Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series

Abstract

Background Chronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can lead to significant morbidity. The use of stents has been described but the need for X-ray and risk of migration have meant limited use in the management of these strictures. Lumen apposing metal stents (LAMS) have traditionally been used for management of pancreatic pseudocysts. They don’t require X-ray and are easy to deploy with a short learning curve. This paper explores the use of LAMS to treat post RYGB strictures and explores their safety and efficacy. Methods A prospective study over a 4-year period looking at 14 patients with post RYGB strictures. These patients were privately insured patients operated within a tertiary Private facility. The patients were followed up for between 1 and 3 years. We have prospectively collected data on the efficacy and safety of LAMS in these patients. Patients were followed up until stent removal or definitive surgery to correct a stricture. Results 421 patients underwent RYGB in the study period. 14 (3.3%) of these patients developed a stricture that resulted in insertion of LAMS. There was no immediate complications and 12 patients had complete resolution of their stricture. There were no reoperations due to migration related issues although a migration rate of 19% was noted. 2 patients required surgery to correct refractory strictures not relieved by a LAMS stent, both of these were strictures associated with marginal ulceration of the gastro jejunostomy. Conclusion LAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication. Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn’t appear to be associated with a long learning curve.

Efficacy of lumen-apposing metal stents for the management of benign gastrointestinal stricture: a systematic review and meta-analysis

“…A 15×10-mm LAMS was the most commonly used stent, with median stent dwell time varying from 60-119 days. Our study quality assessment found that 11 were of medium quality [ 14 - 18 , 21 , 22 , 24 , 26 - 28 ] and 7 were of low quality [ 11 - 13 , 19 , 20 , 23 , 25 ] ( ).…”

“…Table 1 shows the baseline characteristics of the included studies. The majority of the studies were from the USA, and only 2 studies were prospective [ 11 , 25 ]. Tables 2 and 3 summarize the clinical characteristics and clinical outcomes of the included studies, respectively.…”

Marginal ulceration after Roux-en-Y gastric bypass - literature review and management algorithm

“…Inflammation and healing of marginal ulceration at the gastrojejunal anastomosis (GJA) lead to granulation and scar tissue formation, culminating in late-onset anastomotic stenosis [23][24][25]69] . Sundaresan et al [69] observed higher stenosis rates with a 25 mm circular stapler compared to linear and robotic hand-sewn methods.…”

“…Inflammation and healing of marginal ulceration at the gastrojejunal anastomosis (GJA) lead to granulation and scar tissue formation, culminating in late-onset anastomotic stenosis [23][24][25]69] . Sundaresan et al [69] observed higher stenosis rates with a 25 mm circular stapler compared to linear and robotic hand-sewn methods. Stricture rates were 4.9%, 0.5%, and 1.2% for circular stapler, linear, and hand-sewn anastomoses, respectively, with circular stapler showing significant differences compared to linear stapler (P < 0.05).…”

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population

“…Endoscopic balloon dilation has been demonstrated to be safe and effective for gastrojejunal strictures post-RYGB [93]. RYGB-associated strictures may also be safely treated with lumen-apposing metal stents (LAMS) [94][95][96]. In a prospective study of 412 patients who underwent RYGB, 14 patients developed a stricture, of which 12 had resolution of their stricture following LAMS insertion [94].…”