2195 Expanding Therapeutic Options for Ileocecal Valve and Rectal Strictures with Lumen-Apposing Fully Covered Metal Stents

INTRODUCTION: Radiation-induced and Crohn’s-related colonic strictures are debilitating conditions requiring intensive serial endoscopic dilations or surgery. Use of colonic stents in benign strictures are limited by migration risk, lack of removability, and technical difficulties in placement. This is especially true of ileocecal valve (ICV) strictures given the anatomically challenging location and short stents are preferred. We report the cases of an ICV and distal rectal stricture, refractory to endoscopic dilation, that underwent successful lumen apposing fully covered metal stent (LAMS) placement. CASE DESCRIPTION/METHODS: A 32-year-old African American male with a history of Crohn’s disease complicated by ICV stenosis causing recurrent partial small bowel obstruction, was admitted with worsening nausea, vomiting, and abdominal pain. An abdominal CT showed dilated distal ileum to 4 cm with associated fecalization consistent with partial small bowel obstruction. A colonoscopy with balloon occlusion enterography confirmed a short <1 cm severe ICV stricture with non-inflamed colonic mucosa. He opted for an endoscopic dilation to 10 mm with good clinical response but this only lasted for 2 weeks. A stent placement was then performed using a 15 mm × 10 mm LAMS (Figure 1). His abdominal pain markedly improved with radiologic resolution of the small bowel obstruction. A 55-year-old African American female with a history of pelvic radiation for cervical cancer presented with tenesmus and alternating constipation and diarrhea. Barium enema and flexible sigmoidoscopy showed a focal rectal stricture at 10 cm proximal to the anal verge. She underwent serial endoscopic dilations up to 12-mm over a span of 6 months with no significant clinical response and the stricture kept recurring despite 2-3 week intervals between dilations. Ultimately, a 15 mm × 10 mm LAMS was placed (Figure 2). At 8-weeks, her tenesmus and post-constipation diarrhea were completely resolved. DISCUSSION: Our cases demonstrate the feasibility and efficacy of LAMS placement for refractory high-grade strictures even at anatomically challenging locations. LAMS was preferred here due to its removability and short length that could optimally fit in the ICV and distal rectum with an aim to minimize risk of stent migration due to its dumbbell configuration. However, the stricture site has to be reachable by a therapeutic gastroscope. Optimal duration for stent indwelling and risk of restenosis after stent removal remain unclear and warrant further study.