S5198 A Novel Case of Utilizing Overlapping Lumen-Apposing Metal Stents for Treatment of Complicated Marginal Ulcers at the Gastrojejunal Anastomosis

Introduction: Marginal ulcers (MUs), a known complication following Roux-en-Y gastric bypass (RYGB), affect approximately 0.6% to 16% of patients and can lead to significant morbidity, including perforation. Standard treatment for perforated MUs includes medical therapy, surgery, and increasingly advanced endoscopic techniques. We present a novel endoscopic approach using overlapping fully covered lumen-apposing metal stents (LAMS) for a contained perforated MU. Case Description: A 57-year-old woman with a history of RYGB in 2014, chronic marginal ulcers, and multiple comorbidities presented with 4 days of worsening left-sided abdominal pain, nausea, and anorexia. Computed tomography of the abdomen/pelvis showed mucosal hyperenhancement at the gastric bypass site, hepatic steatosis, and sigmoid diverticulosis, without pneumoperitoneum. Given escalating pain, esophagogastroduodenoscopy (EGD) was performed, revealing 3 large marginal ulcers at the gastrojejunal anastomosis: 2 on the jejunal side (largest ∼5 cm, >75% circumferential, with a full-thickness component and abscess cavity suggesting contained perforation), and one 2 cm ulcer on the gastric side. A guidewire was advanced into the perforation under fluoroscopy, confirming the abscess cavity. A fully covered 20 × 10 mm LAMS was deployed across the ulcer. Given the extensive ulceration and risk of peritonitis, a second identical stent was placed with overlap, and a stent fixation device was applied at the proximal end of the distal stent to ensure stability. Post-deployment contrast confirmed no leakage. The patient’s symptoms improved significantly. A diatrizoate meglumine and diatrizoate sodium solution USP upper GI series 24 hours later showed no extravasation, and she was discharged on a liquid diet with instructions for non-steroidal anti-inflammatory drug avoidance and gradual diet advancement. At 2-month follow-up, endoscopy showed healing mucosa, and the stents were removed without complication. Discussion: This case demonstrates an innovative endoscopic approach using overlapping LAMS with fixation for extensive marginal ulceration with contained perforation post-RYGB. This technique allowed for broader ulcer coverage, effective sealing of the perforation, and avoided surgical intervention. It highlights the expanding role of therapeutic endoscopy in managing complex gastrointestinal complications and warrants further investigation to assess long-term outcomes and efficacy.