Novel Lumen-Apposing Metal Stent for Treatment of a Benign Gastric Stricture after Caustic Injury

Abstract

A 69 year old female developed extensive mucosal injury (Zargar Grade 2b) of her esophagus and stomach caused by accidental ingestion of a caustic alkali substance. Eight days after injury, EGD showed esophageal fibrosis with a stricture in the mid-esophagus, diffuse erythema of the stomach and a large ulcer encompassing a large portion of the antrum. The patient underwent a percutaneous endoscopic gastrostomy (PEG) with a 16 French PEG tube confirmed to be 5 cm away from the ulcer. Two weeks after PEG tube placement, the patient reported persistent sialorrhea. Endoscopy revealed worsening of the esophageal stricture and via fluoroscopy, the total length was determined to be 10 cm, with a diameter of 3 mm in the narrowest segment. The patient underwent multiple through-the-scope (TTS) guidewire-assisted endoscopic balloon dilations (EBD) of this esophageal stricture. She then began to have intractable nausea and vomiting after each bolus of tube feeds, and serial measurements of gastric residual volume (GRV) were increasingly elevated. Repeat endoscopy showed a tight prepyloric stricture secondary to the healing antral ulcer, and the PEG tube was replaced with a 16 French PEG tube with jejunal extension (PEG-J). Eleven days after placement, due to retrograde migration of the J-tube, the PEG-J tube was removed. The decision was made to place a novel lumen-apposing self-expandable metal stent (LAMS). A guidewire was inserted into the stomach through the existing gastrostomy tract and was advanced beyond the prepyloric stricture. A 10 mm x 10 mm LAMS (AXIOSTM Stent, Boston Scientific, Marlborough, Massachusetts, USA) was advanced over the guidewire and positioned across the prepyloric stricture with endoscopic and fluoroscopic guidance. This was followed by placement of a 16 French PEG tube into the stomach via the existing gastrostomy tract. During the 12 weeks after stent placement, the area remained patent with no evidence of migration or erosion, and the patient has been able to tolerate tube feedings well with appropriate weight gain. The use of LAMS for treatment of benign strictures can serve as a safe alternative treatment to EBD. Furthermore, the risk of migration, which has been associated with use of traditional fully-covered self-expandable metal stents is potentially lower with LAMS.Figure 1Figure 2