S2549 Endoscopic Management of a Long Benign Duodenal Stricture Using Combination of Fully Covered Stent Placement and Endoscopic Suturing

Abstract

Introduction: Benign duodenal strictures can cause gastric outlet obstruction (GOO) and are challenging to treat, often needing serial esophagogastroduodenoscopy (EGD) procedures with dilation. Stent placement for longer benign duodenal strictures is usually not performed given risk of potential adverse events. Here, we present a case of a benign duodenal stricture that was successfully managed with a fully covered self-expanding metal stent (SEMS) with endoscopic suturing for stent fixation. Case Description/Methods: A 78-year-old man presented with weight loss and poor oral intake. EGD demonstrated a severely dilated stomach and narrowing at the pylorus which was not able to be traversed despite using multiple endoscopes. Cross-sectional imaging did not show any evidence of malignancy. A repeat EGD was performed and fluoroscopic guided stricture assessment revealed the stricture to be approximately 2 cm in length. Dilation was performed using a through-the-scope (TTS) balloon dilator up to 10 mm Hg. However, the endoscope was unable to traverse the stricture. Biopsies obtained from the stricture showed no evidence of malignancy. An endoscopic ultrasound was also performed which did not show any evidence of a focal mass. Repeat EGD was performed and a TTS fully covered esophageal SEMS (20 mm in diameter, 6 cm in length) was placed with the proximal end of the stent in the antrum and the distal end in the second portion of duodenum. To keep the stent in position, three sutures were placed via the Overstitch device using the mucosa-stent-mucosa technique in the antrum. A follow-up EGD with stent removal was performed in 4 weeks and the endoscope easily traversed the stricture. The patient had no symptoms of gastric outlet obstruction and was gaining weight on 8 weeks follow-up. Discussion: Benign duodenal strictures which are > 1 cm in size, can be challenging to treat endoscopically. Duodenal SEMS are uncovered and are not traditionally used for benign disease given the concerns for tissue ingrowth and making subsequent stent removal challenging. In this case, we used a fully covered esophageal SEMS for treating the duodenal stricture. The potential concerns with covered SEMS include the increased risk of migration and blockage of the major papilla leading to jaundice. Stent-fixation with endoscopic suturing significantly reduces the risk of migration and our patient did not develop any evidence of biliary obstruction by blockage of the major papilla.Figure 1.: A, B) Endoscopic view of duodenal stricture. C) 20 mm x 6 cm self-expanding metal stent is deployed. D) Endoscopic view after the stent was sutured in position.