Research Article: 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

Date Published: January 07, 2020

Publisher: Wolters Kluwer

Author(s): Sami Elamin, Daniel Stein, Jonah Cohen.


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.

Partial Text

Afferent limb (loop) syndrome is a known complication in patients who undergo partial gastrectomy with Billroth II reconstruction. Obstruction of the afferent (biliary) limb results in increased intraluminal pressure and distention from the accumulation of enteric secretions and bile. Back pressure is transmitted to the biliopancreatic ductal system, which can lead to ascending cholangitis and pancreatitis. Similarly, obstruction of the efferent limb, as seen, for example, in patients with malignancy, causes functional small bowel or gastric outlet obstruction. Patients classically present with nausea, emesis, and abdominal pain. In severe cases of afferent loop syndrome, high luminal pressures and distention increase bowel wall tension in the afferent loop and can lead to ischemia and gangrene with subsequent perforation and peritonitis. We present a case of concurrent afferent and efferent limb obstruction secondary to a gastric mass in the setting of remote Billroth II gastrojejunostomy for peptic ulcer disease, treated with metal stents deployed into the afferent and efferent limbs. To prevent stent migration, a “kissing-stents” technique was used, and 2 clips were deployed to attach the gastric end of both metal stents.

A 65-year-old man with a history of peptic ulcer disease status postremote Billroth II gastrojejunostomy in 1970 with known metastatic gastric carcinoma presented in the outpatient setting with several months of abdominal pain, fatigue, weight loss, and poor appetite. His body mass index was 15 kg/m2. This constellation of symptoms resulted in interruption of his chemotherapy regimen. On examination, his abdomen was soft and initially nondistended. He had hyperactive bowel sounds, normal pitch. There was moderate tenderness to palpation over the right upper quadrant and left side, no rebound, and no guarding. The laboratory results revealed anemia hemoglobin 7.7 g/dL, alanine aminotransferase 43 U/L, aspartate aminotransferase 45 U/L, alkaline phosphatase 2006 U/L, TBili 0.5 mg/dL, and albumin 2.5 g/dL. He was admitted to the hospital for management.

There are currently few studies on the use of metallic stents in the obstruction at the bifurcation of a surgically reconstructed intestine, and the safety and efficacy of the procedure have not been elucidated.1 Placement of afferent and efferent limb stents can allow resumption of oral intake in patients with afferent limb syndrome with efferent limb obstruction. This is an uncommon complication of Billroth II reconstruction but could likely be applied to another postsurgical anatomy such as hepaticojejunostomy for pancreatic resection. Anchoring of the 2 stents with a clip, using a “kissing-stents” technique, is a novel way to prevent stent migration.1–3 Another method to prevent stent migration is suturing the stents to the gastric wall. We elected to clip the 2 stents together because we felt confident this would successfully prevent migration by forming kissing stents. Given the size and shape of the patient’s stomach, suturing to an adjacent wall would have been difficult and unlikely to be more successful than the endoclip approach we created. A study comparing the outcomes of those 2 techniques would be useful.1 Consideration should always be given to a double-wire technique to prevent an initial stent from occluding the second lumen and preventing passage. Despite the typically advanced malignancies causing these obstructions, intervention should be offered if it would provide therapeutic or palliative benefit.

Author contributions: S. Elamin wrote the manuscript, reviewed the literature, and is the article guarantor. D. Stein reviewed the literature and revised the manuscript. J. Cohen approved the final version.