ALO is a rare complication following distal gastrectomy with Billroth II or Roux-en-Y reconstruction, or pancreaticoduodenectomy, with an estimated incidence of 0.3–13%(1). ALO can lead to cholangitis, pancreatitis and intestinal perforation due to continuous elevation of the blind loop’s pressure. Traditionally, ALO was managed by surgery with repeat anastomosis or bypass, but it is too invasive for the patients who have tumor recurrence with poor tolerance(2, 3). More recently, endoscopic therapy including EUS-EE and stent placement has been reported for malignant ALO in a small number of cases(4, 5). Brewer et al.(5) reported 18 patients treated by EUS-EE with a success rate of 100% and 17 patients treated by stent placement with a success rate of 88.2%. All the patients who had a successful operation had an obvious relief of clinical symptoms without any serious complications, which showed that both EUS-EE and stent placement were effective and safe. The difference in the present study was that stent placement was guided by fluoroscopy instead of endoscopy, which had not been reported previously.
In the present study, the technical success rate of stent placement was 91.7% and the clinical efficacy can be defined as good. The long-term stent function was good except stent restenosis in 1 patient. The data were similar to those of endoscopic therapy reported previously(5). However, we encountered 1 patient who was not suitable for stent placement as the proximal end of the obstructive segment was adjacent to the anastomotic stoma. Our experience suggested that the distance between the anastomotic stoma and the proximal end of the obstruction should be at least 2 cm; otherwise the stent may affect the gastric contents entering the efferent loops.
Compared with endoscopic treatment, fluoroscopy guided stent placement seems to be safer and less invasive, and even the patients with cachexia can also be well tolerated. Combined with preoperative CT, fluoroscopy can provided a great spatial resolution than endoscopy, which helped to located the afferent loop quickly and accurately. In fact, the operation in all the patients were finished in an hour. However, the difficulty that fluoroscopy guided needs to overcome is the insufficient support force of the guidewire when the stent delivery system is introduced, especially when the guidewire form loops in the stomach. Here, we adopted two techniques to improve the successful rate of the operation. Firstly, continuous negative pressure drainage through a transnasal gastric tube kept the gastric cavity from becoming too large, which can prevent the guidewire forming loops. Meanwhile, it reduced gastric-acid-induced damage to the guidewire. Secondly, the use of a long sheath provided a powerful support force, which ensured the delivery system reached the stomach and passed through the obstructive segment smoothly.
However, there were limitations to this study. Firstly, the study was retrospective, with a limited number of cases; therefore, the data may have been affected by various potential biases. Secondly, it was not always easy for the guidewire to pass through the obstructive segment to the distal intestine as the regional anatomy was complex after surgery, which required a good understanding of the type of surgery and preoperative imaging; thus, the treatment was restricted to university hospitals.
In conclusion, fluoroscopy guided stent placement for the treatment of malignant ALO is an effective and safe method. It provides a great option, in addition to surgery and endoscopic treatment, especially for patients who have poor tolerance to the traditional surgery.