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The use of double-pigtailed stents to relieve obstruction of a previous endoscopic gastrojejunal lumen-apposing metal stent

Open AccessPublished:August 19, 2021DOI:https://doi.org/10.1016/j.vgie.2021.07.007

      Video

      (mp4, (59.29 MB)

      EGD, which showed obstructed distal flange of the gastrojejunal lumen-apposing metal stent (LAMS) by the contralateral jejunal wall. Two double-pigtail stents were placed across the LAMS to relieve the obstruction.

      Abbreviations:

      GOO (gastric outlet obstruction), LAMS (lumen-apposing metal stent)
      Endoscopic placement of a lumen-apposing metal stent (LAMS) is a novel means of managing patients with malignant gastric outlet obstruction (GOO), particularly those with prohibitive surgical risk factors. However, long-term data on endoscopic gastrojejunal LAMSs are lacking, and mechanical obstruction may still occur from benign processes. In this video (Video 1, available online at www.giejournal.org), we describe a novel case in which double-pigtail stents were used to manage an obstructed LAMS due to occlusion of the distal flange of the LAMS by the contralateral jejunal wall.
      A 71-year-old woman with locally advanced pancreatic adenocarcinoma was referred for GOO. Her history was notable for prior placement of a gastrojejunal LAMS for management of malignant GOO secondary to infiltration of the duodenum by pancreatic adenocarcinoma. Upper endoscopy revealed recurrent GOO (Fig. 1A and B) at the distal flange of the LAMS owing to occlusion by the contralateral wall of the jejunum.
      Figure thumbnail gr1
      Figure 1A and B, Endoscopic view of contralateral jejunal wall collapsed against distal flange of the gastrojejunal lumen-apposing metal stent (LAMS). C and D, Endoscopic view of Dreamwire coiled in afferent and efferent limb. E and F, Endoscopic view of double-pigtail stent in afferent and efferent limb.
      A 0.035-inch guidewire (Dreamwire; Boston Scientific Corporation, Natick, Mass, USA) was coiled into the afferent and efferent jejunal limbs (Fig. 1C and D). To keep the contralateral jejunal wall away from the LAMS, 2 double-pigtail stents (Advanix Biliary Stents; Boston Scientific Corporation) were placed, one into the afferent jejunal limb across the LAMS and the other into the efferent jejunal limb (Fig. 1E and F). A single pigtail may provide sufficient ability to prevent jejunal wall obstruction on the distal end of the LAMS, but using 2 pigtails (1 in the afferent limb and 1 in the efferent limb) ensures patent drainage.
      • Chen Y.I.
      • James T.W.
      • Agarwal A.
      • et al.
      EUS-guided gastroenterostomy in management of benign gastric outlet obstruction.
      Successful restoration of LAMS patency was then obtained. The patient was able to advance her diet and remained asymptomatic at a follow-up visit 8 weeks after the intervention.
      Shamah et al
      • Shamah S.
      • Waxman I.
      • Chapman C.G.
      • et al.
      Double pigtail stent placement through lumen apposing metal stents reduces adverse events and need for reintervention [abstract].
      and Puga et al
      • Puga M.
      • Consiglieri C.F.
      • Busquets J.
      • et al.
      Safety of lumen-apposing stent with or without coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: a retrospective study.
      have demonstrated the safety of double-pigtail stents through LAMSs to reduce the rate of adverse events and repeat interventions. In this case, the double-pigtail stents allowed successful treatment of a recurrent GOO. Prospective, randomized clinical trials are warranted to validate this procedure as treatment in patients with recurrent GOO.

      Disclosure

      All authors disclosed no financial relationships.

      Supplementary data

      References

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