Endoscopic management of stomal stenosis

Vivek Kumbhari, MD from the Department of Medicine and Division of Gastroenterology and Hepatology at the Johns Hopkins Medical Institutions in Baltimore, Maryland, USA shares this VideoGIE case, “Endoscopic management of stomal stenosis after Roux-en-Y gastric bypass.”

A 39-year-old female was referred for management of a stomal stricture 14 years after Roux-en-Y gastric bypass. She had previously undergone 4 sessions of endoscopic balloon dilation without benefit and was eventually commenced on TPN as she was unable to tolerate fluids. At endoscopy, a tight 2mm diameter stricture was confirmed. Using a therapeutic gastroscope, a 15mm lumen opposing metallic stent (Axios, Xlumena, Mountain View, CA, USA) was deployed across the stricture. The patient was discharged home on soft diet. She returned after 3 weeks and underwent stent removal with the stricture having successfully increased in size to 10-12mm.

Figure 1. A lumen-opposing metal stent to treat stomal stenosis after Roux-en-Y gastric bypass. A, Ex vivo image of the stent. B, Endoscopic view of the stent deployed across the stricture.

Gastrojejunal stomal strictures occur in 3-28% of patients as a late adverse event after Roux-en-Y gastric bypass. They are commonly treated by through-the-scope balloon dilations, though this is associated with a perforation rate of 2-5%. Fully covered self-expandable metallic stents carry a risk of stent migration and surgical intervention has a significant morbidity. We demonstrate the novel use of a lumen opposing metallic stent, deployed through a therapeutic gastroscope, to treat gastrojejunal stomal stenosis after Roux-en-Y gastric bypass. Although success was noted in this case, the optimal duration of stent dwell needs to be determined.

As in the case of this patient, the stent appears to cause some element of discomfort due to its compressive forces. Ideally, we would have preferred to keep this stent in for a longer period of time (4-8 weeks). One must remember that the durability of this therapy is unknown and the management of a patient who has re-stenosis is unclear.

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The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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