Use of lumen apposing metal stent for pyloric stenosis refractory to balloon dilatation

Abstract

J Dig Dis. 2019;20:663-664.wileyonlinelibrary.com/journal/cdd 663 placement, the stent was removed using rat-toothed forceps ( Figure 3). The patient is doing well without recurrence of symptoms at 18-month follow-up. Gastric outlet obstruction in adults can result from various causes, including peptic ulcer disease, malignancy and, rarely, CD. In patients with peptic ulcer disease-caused pyloric stenosis, treatment options include acid-suppressive agents, eradication therapy of H. pylori infection if present, the avoidance of non-steroidal anti-inflammatory drugs and endoscopic balloon dilatation, which have been shown to be effective. Many patients with CD that causes gastroduodenal strictures will require multiple endoscopic balloon dilatation, and 40% of them will eventually require surgery, such as pyloromyotomy and GI bypass. With recent advances in endoscopic techniques and tools, stenting of the narrowed segment has become possible. 1 LAMS has traditionally been used for cystogastrostomy for pancreatic cysts. 5 LAMS has a unique barbell shape that takes advantage of the close opposition of the distal luminal wall and the distal stent edge. 5 This barbell shape reduces the chance of LAMS migration, which is a common complication in self-expanding metal stents. It has also been used in various GI stenotic lesions (such as anastomotic stenosis of gastrojejunum, colon, rectum and esophagus) and pyloric stenosis. 5 Our patient with gastroduodenal CD presented with pyloric stenosis refractory to balloon dilatation. Different options, including invasive surgery and advanced endoscopic interventions, were discussed with the patient. She declined the invasive surgical option and wanted to explore the advanced, less invasive endoscopic options. Subsequently, her pylorus was successfully stented with an Axios LAMS. The optimal time for stent removal, and the long-term effects and safety of LAMS, if left in place, are yet to be studied and determined. 6 Endoscopically placed stents have been associated with complications like bleeding, perforation, peritonitis, abdominal pain, pancreatitis, stent migration or dysfunction. 7 Especially in patients with CD the possibility of bleeding, perforation and fistula formation should be kept in mind, although our patient did not have any of these adverse events or any recurrence of stenosis at 18-month follow-up. If pyloric stenosis had recurred it would have been interesting to see if stent placement for a longer duration would be beneficial.A stent such as the Axios stent (traditionally used for a cystogastrostomy of pancreatic cysts) is a viable, less invasive endoscopic option for pyloric stenosis refractory to balloon dilatation.However, long-term data are required in future to compare its efficacy with invasive surgical options.