De-novo Gastrointestinal Anastomosis with Lumen Apposing Metal Stent

Salvage endoscopic ultrasound-guided gastrojejunostomy as a bridge to definitive surgical therapy for duodenal adenocarcinoma presenting with duodenal stent obstruction

The utilization of endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) in the setting of an obstructed (ingrown) duodenal stent as a bridge to pancreaticoduodenectomy (PD) remains undescribed. Herein, we report a case study of a 51-year-old patient who underwent EUS-GJ using lumen apposing metal stent (LAMS) for an obstructed duodenal stent during neoadjuvant treatment for duodenal adenocarcinoma. The patient ultimately underwent surgical resection by a classic PD 14 weeks after LAMS placement. EUS-GJ using LAMS represents a potential option as a salvage bridge to surgery for duodenal obstruction in the setting of an obstructed duodenal stent.

Short benign ileocolonic anastomotic strictures - management with bi-flanged metal stents: Six case reports and review of literature

BACKGROUND

The endoscopic management of benign short post-anastomotic ileocolonic stricture (PAICS) that is refractory to primary and secondary treatment modalities remains challenging. The lumen-apposing metal stent (LAMS) is a novel device recently developed for therapeutic gastrointestinal endoscopy. LAMSs have demonstrated significantly better results with regard to stent migration than fully covered self-expandable metal stents (FCSEMSs).

CASE SUMMARY

This article presents six cases of symptomatic PAICS successfully treated with a LAMS and a review of the relevant literature. We report a life-saving technique not previously documented and the use of technology to improve patient outcomes. The six patients (median age, 75 years) suffered from vomiting, constipation and recurrent abdominal pain, with symptoms starting 23-25 wk post-surgery. The median stricture length was 1.83 cm. All six patients underwent successful and uneventful bi-flanged metal stent (BFMS)-LAMS placement for benign PAICS. All patients remained asymptomatic during the three months of stent indwelling and up to a median of 7 mo after stent removal. According to the literature, the application of LAMS for PAICS is associated with a < 10% risk of migration and a < 5% risk of bleeding. Conversely, FCSEMS has a high migration rate (15%-50%).

CONCLUSION

The evolving role of interventional endoscopy and the availability of LAMSs provide patients with minimally invasive treatment options, allowing them to avoid more invasive surgical interventions. The BFMS (NAGI stent) is longer and larger than the prototype AXIOS-LAMS, which should be considered in the management of short ileocolonic post-anastomotic strictures longer than 10 mm and shorter than 30 mm.

Long-term placement of lumen-apposing metal stent after endoscopic ultrasound-guided duodeno- and jejunojejunal anastomosis for direct access to excluded jejunal limb

BACKGROUND

 Management of biliary disorders in patients with altered anatomy may be challenging. Endoscopic ultrasound (EUS)-guided gastrointestinal anastomosis using a lumen-apposing metal stent (LAMS) was introduced to allow endoscopic retrograde cholangiography (ERC) in such cases. However, the appropriate stent indwelling time remains uncertain. We report long-term LAMS deployment after duodenojejunal or jejunojejunal anastomosis (EUS-DJA) to allow endoscopic reinterventions in cases of recurrences.

METHODS

 11 consecutive patients underwent EUS-DJA with long-standing LAMS between January 2017 and December 2018. Over a 12-month period, ERC treatment was carried out with multiple endoscopic sessions across the DJA.

RESULTS

 Technical success was 91 % (10/11) for EUS-DJA and 100 % for ERC. Four patients presented stricture recurrence at a mean of 489 days (standard deviation [SD] 31.7) after the end of ERC treatment. A novel ERC across the LAMS anastomosis was feasible in all cases. At a mean of 781 days (SD 253.1), all LAMS remained in place with no evidence of complications.

CONCLUSION

 Long-term LAMS placement after EUS-DJA may be feasible and safe for direct access to the excluded limb.

Fluoroscopy-Guided Gastrojejunostomy Creation with Lumen-Apposing Metal Stent in a Porcine Model

PURPOSE

To evaluate the technical feasibility of fluoroscopy-guided gastrojejunostomy creation in a porcine model.

METHODS

Eight domestic female pigs (median, 15.6 kg; range, 14.5-16.3 kg) were included in this study. The proximal jejunum was punctured from the stomach using a Rösch-Uchida Transjugular Liver Access Set through the mouth, and a lumen-apposing metal stent was placed across the puncture tract between the stomach and the proximal jejunum. All animals were euthanized 6 weeks after the procedure.

RESULTS

The fistulous tract creation and stent insertion with confirmed patency were successful in eight animals, rendering a technical success rate of 100%. Gross inspection showed a matured and patent fistulous tract between the stomach and the proximal jejunum in seven animals. In one animal, the colon between the stomach and the proximal jejunum was inadvertently punctured followed by migration of the stent from the stomach into the colon after the procedure to form a delayed jejunocolostomy. A stent migration and an inadvertent traversing the tail of pancreas by the stent were observed in another two animals without signs of bleeding, infection, or pancreatitis. All animals survived until the end of this study without change in their behavior or appetite. Histological analysis showed that all the fistulous tracts had matured with continuity of submucosal, muscular, and serosal layers, and without destruction of epithelial layers.

CONCLUSIONS

Fluoroscopy-guided gastrojejunostomy creation is technically feasible in a porcine model but requires refinement of the targeting technique to avoid transgression of nontarget organs.

Lumen-Apposing Metal Stent Used to Treat Malignant Esophageal Stricture

Malignant esophageal strictures often require stent placement to alleviate dysphagia and improve quality of life. We present a novel application of a lumen-apposing metal stent to bypass a malignant esophageal stricture in the setting of altered gastric anatomy.