First treatment of Crohn’s disease refractory anastomotic stricture with a lumen-apposing metallic stent suitable for colonoscopy

A 58-year-old patient with Crohn’s disease and prior ileocecal resection, experienced repeated bouts of bowel occlusion related to a short and fibrotic anastomotic stricture despite several endoscopic dilations. To avoid further surgery, endoscopic stenting was chosen to relieve symptoms and prevent relapses.

Colonoscopy was performed under general anesthesia ([Video 1]). The stricture was located 80 cm from the anal margin and could not be passed by the colonoscope ([Fig. 1]). Stricture diameter and length were 0.5 cm and 1 cm, respectively, when measured using contrast injection and traction with an extraction balloon under X-ray control ([Fig. 2]). A guidewire and fully covered lumen-apposing metallic stent (LAMS; Niti-S-SPAXUS; Taewoong Medical, Gyeonggi-do, South Korea) were inserted through the stricture ([Fig. 3], [Fig. 4]). The delivery system allowed deployment of the distal flange in the ileum and the proximal flange in the colon ([Fig. 5]). No immediate complications occurred. The patient experienced immediate relief and remained symptom free after 4 months of follow-up.

Video 1 Stenting of an anastomotic Crohn’s stricture.

Fig. 1 Ileocolonic anastomotic stricture.

Fig. 2 Balloon probe set beyond the stricture confirming the short nature of the stricture.

Fig. 3 SPAXUS stent (Taewoong Medical, Gyeonggi-do, South Korea) set in the ileocolic anastomotic stricture. The whitening of the mucosa reflects the dilation of the stricture by the prosthesis.

Fig. 4 A week after the procedure, a computed tomography scan was performed to investigate rectal bleeding (which happened to be proctologic) and confirmed the correct position of the SPAXUS stent.

Fig. 5 Half-opened SPAXUS stent (Taewoong Medical, Gyeonggi-do, South Korea).

Endoscopic stents are commonly used to treat benign strictures, especially in the esophagus. However, endoscopic stenting in Crohn’s strictures has often been disappointing due to high rates of migration [1] [2]. The design of LAMS reduces the risk of migration while allowing removal when necessary. Despite promising early results showing the efficacy of LAMS in Crohn’s strictures [3] [4] [5], widespread use has not followed, partly because the short delivery catheter of the currently used model (AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) is only compatible with gastroscopes.

The Niti-S-SPAXUS stent has a 180-cm delivery system that is compatible with colonoscopes, making it particularly suitable for benign refractory strictures remotely located in the colon, such as anastomotic Crohn’s strictures.

To our knowledge, this is the first use of this stent in this indication. Being able to use LAMS during colonic examination might ease and increase the use of this effective treatment.

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• References

• 1 Attar A, Branche J, Coron E. et al. An anti-migration self-expandable and removable metal stent for Crohn’s disease strictures: a nationwide study from the GETAID and the SFED. J Crohns Colitis 2021; 15: 521-528
• 2 Shen B, Kochhar G, Navaneethan U. et al. Practical guidelines on endoscopic treatment for Crohn’s disease strictures: a consensus statement from the Global Interventional Inflammatory Bowel Disease Group. Lancet Gastroenterol Hepatol 2020; 5: 393-405
• 3 Jain D, Patel U, Ali S. et al. Efficacy and safety of lumen-apposing metal stent for benign gastrointestinal stricture. Ann Gastroenterol 2018; 31: 425-438
• 4 Majumder S, Buttar N, Gostout C. et al. Lumen-apposing covered self-expanding metal stent for management of benign gastrointestinal strictures. Endosc Int Open 2015; 04: 96-101
• 5 Axelrad J, Lichtiger S, Sethi A. et al. Treatment of Crohn’s disease anastomotic stricture with a lumen-apposing metal stent. Clin Gastroenterol Hepatol 2018; 16: 25-26