Introduction: Distant small bowel strictures are most common in Crohn’s disease, NSAID enteropathy, malignancy, and the post-surgical setting. Whilst surgery remains a mainstay of therapy, pneumatic dilation of selected stenoses via double balloon enteroscopy (DBE) has demonstrated efficacy despite notable risk for perforation. We report a maneuver that allowed for short-segment stenting of a refractory anastomotic stricture in the ileum, adding to the growing arsenal of enteroscopy-based interventions.

Case: 50-year-old female s/p multiple abdominal surgeries was referred for evaluation of small bowel obstruction (SBO). Ten years prior, she underwent an ileal resection to treat sequelae of ischemic enteritis due to SMV thrombosis. A side-to-side enteroenterostomy was created. Whilst she did well for years thereafter, she began to develop recurrent SBOs at the level of the anastomosis, forcing several admissions. Surgical resection was deferred given extensive operative history and response to conservative management. Retrograde DBE expectedly revealed a severe anastomotic stricture (< 1 cm length) in the mid-ileum that was not traversed (Fig 1A). Dilation to 12 mm was performed, after which she did well for one month until obstructive symptoms recurred. Repeat DBE demonstrated regression of anastomotic patency to pre-dilation level, at which point lumen apposing metal stent (LAMS) placement was postulated. In considering a particular salvage technique used previously in cases of LAMS migration during pancreatic necrosectomy, a similar idea was employed to overcome the 60 cm length discrepancy between delivery system and enteroscope channel. A 15 mm x 10 mm LAMS (AXIOS; BOSTON SCI) was deployed into nearby sterile water. The prosthesis, suspected to be both durable and malleable, was twisted by rotating its ends in opposite directions and subsequently backloaded into the distal portion of the 3.2 mm diameter working channel of a double balloon-enteroscope (EN-580T; FUJIFILM) (Fig 1B). This allowed for freehand deployment of the stent across the stricture using biopsy forceps (Fig 1C) under fluoroscopy. No complications were observed, as mild suction impairment and stricture orientation were procedural limitations. Three months later, DBE for LAMS removal demonstrated complete resolution of the anastomotic stricture (Fig 2). The patient has had no further episodes of SBO since.

Discussion: Endoscopic intervention deep within the small bowel remains challenging given limited options for its performance and higher risk of complication. This case demonstrates an off-label manner for LAMS compatibility with an enteroscope and further supports the benefit of such prostheses in selected stricture management. More importantly, cautious reproducibility of this technique may significantly augment advanced endoscopic practice within the distant GI tract.

Rawad Mounzer

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