2116 Salvage Therapy for Recurrent Gastrojejunal Anastomotic Stricture Using a Lumen-Apposing Metal Stent

Abstract

INTRODUCTION: Gastrojejunal (GJ) anastomotic stricture following Roux-en-Y gastric bypass is a well-known complication of the surgery with reported ranges varying from 2.9-23%.1 Unfortunately, prior endoscopic interventions for these strictures have had limited durability of treatment response. CASE DESCRIPTION/METHODS: A 71-year-old male with previous Roux-en-Y gastric bypass presented to our hospital with 2 weeks of nausea, vomiting, weight loss, and severe hypoglycemia. Initial imaging with CT abdomen showed a fluid-filled and distended gastric pouch with likely stenosis of the GJ anastomosis. An upper GI series was performed which confirmed significant stenosis at the GJ anastomosis (Figure 1a). An EGD was performed at which time the stricture was successfully dilated using a through-the-scope (TTS) 6-7-8 mm and then an 8-9-10 mm balloon dilator (Figure 2). Unfortunately, the patient did not clinically respond to dilation and was unable to advance diet beyond liquids, requiring initiation of total parenteral nutrition. Subsequently, the patient underwent a repeat EGD with placement of a 20 mm × 10 mm lumen apposing metal stent (LAMS) (Axios, Boston Scientific) under fluoroscopic guidance. The stent was successfully dilated with a TTS 12-13.5-15 mm balloon dilator to a maximal size of 13.5 mm with obliteration of the waist. The LAMS was then sutured into place with the endoscopic suturing device (OverStitch, Apollo Endosurgery, Inc) using 2.0 polypropylene suture and placing 2 interrupted sutures with cinches on both ends (Figure 3). An upper GI series was repeated 24 hours after LAMS, which showed excellent functioning of the stent without leak or obstruction (Figure 1b). Over the next five days, the patient’s symptoms abated, diet was gradually advanced to low residue diet, TPN was discontinued, and the patient was discharged home. DISCUSSION: Management of these strictures has primarily been pneumatic balloon dilation or fully covered self-expanding stents; however, dilation is unlikely to achieve durable response and other stents are associated with complications of stent migration and recurrence of symptoms after removal. Previous case reports have documented successful treatment of GJ anastomotic strictures using LAMS with excellent response given its novel shape and anchoring phalanges. 1 We further show the successful endoscopic suturing of the LAMS, which will allow for prolonged time for stent placement with enhanced risk-mitigation for stent migration.