Use of Axios Stent to Relieve Short Malignancy Stricture

Abstract

Pancreatic cancer is a leading cause of malignant strictures in the upper gastrointestinal tract, caused by a head of the pancreas mass abutting the duodenum. Often, these tumors are not responsive to chemotherapy or radiation leading to supportive care with gastric decompression via endoscopic stenting or operative bypass to relieve obstruction. The lumen-apposing self-expandable metal stent (LASEMS), which is often used to drain pancreatic fluid collections, may serve as a safe and effective option to stent short strictures from pancreatic malignancy. Axios stents, with their short and flared ends, create an anastomotic conduit between two lumens, allowing short strictures to be bypassed. These stents have lumen-apposing and dual anchoring capabilities. The unique design allows for robust pseudocyst drainage and for the passage of an endoscope with a lower risk of stent migration due to anchoring. The ease of deployment and retrieval serves as an advantage over uncovered and partially-covered stents. We present a patient with history of duodenal cancer and recurrent bleeds in which an Axios stent was used to relieve a malignant duodenal stricture. A 57 year old male presented with 4-5 months of decreased oral intake, weight loss, and coffee ground emesis. Endoscopy revealed a near complete, circumferential stricture between the first and second portion of the duodenum, consistent with malignancy (Figure 1). An Axios LASEMS was advanced over a guidewire, across the duodenal stricture (Figure 2). Ampullary exclusion was confirmed endoscopically and patency was confirmed fluoroscopically. An argon plasma coagulation catheter was used to fenestrate the proximal plastic covering of the stent to allow improved mucosal adhesion and was further secured using an over the scope clip (Figure 3).1426_A.tif Figure 1: Near complete, circumferential stricture between the first and second portion of the duodenum1426_B.tif Figure 2: Advancement of a guidewire over the stricture1426_C.tif Figure 3: Axios stent with an over scope clip; argon plasma coagulation catheter was used to fenestrate the proximal plastic covering of the stentSeveral studies have described the use of LASEMS for the management of benign gastrointestinal strictures. The majority of patients who underwent stenting for benign strictures failed prior therapy. Stricture recurrence was seen in those with prior endoscopic balloon dilation or stricturoplasty, and prior placement of covered SEMS had led to migration. In our literature review we were unable to find a case in which Axios stents were used to relieve malignant duodenal strictures. We demonstrated the feasibility and potential safety and efficacy of LASEMS for management of various types of gastrointestinal strictures.