Self-expandable metal stent through the tumor to treat an intestinal obstruction due to pancreatic squamous cell carcinoma (2017)

Pancreatic squamous cell carcinoma is rare (0.5% to 2% of pancreatic malignancies) and may present with compression of adjacent organs.1Mulkeen A.-L. Yoo P.-S. Cha C. Less common neoplasms of the pancreas.World J Gastroenterol. 2006; 28: 3180-3185Crossref Scopus (82) Google Scholar, 2Makarova-Rusher O.V. Ulahannan S. Greten T.F. et al.Pancreatic squamous cell carcinoma: a population-based study of epidemiology, clinicopathologic characteristics and outcomes.Pancreas. 2016; 45: 1432-1437Crossref PubMed Scopus (30) Google Scholar A 62-year-old woman with pancreatic squamous cell carcinoma and liver metastasis was treated in our unit with fluorouracil, leucovorin, and oxaliplatin (FOLFOX) chemotherapy. After the fourth cycle, the patient was admitted for symptoms of obstruction with severe abdominal pain and vomiting. A CT scan showed distal duodenal obstruction (Fig. 1) resulting from progression of the primary tumor. An upper endoscopy confirmed extrinsic obstruction of the distal duodenum (D4). A contrast study revealed no downstream passage of contrast material. An enteral covered stent could not be placed across the level of obstruction because opacification and catheterization of the stenosis showed communication with the gastric cavity (Fig. 2), and the jejunum could not be reached. Therefore, we examined the gastric cavity. A large, retrogastric, posterior fundic fistula leading to a 3-cm necrotic cavity was observed (Fig. 3), 4 cm below the cardia. At the bottom of the cavity, digestive mucosa corresponding to the jejunum was identified.Figure 2Opacification of the stenosis showing passage of contrast material to the gastric cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Orifice of the fistula on the posterior face of the fundus.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Thus, we decided to place an uncovered prosthesis through the fistula to make the digestive tract permeable (Video 1, available online at www.VideoGIE.org). A steerable cannula and guidewire were used to catheterize the jejunum. Then, an uncovered self-expandable metal stent (Wallflex, Boston Scientific, Natick, Mass), 90-mm long and 22 mm in diameter, was deployed under endoscopic control in this necrotic fistula, through the tumor, to create a GI anastomosis (Figs. 4 and 5). Radiographic study revealed free passage of contrast material into the jejunum.Figure 5Proximal collar of the stent in the gastric cavity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The patient tolerated the procedure well, without any adverse events. On postoperative day 2, the CT scan revealed free passage from the stomach to the jejunum without extravasation of contrast material (Fig. 6). She tolerated oral feeding without adverse events from day 1, and her pain was better controlled. The patient remained free of symptoms of obstruction for 3 months but then died of other tumoral adverse events, not related to this procedure. We report on a rare case of successful endoscopic gastrojejunal stent placement through a gastrojejunal fistula complicating squamous cell pancreatic cancer. This technique optimized the patient’s quality of life and served as a nonsurgical option for intestinal obstruction symptoms. All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJhZjA0YTU0NmNmZjExNmMzYmE5NjQ5MTAyY2I5NDVjYSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NjM5ODA3fQ.bR4rsL0SFH2b3KuQ64biNT_814SVd2RnUyfChwHtj-8UvoafPoL8bcKYYCs7uZnN-F2-yezipEquse9UwrsElUEoGxHm331ErnU201Sk414qnRoTNza5I7CQ2aiSXC11Krz7Q7y1bSwdH0vWK0yyUP2QrEq8vDI_xPdKHZ0ZrVyAhobE9jLIHySoIcHI6GrMfmhbANFWu0GUACDowyqgDNEM9SBvWMLKIP3iZMNwpgzyz-dRO6dp2hktEmMTTVeuAM7X7Zn0-VID0KUoxkDVRCXcukwNbg5hUY4B9JCE41yrwmiDZofj-ErlxM0YAZY9bncV44PW8YNV7Hvy3Nwnuw Download .mp4 (28.87 MB) Help with .mp4 files Video 1Steps of the setup of the GI prosthesis through the fistula. Download .docx (.01 MB) Help with docx files Video Script