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Endoscopic submucosal dissection of a large neoplastic lesion at the ileorectal anastomosis in a familial adenomatous polyposis patient

distal gastrectomy with Roux-en-Y reconstruction because of gastric cancer developed gastrojejunostomy anastomotic obstruction as a result of local anastomotic recurrence and peritoneal dissemination (Fig. 1a,b). An uncovered SEMS (22-mm wide, 60-mm long, Niti-S Pyloric Duodenal D-type Stent; Taewoong Medical Co., Ltd, Gimpo, South Korea) was placed for the anastomotic obstruction using a forwardviewing scope (CF-HQ290I; Olympus Medical Systems, Tokyo, Japan) (Fig. 1c). However, biliary obstruction with jaundice also occurred as a result of dissemination (Fig. 2a); thus, endoscopic retrograde cholangiopancreatography (ERCP) was carried out for biliary stenting using singleballoon enteroscopy (SIF-H290S; Olympus Medical Systems). The endoscope was successfully inserted into the duodenal papilla through the SEMS that was placed for the anastomotic obstruction. Cholangiogram showed severe stricture of the upper bile duct with intrahepatic bile duct dilatation (Fig. 2b). After inserting the guidewire across the stricture, an uncovered SEMS (8-mm wide, 80-mm long, BileRush Selective; Piolax Medical Devices, Kanagawa, Japan) was placed above the duodenal papilla (Fig. 2c; Video S1). The patient’s laboratory values and symptoms quickly improved without any adverse event. Balloon enteroscopy-assisted ERCP is useful in patients with surgically altered anatomy. However, it is uncertain whether balloon enteroscopy-assisted ERCP through a jejunal stent is safe. In the present patient, the enteroscope and balloon overtube was safely inserted through the SEMS without perforation and/or bleeding. For patients with gastrojejunostomy anastomotic and biliary obstruction, endoscopic double stenting could be a useful option. The authors declare no conflicts of interest for this article.