2188 Off-label Use of Lumen-Apposing Metal Stent for Gastro-Jejunal Anastomotic Stricture Following Roux-en-y Gastric Bypass

Abstract

INTRODUCTION: Roux-en-y gastric bypass (RYGB) is the second most common bariatric surgery performed after sleeve gastrectomy. A complication of this procedure is a gastrojejunal (GJ) anastomotic stricture. A lumen apposing metal stent (LAMS), which was initially used for draining pancreatic fluid collections/cystogastrostomy, is now being used in various locations throughout the gastrointestinal tract due to its novel dumbbell shaped design. In this case report we present a case of GJ anastomotic stricture successfully managed with LAMS after failure of serial balloon dilations. CASE DESCRIPTION/METHODS: A 51-year-old woman with a history of RYGB in 2008, complicated by recurrent stricture of her GJ anastomosis, presented for treatment options of her stricture. She had undergone dilations in the past with no change in her symptoms of daily vomiting. The patient requested a more definitive treatment. The patient was taken for placement of a LAMS endoscopically. Her stricture at the GJ anastomosis measured 7mm in diameter and <1 cm in length. A hydrophilic wire was inserted into the jejunum under fluoroscopic guidance. A 15mm LAMS was advanced over the wire into the jejunal lumen. Placement was confirmed with endoscope and fluoroscopic image. Finally, a 12-13.5-15 mm CRE balloon was advanced over the wire and used to dilate the lumen of the stent. The patient returned to the clinic 5 weeks later with complete resolution of her symptoms. She will have the stent removed in 2 weeks. DISCUSSION: GJ anastomoses can initially be managed with pneumatic dilations. However, this requires repeat interventions with limited success. A common alternative is the fully covered self-expanding metal stent (FCSEMS). The FCSEMS has a high rate of adverse events including stent migration, perforation, and recurrence of strictures after removal. A LAMS has a novel dumbbell shape design that prevents leakage and migration due to 24 mm anchoring flanges, while also being shorter and smaller than FCSEMS. Additionally, because of the dumbbell shape, when inflated with a CRE balloon, the risk of migration is very low. For these reasons, in addition to its expanding use within the GI tract, it was used in our patient with success. This case demonstrates another use for LAMS that is safe and effective in an expanding population.