Post written by Andrew Canakis, DO, from the Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, USA.
In this video case report, we describe endoscopic management of a long, ulcerated, ischemic jejunal stricture in a patient with an extensive surgical history for weight loss and colon cancer who presented with chronic nausea, vomiting, abdominal pain, and malnutrition on total parenteral nutrition.
Given the patient’s complex surgical history, she was not deemed an ideal operative candidate. The stricture was managed with sequential upsizing using various fully covered self-expanding metal stents (FCSEMSs) secured to a percutaneous endoscopic gastrostomy tube and the jejunal wall to prevent stent migration.
Endoscopic reassessment between stent changes demonstrated gradual improvement in the stricture with villous regeneration. The stent was removed after 13 months.
For 2 years after stent removal, the patient did not require any endoscopic intervention until she started to experience mild symptoms of recurrent nausea and vomiting. A mild, recurrent stricture that was now not ulcerated was managed with through-the-scope balloon dilation alone. Clinically, she was able to tolerate a regular diet and gain weight with resolution in her symptoms over a 6-year follow-up period.
Although no FCSEMSs are available for enteral stenting in the United States, biliary and esophageal stents could be repurposed. Our case shows that refractory strictures that are nonoperative can be successfully managed with repurposing of these FCSEMSs. We found that sequential upsizing allows expansion of a deeply ulcerated stricture while reducing the risk of perforation. We also demonstrate mucosal healing and long-term patency can be achieved over time.
One can safely and effectively use FCSEMSs in this setting by securing the stent to an external device (such as a percutaneous endoscopic gastrostomy tube) to prevent downstream migration, which is risker than a proximal migration into the stomach. Suturing just to the gastric wall may hold for a short period. However, the sutures likely will eventually break, leading to a risk of migration.
Endoscopic view of the initial stricture before (A) and after (B) stent placement.
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