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Andreas Wannhoff, Karel Caca | Medizinische Klink I, Klinikum Ludwigsburg


Sequence 1:  Case description / initial findings

This 83-year-old female patient had an advanced, inoperable scirrhous carcinoma in the stomach, with tumor stenosis in the antrum. Clinically, the patient reported postprandial vomiting and a feeling of pressure in the upper abdomen. To maintain passage of food, we planned to establish an endoscopic gastroenterostomy using a lumen-apposing metal stent. At gastroscopy, a marked tumor-related stenosis was noted in the antrum, which the endoscope only passed with difficulty.

Sequence 2: Placement of a balloon catheter

Passage into the upper duodenum was ultimately successful. Via a guide wire, a balloon dilation catheter was introduced and the gastroscope was removed.

Sequence 3: Endosonography

In the next step, a switch is made from the gastroscope to the endoscopic ultrasound (EUS) scope. In the area of the greater curvature of the stomach, EUS is now able to demonstrate the proximal small-bowel loops and the liquid-filled dilation balloon located in them. The small-bowel loops have been filled with liquid, like the balloon before them, so that they appear as anechoic structures on EUS.

Sequence 4: EUS-guided puncture

Once a small-bowel loop that is suitable for puncture has been selected and visualized on EUS, a puncture needle is introduced via the endoscope’s working channel. EUS-guided puncture of the fluid-filled small-bowel loop is then carried out with the needle, which is easily recognized as a hyperechoic reflex in the image. Once the small-bowel loop has been successfully punctured, a wire is advanced through the puncture needle and the needle is removed again.

Sequence 5: Placement of the lumen-apposing stent (LAS)

The Hot Axios lumen-apposing metal stent is contained in a special introducing device, which is introduced over the guide wire into the working channel of the EUS endoscope. Again with EUS guidance, the introducing device is advanced along the guide wire as far as the small-bowel loop. Once positioning has been checked, the distal stent bulb is released first. The stent’s hyperechoic pattern is easily recognized on EUS. Once the distal stent bulb has been released, a switch is made from EUS mode to endoscopy mode, and the endoscope and introducing device are withdrawn slightly. The stent is then fully released under endoscopic guidance.

Sequence 6: Balloon dilation

The released stent then still has to be dilated to its final size. Via the guide wire, which is still in place, a balloon dilation catheter is introduced to do this. The catheter is positioned inside the stent, and the stent is dilated to its final size.

Sequence 7:  Checking the findings

Subsequent checking of the findings using the gastroscope shows the proximal stent bulb correctly placed in the stomach. Once the stent has been passed with the gastroscope, the correct positioning of the distal end of the stent can also be verified. The small-bowel mucosa on the distal side of the stent is easily recognizable. The gastroenteric anastomosis has been successfully established. No signs of any acute complications, particularly bleeding or perforation, are seen at the subsequent check-up.

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