Small Bowel Stent-in-Stent Placement for Malignant Small Bowel Obstruction Using a Balloon-Assisted Overtube Technique
An 80-year-old woman who underwent a pylorus-preserving Whipple procedure 6 years previous for pancreatic head cancer and recurrent disease with duodenal obstruction of the previous placement of two palliative SEMSs was referred to our institution for bowel obstruction distal to the ligament of Treitz. The stents had been placed 2 years and 11 months prior, respectively. Placement of a third stent using esophagogastroduodenoscopy and standard and pediatric colonoscopes had failed. We used a double-balloon enteroscope (DBE) to perform the procedure. The previously placed SEMS was obstructed owing to ingrowth with tissue and the small bowel kinking distally to the stent (). A large amount of impacted food was removed by flushing and suctioning. Using endoscopic and fluoroscopic visualization, the enteroscope was carefully advanced into the jejunum after dilating the stricture. After the scope was advanced, the overtube was gently pushed across the dilation. Deep enteroscopy was then performed, and no other obstructions were found in the afferent or efferent limbs. The Roux-en-Y anastomosis was located approximately 50 cm distal to the pylorus.\nA new SEMS (90-mm length, 10-mm diameter; Boston Scientific, Natick, MA, USA) was inserted across the previous two SEMS using the herein described balloon overtube technique using the following six steps. First, the enteroscope was kept across the stenosis in the upper jejunum (). Second, a Jagwire guidewire (Boston Scientific) was inserted in the jejunum (, ). Third, the scope was removed under fluoroscopic guidance and the wire was left in place (). Fourth, the overtube, which was looped and kinked in the J-shaped stomach, was straightened (). A trick was used to straighten the overtube without losing its position; that is, the balloon of the overtube was inflated distally to the stent. This maneuver allowed the overtube tip to get hooked to the distal part of the overtube while being pulled (i.e., straightened). The overtube straightening was essential to advance the stent through the wire inside the overtube and across the previous stents (; step 5). Sixth, the distal part of the stent was deployed under fluoroscopic guidance while the now deflated overtube was carefully brought back into the stomach through the old stent, thus permitting the new stent to deploy distal to the old stent and the overtube tip across the obstruction (, ). The patient is asymptomatic 3 months after the procedure.