PMC7452590_01
Pre-operative CT, endoscopic findings.. (a, b) CT scan reveals stricture of the gastrojejunal anastomosis (yellow arrow) due to peritoneal dissemination (P/white dotted line). The stomach (G) and duodenum (D) are dilated. The primary tumor (T/white dotted line) and lymph node metastasis (LN/yellow dotted line) is also seen. J: jejunum. (c) Endoscopy revealing invasion of the tumor into the lumen of the anastomosis.
gr1.jpg
PMC7452590_01_gr1.jpg
fig0005
This was thought to be caused by a disseminated tumor invading into the anastomosis (Fig. 1a, b). Gastrointestinal endoscopy revealed an ulcer formation at the site of the anastomosis, which suggested tumor invasion into the lumen (Fig. 1c).
Schematic illustration of (a) port placement and (b) anatomy of anastomosis in laparoscopic duodenojejunostomy.
gr2.jpg
PMC7452590_01_gr2.jpg
fig0010
A 5-port procedure (Fig. 2a) was taken with the operator on the left side of the patient. The jejunum was brought to the exposed duodenum and anastomosed side-to-side (Fig. 2b), with a stapling device (Signia  with 45 mm purple reload).
Laparoscopic images of duodenojejunostomy. (a) The transverse colon is retracted cranially, and the second to third portion of the duodenum (D) is exposed by excision of the mesentery. (b) Enterotomy is created in the duodenum and the jejunum. (c) Side-to-side anastomosis is formed with 45-mm stapling device. (d) The enterotomy is closed using a 3-0 Vloc  suture.
gr3.jpg
PMC7452590_01_gr3.jpg
fig0015
The enterotomy was closed with a continuous absorbable V-Loc  suture (Fig. 3).
Radiological images after duodenojejunostomy. (a) Gastrografin accumulated in the stomach (G), duodenum (D) and afferent jejunal loop (J). (b) CT scan on the following day showed accumulation of dye in the transverse colon (TC).
gr4.jpg
PMC7452590_01_gr4.jpg
fig0020
Repeated vomiting occurred 5 days later and a nasogastric tube was placed (Fig. 4). With the results seen in Fig. 4, bowel dysmotility was suspected, which was thought to be caused by stasis from opioid treatment.
Schematic illustration of (a) port placement and (b) anatomy of anastomosis in laparoscopic side-to-side jejunojejunostomy.
gr5.jpg
PMC7452590_01_gr5.jpg
fig0025
The EZ Access  system was inserted into the umbilicus via the open method, and 3 trocars were used (Fig. 5a). A side-to-side anastomosis (Fig. 5b) was done outside the abdomen using a linear stapler (Echelon  with 60 mm white reload for enterotomy, 60 mm blue reload for defect closure).
Radiological images after jejunojejunostomy (a) Gastrograffin passing from the jejunal loop (J(oral)) into the jejunum anal to the anastomosis (J(anal)). Contrast material given 2 days prior was seen in the transverse colon (TC). (b) CT scan taken 4 h after gastrograffin injestion.
gr6.jpg
PMC7452590_01_gr6.jpg
fig0030
Re-examination on POD 4 revealed contrast material flowing into the anastomosed jejunum, and most of the accumulation was seen in the colon on a CT scan 4 h later (Fig. 6).