Montefiore Medical Center Bronx, NY, United States
Gaurav Bhardwaj, MD, Tehseen Haider, MD, Hilary I. Hertan, MD, FACG Montefiore Medical Center, Bronx, NY
Introduction: A Billroth I procedure is a type of reconstruction after a partial gastrectomy in which the stomach is anastomosed to the duodenum. One of the late complications of this procedure is gastroduodenal (GD) anastomotic stricture and is seen in 2-4% of the patients.
Case Description/Methods: 88 year old man, lifelong smoker with history of gastric cancer s/p Billroth I in 2000, anemia presented with anorexia and failure to thrive. Patient further reported 50 lb weight loss over last few months but denied dysphagia, vomiting and abdominal pain. Exam showed a severely cachectic man with a BMI of 7.6 kg/m2. Labs were remarkable for hb of 7.8 g/dL. CT chest showed significant residual food in the stomach concerning for a partial obstruction. Esophagogastroduodenoscopy (EGD) revealed Billroth I anatomy with severe stenosis at the anastomotic site and a large food bezoar in the gastric body. A regular scope could not traverse through the stricture, so a sphincterotome was used to insert a guidewire using fluoroscopy to confirm luminal placement. A through the scope (TTS) CRE 6 mm balloon dilator was passed, and after dilation, the site was traversed up to the duodenum successfully using a neonatal scope. A 15 mm x 15 mm LAMS was deployed under fluoroscopic guidance and endoscopic direct visualization. The patient did not develop any immediate stent related adverse events. He was able to tolerate diet and was scheduled for outpatient follow up.
Discussion: The underlying etiology of GD stricture formation is complex and associated with factors such as excessive tension at the site, method of sewing or stapling, ischemia, gastric hypersecretion, NSAID use and smoking. Patient may present with symptoms of nausea, vomiting, early satiety, epigastric abdominal pain, with progression to intolerance of food intake. A stricture is typically diagnosed by upper GI series and if found, EGD evaluation is warranted to rule out recurrent cancer. Such strictures can be treated with dilation, incisional therapy, steroid injection and stents. Some of the features which favor LAMS over other stents are their anti-migratory flanges, short saddle and moderate radial force that decreases the risk of migration and allowing for a longer duration of therapy. However, we must consider that the method chosen for an individual should be based on the nature of the stricture, course of disease and complications. Moreover, future randomized controlled trials are warranted to compare the safety, efficacy and cost effectiveness of LAMS.
Figure: A. Large food residual in gastric body, B. Stricture at gastroduodenostomy site, C. CRE balloon dilatation to 6 mm, D. Neonatal scope traversed to the duodenum, E.LAMS sent deployed with proximal and distal phalanges, F. Proximal phalange of LAMS in gastric body
Gaurav Bhardwaj indicated no relevant financial relationships.
Tehseen Haider indicated no relevant financial relationships.
Hilary Hertan indicated no relevant financial relationships.
Gaurav Bhardwaj, MD, Tehseen Haider, MD, Hilary I. Hertan, MD, FACG. P2764 - Luminal Apposing Metal Sent (LAMS) Therapy for Anastomotic Stricture of Billroth I Gastroduodenostomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.