a 56-year - old female was admitted for nausea and vomiting . she had a history of stage iv gastric cancer and had undergone proximal gastrectomy and bilateral adnexectomy simultaneously due to metastasis of gastric cancer . in addition , she had undergone right hemicolectomy and near - total small bowel resection for bowel ischemic necrosis caused by metastatic bowel obstruction . after the operation past history and the presence of emesis suggested small bowel obstruction due to abdominal carcinomatosis . the day after admission , a contrast x - ray showed a small bowel stricture at the beginning of the jejunum , for which we inserted a small transnasal small bowel tube as a palliative drainage pathway ( fig . 1 ) . since the patient found the nasal and throat discomfort accompanying the transnasal tube intolerable , we performed percutaneous endoscopic duodenostomy ( ped ) with fixation of the duodenum to the skin but failed to reach the stomach due to postoperative gastric shortening . the skin around the duodenostomy became severely eroded due to digestive secretion leakage and the patient continued to complain of discomfort . furthermore , serum albumin levels could not be maintained by ivh due to the massive loss of digestive enzymes . 2 ) ; however , the stent did not completely open the passage and the skin erosion did not heal . to correct this situation , we elected to perform the stenting by open surgery . because of severe carcinomatosis we could not confirm a mobile jejunum , which would have been suitable for anastomosis of the bypass . due to the stricture the stent was placed at the stricture just distal to the first stent ( toward the anal end ) . although stent placement was successful , the operative scar became a skin fistula due to poor alimentation , and digestive secretions leaked from the scar . next we inserted a transanal ileal tube into the duodenum through the operative fistula , and additionally inserted an endoscopic bile duct stent for obstructive jaundice . after the stenting and the insertion of a transanal ileal tube , the patient remained stable . however , she could only take liquid or paste food and digestive secretions continued to leak from the operative fistula . to correct this situation this minimized the leakage and the digestive secretions flowed from the stoma . despite successful stenting , percutaneous endoscopic gastrostomy ( peg ) has been widely used to maintain enteral nutrition , particularly in dysphagic patients diagnosed with neurological diseases such as amyotrophic lateral sclerosis , parkinson 's disease , or multiple system atrophy . peg may also be used palliatively in patients with malignant , pyloric , or duodenal stenosis and other small bowel obstructions requiring decompression . this procedure reduces abdominal discomfort , but may cause loss of digestive enzymes and ultimately hypoalimentation . if it is possible to insert a self - expandable metallic stent , this may be superior to palliative peg decompression . self - expandable metallic stents were originally used for esophageal stenosis and occasionally for malignant gastroduodenal obstruction [ 2 , 3 , 4 , ] . however , due to the flexibility and limited reach of the gastroscope as well as the loop anatomy of the stomach , stent placement in the distal duodenum or proximal jejunum can be very difficult . a good option may be to use a longer stent and a colonoscope . in addition , with peg , trans - peg stenting for the duodenum or proximal jejunum is technically easier than the normal peroral access . currently , transnasal esophagogastroduodenoscopy is routinely used for upper gastrointestinal examination and the availability of thin scopes is better than before . the combination of ultrathin endoscopy and peg makes it easier to access the duodenum or proximal jejunum . however , in our case , we cut a proximal open - type stent to produce a very short tip for delivery . furthermore , we employed double - balloon endoscopy that allowed a deep approach to the small bowel . despite our trial we had another successful experience with intraoperative transcystic ductal common bile duct stenting for a patient of pancreatic head cancer which turned out to be inoperable after laparotomy . therefore in this particular case , we thought intraoperative stenting with minimum laparotomy was also feasible due to the widespread cancer . insertion of the third covered stent was effective for protecting against digestive secretion leakage , indicating that a covered stent may be useful for some fistulas . in this case , we believed that one stent would correct the situation and improve the quality of life for this patient . a further problem with this patient was that she had short bowel syndrome ( sbs ) . the most common cause of intestinal failure is sbs , defined as < 200 cm of functional small intestine . for the past three decades , patients with severe sbs have been managed with home parenteral nutrition . this patient had an ivh port and was receiving home parenteral nutrition , but there were some difficulties related to the sbs , including slow healing of the ped fistula and the small incision made for the stenting procedure . in addition , long - term continuous hyperalimentation resulted in unstable blood glucose levels , followed by hypoglycemic syncope , infectious sepsis , and death . this was a very rare case of proximal jejunal stenting for a patient with sbs .
gastrointestinal obstruction is a common preterminal event in patients with gastric and pancreatic cancer who often undergo palliative bypass surgery . 
 although endoscopic palliation with self - expandable metallic stents has emerged as a safe and effective alternative to surgery , experience with this technique remains limited . in particular , a proximal jejunal obstruction requires more technical expertise than a duodenal obstruction . 
 palliative treatment modalities include both surgical and nonsurgical approaches . in this report 
 , we describe the successful placement of self - expandable metallic stents at the proximal jejunum using a combination of percutaneous endoscopic , intraoperative , and transstomal stenting . 
 usually endoscopy is not indicated in cases of proximal jejunal obstruction , but some cases may require palliative endoscopy instead of bypass operation .