Novel use of lumen-apposing metal stent for recanalization of complete stenosis of colo-colonic anastomosis

Combined antegrade-retrograde dilation [1] is an established technique that has been adapted for benign colonic obstruction [2] [3] but requires use of accessory devices and predilation followed by deployment of self-expanding metal stents [2] [3]. Rendezvous sigmoidorectal reanastomosis using a lumen-apposing metal stent (LAMS) has also been described with endosonographic (EUS) guidance [4]. We hereby report a recanalization of complete stenosis of a colo-colonic anastomosis without EUS guidance.

An 81-year-old woman with a history of large-bowel obstruction secondary to benign sigmoid diverticular stricture underwent a two-step diverting transverse loop colostomy creation followed by transverse loop colostomy takedown with colo-colonic anastomosis, open sigmoidectomy with colorectal anastomosis, and diverting loop ileostomy creation. Subsequent barium enema and sigmoidoscopy showed a patent colorectal anastomosis but complete stenosis of the colo-colonic anastomosis in the distal transverse colon ([Fig. 1]). Given the distant location of the stenosis from either orifice, we opted for combined antegrade-retrograde forward-viewing colonoscopy for recanalization of the colon lumen.

Fig. 1 Initial findings. a Barium enema with contrast filling terminating at the distal transverse colon. b Schematic diagram demonstrating anatomy of the patient’s colon. Source for [Fig. 1 b]: Lance Powell.

Using fluoroscopy and transillumination, a 15 × 15 mm LAMS (AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) was safely deployed across the stenosis ([Fig. 2 a, b]). Balloon dilation was performed within the saddle of the stent ([Fig. 2 c]).

Fig. 2 Recanalization procedure. a Combined antegrade-retrograde positioning of endoscopes on fluoroscopy. b Lumen-apposing metal stent (LAMS) puncture across the anastomosis. c Dilation of the LAMS post deployment.

The patient was discharged home and a subsequent colonoscopy was performed 2 months later for retrieval of the LAMS and dilation of the remnant anastomosis to 18 mm ([Video 1]). Given patent colo-colonic and colo-rectal anastomosis, the patient underwent loop ileostomy takedown and had complete remission of symptoms with regular bowel movements.

Video 1 Retrieval of the lumen-apposing metal stent and dilation of the colo-colonic anastomosis.

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LAMS allows puncture and release in a single-step procedure, thus enabling deployment of the stent into the target lumen without prior guidewire insertion or preliminary dilation, thereby simplifying the procedure with low enteroanastomosis migration risk [5]. Although EUS guidance is typically utilized, this may be technically challenging or unavailable; however, safe LAMS deployment can be performed using only transillumination and fluoroscopy.

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Publication History

Article published online:
24 February 2023

• References

• 1 van Twisk JJ, Brummer RJ, Manni JJ. Retrograde approach to pharyngo-esophageal obstruction. Gastrointest Endosc 1998; 48: 296-299
• 2 Moyer MT, Mathew A, Chintanaboina J. et al. Restoration of colonic patency of a completely obstructed Crohn’s stricture using the combined antegrade-retrograde dilation procedure. VideoGIE 2017; 2: 359-360
• 3 Ngamruengphong S, Mohapatra S, Runge T. et al. Recanalization of a complete coloanal anastomotic obstruction using a combined antegrade-retrograde rendezvous technique. Endoscopy 2020; 52: E312-E314
• 4 Kozieł S, Kozłowska-Petriczko K, Pawlak K. et al. Endoscopic sigmoidorectal reanastomosis using a dual endoscope technique: rendezvous single-balloon enteroscopy and endoscopic ultrasound. Endoscopy 2021; 53: E257-E258
• 5 Garcia-Alonso FJ, Sanchez-Ocana R, Peñas-Herrero I. et al. Cumulative risks of stent migration and gastrointestinal bleeding in patients with lumen-apposing metal stents. Endoscopy 2018; 50: 386-395