Our Case Involves a 54-Year-Old Male with a Remote History of Ileocolonic Resection, Which

Our case involves a 54-year-old male with a remote history of ileocolonic resection, which was complicated by an anastomotic stricture. The patient had multiple hospitalizations secondary to recurrent small bowel obstruction at the level of his anastomotic stricture, and was therefore referred to our clinic for evaluation and further management of his disease.

The patient has a medical history of multiple chronic medical problems including hypertension and previously uncontrolled HIV complicated by MAC and CMV, requiring an ileocolonic resection in 2009 due to stricture formation, with removal of 3 cm of ileum and the ileocecal valve.

The patient was asymptomatic for several years after his operation; however, in 2016 he developed s episodes of partial small-bowel obstruction over 3 months, which manifested by nausea, vomiting, abdominal pain, and dehydration. Radiographic imaging was consistent with a distal obstruction in the region of the prior enterocolic anastomosis. For both episodes he was hospitalized and treated conservatively with intravenous fluids and bowel rest with a slow progression of his diet. He was discharged home after each admission in a stable condition without any surgical or endoscopic interventions performed.

Upon evaluation in the clinic, the patient appeared clinically well and was tolerating a low residue diet. He admitted to being compliant with his HAART therapy for many years and had a CD4 count of greater than 1000. He did complain, however, of loose stools and intermittent abdominal bloating discomfort, which was reminiscent of his prior partial small-bowel obstructions.

Based on his history, there was concern for a possible anastomotic stricture at his previous ileocolonic resection. Therefore, the patient was set up for a colonoscopy and upper GI series (UGIS) with small-bowel follow-through for evaluation.

The colonoscopy demonstrated a benign anastomotic stricture with a luminal narrowing to an inner diameter of 2 to 3 mm, which was not amenable to further passage of the colonoscope. Biopsy of this anastomotic stricture showed no malignant tissue. The UGIS with small-bowel follow-through demonstrated a persistently dilated loop of the distal ileum proximal to the anastomosis, with a suspected partial small-bowel obstruction.

After these studies, therapeutic options were discussed with the patient, including both surgical and endoscopic. The decision was made to place a fully covered lumen-apposing metal stent via colonoscopy across the anastomotic stricture.

A therapeutic upper endoscope was inserted into the rectum and advanced through the colon to the ileocolonic anastomosis. An anastomotic stricture with luminal narrowing to 2 to 3 mm was again visualized. Under direct fluoroscopic guidance, a long 0.035-inch guidewire was inserted across the anastomosis and coiled into the small bowel. Contrast injection with a 9- to 12-mm balloon catheter confirmed wire position in a dilated segment of small bowel. Subsequently a 21 mm flange, 10 mm diameter, 10 mm length fully covered lumen apposing self-expanding metal AXIOS stent was deployed over the wire across the strictured area. The proximal flange was deployed into the small bowel and during deployment of the distal flange, the catheter delivery system of the stent migrated proximally and the entire stent was deployed in the small bowel.

Using rat tooth forceps, we grasped the distal flange of the stent, and the entire stent was withdrawn until the distal flange was in the correct position across the anastomosis. After deployment, copious liquid and solid stool was seen flowing through the stent. Final fluoroscopic imaging showed a fully deployed lumen-apposing metal stent across the anastomotic stricture.

The patient was seen 1 month later for an outpatient follow-up. He had done well after his procedure. He was tolerating a low-residue diet with no evidence of obstruction. Bowel movements were regular, and he did note that his stools were becoming more formed.

A KUB 1 month after the procedure confirmed good position of the AXIOS stent with no evidence of any bowel distention or obstruction.

A repeat colonoscopy for stent removal was performed approximately 6 weeks after stent placement. The AXIOS stent was visualized in good position across the ileocolonic anastomosis. Removal of the stent was achieved with rat tooth forceps with complete retrieval and extraction of the stent through the rectum with the colonoscope. The colonoscope was then re-inserted with passage of the scope to the ileocolonic anastomosis. There was minimal oozing of blood at the site of stent extraction, but the anastomosis was now patent with an inner luminal diameter of at least 1 cm. The scope was easily able to pass through the anastomosis into the small bowel. There was no evidence of perforation.

At 10 months of follow-up, the patient has remained asymptomatic with no further evidence of obstruction. His bowel movements have been regular and he has continued to tolerate diet, with no nausea, vomiting, or bloating, stating that he has actually been gaining weight.

In conclusion, our case demonstrates the efficacy and safety of lumen-apposing stent placement for management of short benign strictures of the gastrointestinal tract. This strategy provides a minimally invasive solution with the potential to delay or ultimately prevent the necessity for recurrent endoscopic dilations or surgical intervention. One caveat to deploying lumen apposing metal stents through a therapeutic endoscope, as opposed to a linear echoendoscope, is that the catheter delivery system is longer that the shaft of the therapeutic endoscope. During deployment of the stent, the endoscopist should deliver counter-traction on both the scope and the catheter delivery system to prevent forward migration of the stent during deployment.

Deployment of a lumen-apposing metal stent through a double channel therapeutic endoscope requires some technical precision. The lumen-apposing metal stent catheter delivery system fits through the larger instrument channel of a therapeutic endoscope. When the catheter tip exits the tip of the endoscope and the lumen-apposing metal stent is in position for deployment, you can see that the actual back end of the catheter delivery system is not secured to the therapeutic endoscope because it is too long. It is designed to lock into a linear echoendoscope based on its length. Because of the lack of securement of the lumen-apposing metal stent device it may be prone to forward migration during deployment.

Therefore, it is important during deployment to not only hold traction on the endoscope, but also on the catheter delivery system itself. This is best achieved by the endoscopist, who can precisely control the position of deployment. The actual deployment of the device should be done by an assistant directed by supervision of the endoscopist. The deployment of the first flange is less crucial, as proximal migration can be adjusted by pulling back on the catheter or endoscope. The most crucial step in deployment is during deployment of the distal flange, with concurrent countertraction on the endoscope and catheter delivery system applied by the endoscopist. This assures that the lumen-apposing metal stent is deployed across the lesion of interest and does not migrate proximally during deployment.