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Tuesday 10th April 2018 Back to list

Gastrointestinal stenting: transhepatic and gastrostomy pathways

Today we introduce two methods that have clinical efficacy of complex gastroduodunal obstruction.

 

1. Two cases of duodenal afferent loop malignant obstruction stenting accompanied by secondary biliary obstructions after Roux-en-Y anastomosis were treated by transhepatic way of stenting.

For these two cases of malignant duodenal tumor, the patient’s jejunum was re-constructed during Rout-en-Y operation, stent could not be delivered to the stricture through peroral approach. Transhepatic percutaneous was applied.

Operation process

Make percutaneous through right hepatic duct, super slippery guide wire and contrast catheter are inserted. Under the guide of X-ray, make percutaneous transhepatic cholangial drainage. 8F drainage catheter is used. Wait 3~5 days for the recovery of the eclasis common bile duct and duodenum. Insert the super slippery guide wire through the drainage tube and reach the distal end of the stricture, remove the drainage tube, introduce a 10 F sheath into the bile duct and then 5F Cobra catheter is inserted.

Measure the length of the stricture under contrast medium. Replace with 260 cm Amplaz hard guide wire before stent placement. Duodenal stent system is inserted through the guide wire and stent is released to expand the stricture. Check the expanding stent under contrast medium. Leave 10.2 FR bile duct stent for endoscopic retrograde biliary drainage and close the percutaneous pathway.

Experience share: 

For the patients who had the history of GI reconstruction operation, the implantation of metal stent should be applied 3~5 days after PTCD operation. The above operation could be applied for the obstruction of duodenal horizontal stenosis with bile duct obstruction and bile duct eclasis.

In our two cases, malignant obstruction jaundice recovered two weeks after stent placement. The drainage tube was removed three weeks after stent placement. The survival rate of both patients is longer than 12 months.  

 

2. Two cases including 1 pyloric and 1 duodenal obstructions treated by stent-placement through gastrostomy for the failure of peroral approach.

Operation process

Owing to large gastric cavity caused by asthenic stomach and stomach with acute angle, the delivery device of stent could not pass the stricture.  Stent-placement through gastrostomy is applied. Choose the avascularity location on the gastric angle for puncture and prop up the gastric wall with endoscope. Gastrostomy device is applied. Cut the gastric skin and make puncture with needle. Insert the guide wire, the guide wire is captured out of the oral cavity through endoscope . Connect the gastrostomy tube system on the wire. Retreat the guide wire and pull the gastrostomy system outside the body from the point of puncture. Fix the location of the gastrostomy system and wrap up the scar.  

Under the guide of X- ray, insert 7F coronary guide tube with length 70cm and 5F Cobra contrast tube. Then insert the super slippery guide wire and get it through the stricture and reach the jejunum. Replace with 260 cm Amplaz hard guide wire. Duodenal stent system is inserted through the guide wire and stent is released to expand the stricture. Check the expanding effect of stent under contrast.

Experience share

Both patients were treated with acid suppression and hemostasis. Antibiotics was used to prevent inflammation. The patients who had upper GI obstruction were prohibited to take food after the operation. Liquid food could be taken 48 hours after the operation. The normal diet recovered one week after the operation. Gastrostomy system was removed 4 weeks after the operation. Either patients in our record did not have any inflammation on the gastrostomy orifice. The orifice sealed five weeks after the operation.

The stent was completely expanded 5 days after the placement and remained unobstructed.Duodenal stents were implanted successfully. (Wallstents are used in these cases). All the patients were recovered with liquid food intake. Neither restenosis nor displacement occurred during the period of follow-up. The survival rate of the two patients were 4.5 months and 7 months. One patient died because of tumor metastasis and the other died of cardiovascular disease.

Reasonable pathway stent application, complex gastrointestinal obstruction could be treated properly.

(From Chinese Intercent Radiol 2006,15:160-162)