Two overlapping uncovered metallic stents for duodenal obstruction due to primary lymphoma
Mohammed Amine Benattaa, Ariane Desjeuxb, Jean-Charles Grimaudb
Military University Hospital, Oran, Algeria; Hopital Nord Marseille France
Primary non-Hodgkin’s lymphoma (NHL) of the
duodenum is an uncommon primary tumor of the gastrointestinal tract which
accounts for less than 12% of all NHL [1,2]. Obstruction
is a preterminal event. A
decision-analytic model comparing open gastrojejunostomy, laparoscopic
gastrojejunostomy, and endoscopic stenting for malignant gastroduodenal
obstruction showed that self-expandable metal stent (SEMS) placement was
the most cost-effective strategy and was associated with the lowest rate of
complications and the highest success rate over a 1-month period [3]. This is a
rare case of primary duodenal lymphoma with
a poor response to chemotherapy, inoperable given the poor nutritional status
and treated with SEMSs. A 24-year-old man was referred to our hospital
with abdominal pain and upper obstruction signs, consisting of nausea,
vomiting, dysphagia and progressive weight loss. Physical examination showed
tenderness in the epigastrium without peripheral lymphadenopathy,
hepatosplenomegaly, or intra-abdominal mass. Laboratory tests were normal.
Upper gastrointestinal endoscopy demonstrated an ulcerated polypoid lesion with
a near-complete duodenal obstruction. Histopathology
of the lesion was compatible with large B-cell lymphomas and immunohistochemical
study was positive for CD20. Abdominal CT scans showed a circumferential
thickening of the duodenal wall and revealed several lymph nodes. Chest CT scans showed no evidence of lymph node enlargement in the mediastinum. Bone marrow
laboratory showed no tumor infiltration. Our patient received several cycles of
systemic Rituximab (Mabthera®), Cyclophosphamide, Doxorubicine, Vincristine,
Prednisone.This treatment failed to ameliorate the obstructive symptoms with
objective weight loss of 9 kg. Upper endoscopy showed a near-complete
obstruction. To alleviate this obstruction surgical intervention was deemed
necessary but impossible given the poor
nutritional status of our patient.
In conscious sedation under both fluoroscopic and endoscopic control, a
0.035-inch biliary guidewire was indwelled over the stenosis (Fig. 1A). Without
balloon dilatation, due to the length and anatomy of the stricture, and to a
tendency for the stent to move away from the stricture it was essential to
insert two overlapping uncovered SEMSs
through the scope, 22 mm in diameter and 60mm in length (WallFlex duodenal
stent, Boston Scientific) in D2-D3 and D1-D2.
No immediate complications were noted. The patient resumed oral intake immediately, received proton pump inhibitor treatment and was instructed to avoid leafy and uncooked vegetables. A few days after insertion the abdominal X-ray control showed the two overlapping SEMSs in place (Fig. 2).
After follow up of 36 months, no migration, re-obstruction, or occlusion was noted in our patient with two uncovered stents. Our patient was able to resume oral intake with objective weight gain of 10 kg. Endoscopic controls regularly performed showed the two SEMSs in place and functional (Fig. 1B).
Duodenal SEMSs are still underused in patients with malignant gastroduodenal obstruction. In our patient presenting a primary duodenal obstructing lymphoma, the SEMSs placement was effective in alleviating the intestinal obstruction. SEMSs should be recommended in treatment of malignant gastroduodenal obstruction especially in patients with poor performance status.
References
1. Tari A, Asaoku H, Kunihiro M, Tanaka S, Fujihara M, Yoshino T. Clinical features of gastrointestinal follicular lymphoma: comparison with nodal follicular lymphoma and gastrointestinal MALT lymphoma. Digestion 2011;83:191-197.
2. Muchmore JH, Haddad CG, Goldwag S. Primary non-Hodgkin’s lymphoma of the duodenum. Am Surg 1994;60:924-928.
3. Siddiqui A, Spechler SJ, Huerta S. Surgical bypass versus endoscopic stenting for malignant gastroduodenal obstruction: a decision analysis. Dig Dis Sci 2007;52:276-281.
aGastroenterology Department, Military University Hospital, Oran, Algeria (Amine Benatta); bGastroenterology Department, Hospital Nord Marseille France (Ariane Desjeux, Jean-Charles Grimaud)
Conflict of Interest: None
Correspondence to: Mohammed Amine Benatta, 156 Bakhti Nouba Oran, Algeria, e-mail: benattaamine@yahoo.fr
Received 17 April 2013; accepted 22 April 2013