Rescue lumen-apposing metal stent to treat a perforation secondary to balloon dilation of a Crohn’s disease stenosis

A 61-year-old woman was followed for ileocolic Crohnʼs disease (CD) with multi-complicated colonic and ano-perineal involvement, evolving over 17 years, with a subtotal colectomy protected by an upstream lateral ileostomy. Optimized adalimumab allowed control of the disease with healing of fistulas.

However, a scarring colonic stenosis ([Fig. 1]) persisted 30 cm from the anal margin; it could not be crossed by an endoscope and prevented restoration of continuity. Hydrostatic endoscopic dilatation ([Fig. 2], [Video 1]) up to 15 mm was performed after multidisciplinary discussion. After dilation, visualization of pericolic fat confirmed digestive perforation ([Fig. 3]). The proximity between the perforation and the ileocolic anastomosis did not allow the option of a covered metallic stent. A 15-mm lumen apposing metal stent (LAMS) was used ([Fig. 4]). The colonoscope was removed and a therapeutic gastroscope was substituted because of the excessive length of the working channel of the colonoscope (140 cm). Release of the two flanges was performed under endoscopic guidance, and good positioning was confirmed by opacification without any leakage.

Fig. 1 Colonic stenosis located 30 cm from the anal margin.

Fig. 2 Hydrostatic dilatation was performed up to 15 mm.

Video 1 Rescue lumen-apposing metal stent to treat a perforation secondary to balloon dilation of a Crohn’s disease stenosis.

Fig. 3 Visualization of pericolic fat confirmed perforation.

Fig. 4 Positioning of a 15-mm lumen-apposing metal stent.

The post-procedure care was easy, with only 5 days of oral antibiotics and return home on the first day. The LAMS was removed 1 month later with perfect healing of both the perforation and the stenosis ( [Fig.5]). The patient presents stool by the anus for the first time in 4 years, and removal of the ileostomy is being discussed. In cases of perforation during dilation of short fibrous stenosis, off-label use of LAMS through a therapeutic gastroscope seems to be a promising rescue solution.

Fig. 5 Good healing was confirmed 1 month later.

Endoscopy_UCTN_Code_CPL_1AJ_2AF

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Artikel online veröffentlicht:
12. Mai 2021