and it showed
stricture at the Roux-en-Y jejunojejunal anastomotic site [Figure 3]. Dilatation was done with through the scope (TTS) balloon dilator (Olympus) up to
18 mm [Figure 4]. Postdilatation barium meal follows through showed the free passage of contrast
into the small bowel [Figure 5]. Patient symptoms are improved, and she underwent one repeat dilatation after 1
month and now on follow-up.
Figure 3: Narrowing of the jejunojejunostomy site
Figure 4: Jejuno jejunostomy site dilatation with through the scope balloon
Figure 5: Barium meal follow through showing free passage of contrast into the small bowel
DISCUSSION
Surgical treatment plays a predominant role in the management of patients with gastric
carcinoma. Total gastrectomy is the most common surgical procedure, which can achieve
adequate safety margins in relation to the tumor to offer patients a chance of cure.
Various reconstructive procedures can be chosen after total gastrectomy.[2],[3],[4],[5],[6] The optimal method of reconstruction after total gastrectomy would provide for a
functional reservoir, preserve duodenal and jejunal continuity, and minimize postgastrectomy
functional disturbance. No one reconstruction technique fulfills all these criteria.
Postoperative complications can be broadly grouped into early and late complications.
By definition, early complications occur within the immediate perioperative period
– the first 2-week postsurgery. Late complications arise after the second postoperative
weeks. The early complications include anastomotic or staple line leak, postoperative
hemorrhage, bowel obstruction, and incorrect Roux limb reconstruction. Late complications
include anastomotic stricture, marginal ulcer formation, fistula formation, and nutritional
deficiencies.
Stricture of the esophagojejunal anastomosis represents a well-described, long-term
complication, with a documented incidence ranging from 0.05% to 6%, with an incidence
slightly higher if performed with mechanical staplers.[7] Factors affecting the development of anastomotic strictures include tension or ischemia
at the anastomosis and the healing capacity of individual patients. It has been noted
that this complication is substantially more frequent with the laparoscopic than the
open approach. Various treatment modalities have been described for the management
of this anastomosis in published case reports, such as endoscopic balloon dilatation,
argon plasma coagulation, YAG laser, endoscopic self-expandable metal stenting, and
surgical revision.
However, stricture at the Roux-en-Y jejunojejunal anastomotic site is rarely reported.
We dilated the jejunojejunostomy site stricture with TTS balloon up to 18mm. Follow-up
barium meal showed the free passage of the contrast material into the small bowel.
CONCLUSION
We are reporting a rare case of Roux-en-Y jejunojejunostomy stricture managed endoscopically
with TTS balloon. Endoscopic balloon dilatation is an effective treatment for benign
anastomotic strictures after radical gastrectomy for gastric cancer and should be
considered as a primary intervention before proceeding with surgical revision. The
importance of less invasive management is clearly highlighted in our case.
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