Prianka Gajula, MD
Houston, TX
Prianka Gajula, MD1, Sunil Dacha, MD2
1Houston Methodist Hospital, Houston, TX; 2Houston Methodist Hospital / Underwood Center for Digestive Disorders, Houston, TX
Video Link: View Video
Introduction: Lumen-apposing metal stent is being increasingly used for transmural drainage of pancreatic fluid collections (PFC). More recently, certain off label uses for LAMS are being explored1 such as benign gastrointestinal strictures, gastrojejunostomy, and gastro-gastrostomy. Here we present a case of LAMS-assisted ERCP for stenosis in a patient with silastic ring vertical banded gastroplasty.
Case Description/Methods: An 82yo F with h/o breast cancer and diabetes mellitus type 2 was referred for EUS guided biopsy of a pancreatic head mass identified on CT scan of the abdomen, performed during evaluation of abdominal pain. The patient had normal liver enzymes. An EUS was planned for biopsy of pancreatic mass. At the time of the procedure, a benign-appearing, severe, intrinsic stenosis was found in the gastric body. An echoendoscope could not be advanced across this mid-gastric body stenosis, despite balloon dilation to 15mm. No significant mucosal disruption was seen. It was suspected that the stenosis was due to adhesions related to the silastic ring. A 15 mm x 10 mm LAMS was deployed across the stenosis to facilitate EUS. LAMS was dilated to 15 mm with balloon dilation under fluoroscopic guidance. An EUS scope could not be advanced despite dilation of LAMS to 15 mm. A duodenoscope could not be advanced, either. The plan was made to repeat EUS in 48 hrs. However, the patient developed obstructive jaundice, and an ERCP was planned instead. LAMS was removed prior to ERCP due to mild resistance to passage of the scope. This was done to prevent stent dislodgement. Following LAMS removal, a duodenoscope could be advanced across the stenosis with minimal resistance. An ERCP was successfully performed, which revealed a tight distal biliary stricture. Brush cytology was performed using a large caliber brush. A biliary stent was placed. Her immediate post-ERCP course was uncomplicated. She had normalization of her liver function tests. Final cytology results revealed pancreatic adenocarcinoma.
Discussion: ERCP is a challenging procedure in patients with previous bariatric surgery due to anatomical variations. LAMS have a high success rate for the drainage of PFCs. Many new off-label indications are being identified for LAMS, and the early results are promising1. We present an off-label use for LAMS placement, for facilitating ERCP in patients with stenosis related to silastic ring vertical banded gastroplasty.
Citation: Prianka Gajula, MD; Sunil Dacha, MD. P1159 - LUMEN-APPOSING METAL STENT ASSISTED ERCP IN STENOSIS ASSOCIATED WITH SILASTIC RING IN VERTICAL BANDED GASTROPLASTY. Program No. P1159. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.