Self-expandable Lumen-Apposing Metal Stent Placement in a Refractory Post-Roux-en-Y Anastomotic Stenosis With Prior Perforation

Abstract

A 39 year-old male patient with a past surgical history notable for cholecystectomy and Roux-en-Y gastric bypass presented 1 year post operatively with vomiting and abdominal pain. An initial EGD revealed an anastomotic gastro-jejunostomy stricture with multiple network of sutures at the anastomosis causing obstruction that were removed. The stricture was dilated using a CRE balloon up to 12 mm. The patient's symptoms did not improve and he subsequently underwent monthly EGDs with serial balloon dilation. Despite multiple dilations and the use of local triamcinolone injections, the stricture recurred and the symptoms prevailed. His course was complicated by a perforation at the gastrojejunal anastomosis after the last dilation requiring surgical repair. Over the following year, the patient required another dilation. On the follow-up endoscopy done by the advanced endoscopist, a very tight stricture at the G-J site was noted without extrinsic compression. Given the history of perforation, we opted for a less aggressive approach to avoid perforation recurrence. The decision was to place a fully covered metal lumen apposing stent to achieve dilation induced by the stent and protect the fibrotic tissue from perforation. A 0.035 guidewire was passed into the jejunum through a scope and dilation using a CRE balloon was done. Sequential dilatations from 8 to 11mm were performed. A catheter was then placed in the channel of an adult gastroscope and a guidewire was fed into the catheter inside the therapeutic gastroscope. A 15 x 10 mm fully covered metallic stent was placed over the guidewire and the deployment was done while ensuring that the distal end was in the efferent limb. We present an “off label” use of a fully covered lumen apposing stent in a case of postoperative anastomotic strictures resistant to conventional treatment with balloon dilations complicated by subsequent perforation. On top of their indicated use for pancreatic pseudocysts, Lumen Apposing Metal Stents (LAMS) are a viable, safe and technically feasible option for managing recurrent anastomotic benign stricture after a repaired perforation. Watch the video: https://goo.gl/uQ3cby