1386 Narrow Tunnel, Zero Visibility: Role of Lumen-Apposing Metal Stent in the Treatment of Short Luminal Stricture Prior to Endoscopic Retrograde Cholangiopancreatography Procedure

Abstract

INTRODUCTION: Managing short-segment benign gastrointestinal (GI) strictures can be challenging if they become refractory to conventional endoscopic therapies. Even though lumen-apposing metal stents (LAMS) are approved for access to and drainage of pancreatic fluid collections, endoscopists are using it in off label manner to treat these short GI luminal strictures. Here we present a patient with short duodenal stricture who was treated with LAMS, resulting in improvement of duodenal patency to accomplish ERCP. CASE DESCRIPTION/METHODS: 69-year-old male with signs of obstructive jaundice (choledocholithiasis) could not get ERCP due to a large duodenal ulcer and associated duodenal stricture. He underwent percutaneous biliary drainage (PTC), treated with antibiotics and later internalization of biliary plastic stent through interventional radiology. Three months later, follow up endoscopy showed healed duodenal ulcer but persistent duodenal stricture. CT revealed proximal migration of the biliary stent. Esophagogastroduodenoscopy was done and under endoscopic and fluoroscopic guidance, a 20 mm LAMS was placed across the duodenal stricture (measured to be <1 cm) with its Distal flange of LAMS was deployed first followed by proximal flange successfully. Two weeks later, the site was found to be patent with the LAMS intact. LAMS was removed with rat tooth forceps without any complication and ERCP was accomplished easily through improved duodenal lumen. Migrated biliary stent was removed and duct was cleared of stones and sludge followed by placement of 10 mm by 60 mm fully covered biliary metal stent and treatment with antibiotics. DISCUSSION: Our case represents another success story of treatment of short GI luminal stricture with LAMS in a patient who required ERCP and eventually had it after duodenal stricture treatment. The short length and wide flanges make LAMS potentially an attractive alternative treatment for short GI luminal stricture without any significant complications and better patient tolerance. Long term data and efficacy still needs to be studied. However, it is likely to continue to substitute as an alternative to traditional endoscopic option for short GI luminal stricture.