Post written by Michael Lajin, MD, from Sharp Grossmont Hospital, La Mesa, California.
A 66-year-old man was diagnosed with gastric lymphoma and received chemotherapy. He developed pulmonary tuberculosis and was started on TB medications. He presented with vomiting and 80-pound weight loss. Endoscopy revealed a pyloric ulcer resulting in outlet obstruction and proximal gastric ulcers. PEG-J tube by interventional radiology was unsuccessful. He was deemed a poor surgical candidate and remained on TPN and in respiratory isolation. The pylorus was traversed using an ultraslim endoscope, which was used to distend the jejunal loop with contrast. EUS was advanced to the stomach. The site of the gastroenterostomy seemed near the proximal gastric ulcer. We decided against direct LAMS deployment to avoid going through the ulcer. A 19-gauge needle punctured the jejunum. A long wire was advanced and was pulled by the endoscope to the mouth. The echoendoscope was removed. A therapeutic endoscope was advanced over the gastric end of the wire. The wire entry was confirmed to be clear from the ulcer. The track was dilated and a 2-cm LAMS was deployed and dilated. Oral diet and TB medication were resumed, and the patient was eventually discharged. Four months later, he regained back the lost weight and was clear from TB and lymphoma. Endoscopy confirmed ulcer healing resulting in complete closure of the pylorus. The EUS was advanced to the antrum. The duodenal bulb was punctured with a 19-gauge needle. Despite injecting contrast, the bulb did not distend prohibiting direct LAMS deployment. A long wire was passed to the duodenum. EUS was removed. The wire was pulled by a pediatric colonoscope to the mouth. A therapeutic endoscope was advanced over the gastric end of the wire to the pylorus. The track was dilated and a 2-cm LAMS was deployed across the pylorus and dilated to 15 mm. Eight weeks later the pyloric stent was removed. Two months following stent removal, the pylorus was patent and was dilated to 15 mm. Our plan was a gradual pyloric dilation and eventual removal of the gastroenterostomy stent once long-term pyloric patency was confirmed.
We wanted to show the impact of advanced endoscopy on modern medicine regarding saving lives, morbidity, cost, and shortening hospital stay. This patient had a gruesome illness with lymphoma, tuberculosis, and cachexia. He was unable to eat or take his TB medications and remained hospitalized in respiratory isolation. There were no surgical or IR alternatives. He had an endoscopic procedure that enabled him to eat, resume his TB medications, and eventually be discharged from the hospital. Four months later, he was in excellent health: TB was cured, lymphoma was in remission, and he regained back the weight he lost.
The Rendezvous technique can be used to perform an endoscopic gastroenterostomy when the forward view is needed to ensure a safe path or when the target loop is not adequately distended to allow a direct approach.
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