A "Kissing-Stents" Technique in the Management of Afferent Limb Syndrome With Concomitant Efferent Limb Obstruction in a Patient With Gastric Cancer and Billroth II Anatomy

Abstract

The "kissing-stents" technique has been used in endovascular interventions for the management of aortic and arterial stenosis at bifurcation sites. However, to our knowledge, the use of this technique to prevent stent migration in endoscopy has not been described to date. We present a 65-year-old man with metastatic gastric adenocarcinoma status post-Billroth II gastrojejunostomy complicated by simultaneous afferent and efferent limb syndrome with gastric outlet obstruction and biliary dilatation. Two uncovered metal stents were used to relieve the afferent and efferent loop obstructions. These 2 stents were anchored together in a "kissing-stents" technique and using a clip to prevent migration. The patient was able to resume oral intake, and his liver function tests improved. This intervention should be considered in other cases of advanced malignancies causing obstructions for curative or palliative intent.

Figure 1.

(A) High-grade afferent loop obstruction due to enlarging gastric mass with probable extragastric extension into the left upper quadrant and decompressed distal bowel. (B) Biliary and ductal dilatation, gallbladder dilatation, and pancreatic ductal dilatation.

Figure 2.

Gastric mass.

Figure 3.

Double-guidewire technique.

Figure 4.

(A) Afferent and efferent limb stents. (B) Afferent and efferent limb stents anchored together with a clip to prevent migration, demonstrating a “kissing-stents” technique.

Figure 5:

Fluoroscopy showing afferent and efferent limb stents anchored with a clip.