A 56-year-old male with metastatic unresectable cholangiocarcinoma presented to our clinic with worsening nausea and vomiting. Prior to presentation, the patient underwent placement of a palliative metal biliary stent and an uncovered self-expandable metal stents (UCSEMS) through the pylorus and duodenum for gastric outlet obstruction (GOO) from tumor burden. However, the patient subsequently developed a repeat duodenal obstruction from tissue ingrowth and had a second UCSEMS deployed within the first stent 6 months after the original stent placement.
At our evaluation, 4 months after the second stent placement, another stricture from further tissue ingrowth was noted (Figures 1 and 2). Gastrojejunostomy tube placement was offered to the patient, but he declined. The decision was made to place a third stent for symptom palliation. On endoscopy, a tight stricture was noted within the existing stents. Under endoscopic and fluoroscopic guidance, a wire was placed distally into the duodenum, and a Tae-Woong 100 x 18-mm fully covered self-expandable metal stent (FCSEMS) was placed within the previous stents making sure not to overlap it with the intact biliary stent.
Figure 1. Endoscopic image of the duodenum before our intervention. The arrow shows the small visible portion of the original stents. The remainder of these stents are buried under tissue ingrowth.
Figure 2. CT image of the abdomen showing occlusion of the original stents at the gastric outlet.
Using Apollo OverStitchTM, the proximal edge of the stent was sutured into the antral gastric mucosa, and the lateral side of the stent was sutured into the proximal edge of the original stents (Figures 3–5). The patient tolerated the procedure well, and his symptoms of nausea and reflux resolved. Follow-up at 6 months revealed continued relief of obstructive symptoms.
Figure 3. Endoscopic image of the proximal edge of the FCSEMS being sutured into antral gastric mucosa.
Figure 4. Endoscopic image of the lateral side of the FCSEMS being sutured into the proximal edge of the original stenting.
Figure 5. Endoscopic image of the FCSEMS secured within preexisting stents with Apollo OverStitchTM, resulting in decreased GOO symptoms.
UCSEMS are commonly used for palliative treatment of malignant tumors resulting in GOO. Tumor ingrowth is a frequent complication leading to stent restenosis and treatment failure requiring the need for additional intervention. Placement of a FCSEMS within an UCSEMS has been reported with successful alleviation of reobstruction caused by stent ingrowth.1 While this technique can provide relief, it can be further complicated by migration of the fully covered stent.2 Placement of clips at the proximal ends of secondary stents has been shown to decrease stent migration rates.3 To our knowledge, no other stent-in-stent securing methods have been evaluated.
The Apollo OverStitchTM has been shown to be effective in a variety of clinical applications. A study described using the OverStitchTM for perforation closures, fistula/leak closures, endoscopic mucosal resection/submucosal dissection closures, bariatric and obesity surgery, and stent fixation.4 Several studies have demonstrated endoscopic suturing to be an efficacious means to reduce stent migration rates.5,6 Once the technique for using OverStitchTM is learned, using the device for stent-within-stent fixation or primary stent anchoring is one of its easiest applications, and stent-fixation is not overly time consuming. With the growing utilization of the Apollo OverStitchTM for a wide spectrum of interventions, novel use of the tool for stent fixation, particularly stent-within stent fixation, is promising.
Author contributions: S. Kaye, KJ Kim, and N. Chaurasia drafted the case report and edited the manuscript. K. Chang reviewed the manuscript. J. Samarasena reviewed the manuscript and is the article guarantor.
Financial disclosures: None to report.
Informed consent was obtained for this case report.
Correspondence: Shawn Kaye, School of Medicine, University of California, Irvine, Orange, CA 92868 (firstname.lastname@example.org).
Received October 30, 2015; Accepted March 16, 2016
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