Application to Stenting for Stenosis

By applying the aforementioned balloon dilatation technique, we successfully placed a metal stent for circumferential stenosis associated with inoperable jejunal malignancy. A 65-year-old woman with primary jejunal carcinoma and multiple hepatic metastases was referred to our hospital for treatment of bowel obstruction. On presentation, the patient had not eaten for a long time. Bypass surgery was initially considered to improve her quality of life, but she refused to undergo laparotomy and insisted on endoscopic treatment. Thus, we located the stenotic site in the jejunum by double-balloon endoscopy and applied the aforementioned balloon dilatation technique to place an esophageal stent (Ultraflex, Boston Scientific) at the stenotic site. She resumed oral food intake immediately after stenting, and bowel obstruction did not recur until she died about 1.5 months later (Figs. 11.4.9-11.4.12).

Advice

Points to Consider Regarding Balloon Dilatation J

For smooth insertion of a therapeutic device, the intestinal route to the affected region is 2 preferably well shortened. Considerable caution should be observed to avoid intestinal per- J

J foration, and balloon dilatation should be performed in a stepwise fashion under fluoro-

scopic guidance.

Advice

Points to Consider in the Presence of Multiple Stenotic Sites

If the initial contrast-enhanced study shows multiple stenotic sites in a short segment, a guidewire is preferably advanced through as many stenotic sites as possible at a time. This allows consecutive dilatation of multiple stenotic sites with a dilatation balloon, thereby reducing the intervention time.

Advice

Tips for Injection with the Double-Balloon Endoscope

The double-balloon endoscope has a thin forceps channel and a working length of 200 cm, which is longer than the conventional endoscope, thereby requiring a thin, long injection needle. Such a needle is generally floppy, and it is sometimes difficult to advance it through the forceps channel to the tip. To solve this problem, it is recommended that a trace amount of olive oil be injected into the forceps channel before inserting an injection needle. A stylet used with an injection needle should be removed after the injection needle is found to come out of the endoscope tip, followed by filling in the injection needle.

Figs. 11.4.9 to 11.4.12 are from the same patient.

Fig. 11.4.9. Circumferential stenosis associated with jejunal carcinoma

Fig. 11.4.11. Double-balloon endoscopy performed 5 days later

Stent patency was demonstrated

Fig. 11.4.11. Double-balloon endoscopy performed 5 days later

Stent patency was demonstrated

Fig. 11.4.10. Selective, contrast-enhanced radiograph

Selective, contrast-enhanced radiograph showing a stenotic site (arrows)

Fig. 11.4.10. Selective, contrast-enhanced radiograph

Selective, contrast-enhanced radiograph showing a stenotic site (arrows)

Fig. 11.4.12. Selective, contrast-enhanced radiograph obtained at the same time as Fig. 11.4.11

Selective, contrast-enhanced radiograph obtained at the same time as Fig. 11.4.11 demonstrated substantial flow of a contrast agent to the anal side and stent patency

Fig. 11.4.12. Selective, contrast-enhanced radiograph obtained at the same time as Fig. 11.4.11

Selective, contrast-enhanced radiograph obtained at the same time as Fig. 11.4.11 demonstrated substantial flow of a contrast agent to the anal side and stent patency

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