How to treat intestinal obstruction due to malignant recurrence after Whipple’s resection for pancreatic head cancer: Description of 2 new endoscopic techniques

Figure 4 Fluoroscopic image. A: A percutaneous transhepatic cholangiography confirming patency of the biliary anastomosis. The malignant stricture (arrow) is located at the level of the afferent limb (afferent limb syndrome), leading to dilated intrahepatic bile ducts and a dilatation of the afferent limb. Note the presence of an old Ovesco clip in the stomach. B: The single-balloon enteroscopy up to the level of the malignant stricture in the afferent limb. Contrast injection through the working channel of the enteroscope clearly delineates the length and the malignant aspect of the stricture (arrow). C: The peroral insertion technique of the self-expandable metal stent over a stiff guidewire through the overtube with the balloon inflated to protect the intestinal mucosa and to guide the catheter up to the malignant stricture of the afferent limb. D: The self-expandable metal stent in place in the malignant stricture of the afferent limb. Both the stiff guidewire and the overtube of the single-balloon enteroscope were used to insert the SEMS. SEMS: Self-expandable metal stent.