Use of a Lumen-Apposing Metal Stent in the Management of a High-Grade Ileocolic Anastomotic Stricture

Abstract

Introduction:

Lumen-apposing metal stents (LAMS) were initially developed for the endoscopic management of pancreatic fluid collections; however, numerous off-label uses have been utilized, including management of anastomotic strictures (1 –4). Limited data exist for its efficacy in lower gastrointestinal strictures, and its utility is limited by the ability of the gastroscope to reach the area of stricture. Small retrospective studies and case reports have shown clinical success rates upward of 85% in managing colonic anastomotic strictures (5). In this video case report, we describe our technique for the use of a LAMS for the management of a high-grade ileocolic anastomotic stricture.

Materials and Methods:

We present a case of a 31-year-old female with cervical cancer previously treated with chemotherapy and radiation with external beam radiation and brachytherapy. This was complicated by radiation enteritis and colitis requiring a sigmoid colectomy with diverting loop ileostomy. This was eventually reversed with the creation of an end-to-side ileocolic anastomosis. However, she developed an adhesive small bowel obstruction requiring an exploratory laparotomy with abdominoperineal resection and end-colostomy creation and eventual development of a stricture at the site of her ileocolic anastomosis. Given her high-grade stricture, chronic malnutrition, and potential need for proximal diverting ostomy, the decision was made to place a temporizing stent. A gastroscope was advanced through her colostomy site and advanced to the area of the ileocolic anastomotic stricture. A guidewire was advanced under fluoroscopic guidance, and a 10 × 15 mm LAMS was advanced over the wire and deployed. Positioning was then confirmed using fluoroscopy, and the lumen appeared widely patent on visual inspection. She was then taken for elective stent upsizing 2 months following placement. A new 20 × 10 mm LAMS was deployed across the anastomosis and was able to be endoscopically removed 1 month later.

Results:

The patient underwent revisional surgery with an ileocolectomy and creation of a side-to-side isoperistaltic anastomosis (4 months after initial stent placement, 1 month post-removal). Although she ultimately required revisional surgery, the stent allowed for the delay of surgery until more nutritionally optimized with the ability to tolerate oral intake. She has since had resolution of her obstructive symptoms and has been progressing appropriately from a surgical standpoint.

Conclusions:

The management of proximal colonic strictures remains clinically challenging. The use of LAMS is an option in patients with shortened colonic anatomy due to prior colorectal operations and represents an efficacious option for both temporization and definitive therapy.

Runtime of video:

6 mins 19 secs.

Disclosure Statement:

None of the authors have any competing financial interests.

E.M.P. is a speaker for Becton-Dickinson and Medtronic and is a consultant for Scientific Corp., Actuated Biomedical, Inc., Cook Biotech, Neptune Medical, Surgimatix, Noah Medical, Allergan, Intuitive Surgical, ERBE, Integra, Steris, Vicarious Surgical, and Telabio. He has royalties in Up To Date, Inc. and Springer and financial interests in IHC, Inc., Cranial Devices Inc, Actuated Medical.

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

No funding was received for this study.

Presented at 2024 Society of American Gastrointestinal and Endoscopic Surgery Annual Meeting as a Video Reel.