Lumen-Apposing Metal Stent for the Treatment of Colonic Primary Crohnʼs Disease Stricture

Abstract

52-year-old male with past medical history of Crohn's disease (CD) presents to the clinic for evaluation of abdominal pain, distention and bloating. The patient has had CD for 30 years localized to the terminal ileum, perianal area and most recently the colon. He underwent ileocecectomy in 2014 with primary anastomosis complicated by leak, abscess and enterocutaneous fistula, requiring multiple surgeries. The patient has been on Infliximab, which was stop due to a medication reaction, and then he was switched to Vedoluzimab, however this was also stop because of a severe pulmonary infection. While off biologics the patient has been developing abdominal pain, bloating and distention. CT enterography revealed dilated ascending colon and stricture in the proximal transverse colon measuring about 2cm in length. Given that he was off biologics and was a poor surgical candidate, endoscopy therapy was attempted. He had three endoscopic dilations with balloon ranging from 16-18 mm in diameter along with needle knife dilation. The patient had improvement on symptoms after each therapy however symptoms returned. The decision was made to attempt LAMS. A colonoscopy showed severe stricture in the proximal transverse colon and the pediatric scope could not be advanced. After confirmation of the lumen with the use of a guidewire the stricture was treated with a 15mm x 10mm LAMS. The patient did well after the procedure with improvement of his symptoms. LAMS are a great tool for different gastrointestinal conditions and they have been applied succesfully to upper and lower gastrointestinal conditions. We present the first case describing the use of LAMS for primary recurrent CD stricture. Our patient had significant obstructive symptoms and was a poor medical and surgical candidate because of severe pulmonary infection and poor nutritonal status respectively. The patient did well after the procecure with resolution of abdominal obstructive symptoms. Although more studies are needed in this area, LAMS could serve as a temporizing measure until definitive treatment with biologics or surgery is performed. Surgical support should always be available when considering stenting CD strictures. Watch the video: https://goo.gl/KEdmJc