2129 Lumen-Apposing Metal Stent for Benign Gastric Outlet Obstruction!

Abstract

INTRODUCTION: Lumen-apposing metal stent (LAMS) placement via endoscopic ultrasound (EUS)-guided gastroenterostomy has recently emerged as a promising technique for the management of malignant gastric outlet obstruction (GOO). This is safe, effective and technically feasible if performed by trained advanced endoscopists. Despite that LAMS use in malignant GOO is well defined, it is rarely performed for benign etiologies of GOO and only 4 cases have been reported in the literature. We report the case of a patient with GOO secondary to benign duodenal stricture that was successfully managed by LAMS placement. CASE DESCRIPTION/METHODS: A 60-year-old man with history of recurrent duodenal ulcers presented for vomiting and food intolerance for few days. Two years ago he had a GOO secondary to his ulcer disease and was managed by surgical gastrojejunostomy (GJ). A subsequent marginal ulcer perforation required resection of the GJ with small bowel anastomosis and insertion of a GJ tube. Upon presentation, physical examination was notable for epigastric tenderness with no rebound or rigidity. Contrast computed tomography (CT) scan of the abdomen showed a markedly distended stomach and proximal duodenum with focal narrowing near the pancreatic head (Figure 1). Enteric contrast reached the rectum indicating the absence of complete obstruction. Upper endoscopy showed retained solid material in stomach and an almost completely occluded “pin hole” duodenal lumen that could not be traversed with the endoscope. A wire-guided through the scope dilation with a balloon was performed in conjunction with fluoroscopy but was unsuccessful (Figure 2) so a 10 mm × 15 mm EUS-guided LAMS was successfully deployed. Patient’s symptoms resolved and he was able to tolerate diet. DISCUSSION: GOO usually occurs secondary to malignancy-related mass effect or luminal invasion. Less commonly GOO can be attributed to benign etiologies namely ulcers, caustic ingestion and inflammation. Often managed by endoscopic balloon dilation, benign strictures can recur. Other less favored options include self-expandable metal stents which use is limited by a high rate of migration and failure and surgical approach which provides definitive treatment but is associated with a high risk of mortality and morbidity. LAMS is a novel and appealing less invasive approach proven to be a safe alternative allowing early restoration of enteral luminal access with good short term success and satisfying safety profile. Further studies and long term follow up are recommended.