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Creation of a neopylorus after pyloric exclusion using a "double-endoscope" technique
Alexander T Gibbons1,2, Nicholas E Bruns1, Reinaldo Garcia3
1Department of Pediatric Surgery, Akron Children's Hospital, One Perkins Square, Suite 8400, Akron, OH, 44308, USA.
Insights
A novel double-endoscope technique successfully reopened a patient's pylorus after failed exclusion. This endoscopic approach established a patent neopylorus, avoiding major surgery.
Area of Science:
- Gastroenterology
- Surgical Innovation
- Endoscopic Procedures
Background:
- Pyloric exclusion is a surgical technique for severe duodenal or pancreatic injuries.
- Delayed pyloric patency after exclusion can lead to complications.
- Standard recovery for pyloric patency is typically 3-6 weeks.
Observation:
- A 17-year-old male with a gunshot wound experienced failed pyloric patency 5 months post-stapled pyloric exclusion.
- A "double-endoscope" technique was employed, visualizing the obstructed pylorus from both oral and retrograde jejunostomy routes.
- A needle knife and balloon dilation catheter were used to create and dilate a neopylorus.
Findings:
- The "double-endoscope" technique successfully created a patent neopylorus.
- The patient recovered well, tolerating a regular diet after initial endoscopic dilation.
- Four serial endoscopic dilations maintained pyloric patency, leading to the removal of feeding tubes.
Implications:
- This case highlights a rare complication of pyloric exclusion.
- The "double-endoscope" technique offers an innovative, less invasive solution for failed pyloric exclusion.
- Endoscopic management of neopylorus strictures can avoid significant surgical morbidity.
Objective:
Pyloric exclusion may be implemented in the setting of a high-grade duodenal or pancreatic injury. After exclusion, the pylorus should spontaneously open in 3-6 weeks. However, we present the case of a critically ill 17-year-old male with a gunshot wound to the abdomen that underwent stapled pyloric exclusion with gastrostomy and jejunostomy tube placement who did not achieve pyloric patency after 5 months, and describe an innovative "double-endoscope" technique to correct it.
Methods:
A gastroscope was inserted through the mouth into the stomach, and an endoscope was inserted retrograde through the jejunostomy site to the duodenum. The closed pylorus was seen from both ends with transillumination. A needle knife was pushed through the membrane with clear visualization from the contralateral side. A balloon dilation catheter was then passed over a guidewire, and the neopylorus was sequentially dilated. A gastrojejunostomy tube was placed to ensure patency of the neopylorus. Postoperative imaging showed no evidence of leak or pneumoperitoneum. Serial endoscopic dilations were performed every 1-4 weeks to prevent restricturing.
Results:
The patient recovered well. After the first follow-up endoscopic dilation, he was eating a regular diet and had no retained food products. After four endoscopic dilations, the patient remained symptom free and the pylorus was widely patent. His gastrostomy and jejunostomy tubes were removed.
Conclusions:
Here we presented a rare complication of pyloric exclusion and an innovative approach that used a "double-endoscope" technique and serial endoscopic dilations to establish and maintain a neopylorus, avoiding the morbidity of a major surgical procedure.
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