S5291 Here a LAMS, There a LAMS: Management of Refractory Hepaticojejunostomy Anastomotic Stricture With Lumen Apposing Metal Stent (LAMS) Following Recurrent Plastic Stent Migration

Introduction: We present a case of hepaticojejunostomy (HJ) anastomotic stricture after Whipple procedure with management complicated by multiple plastic stent migrations – infrequently a complication in a common management strategy. The stricture was ultimately managed with a lumen apposing metal stent (LAMS) - a potential new strategy for refractory strictures. Case Description: A 59-year-old man with history of a Whipple resection for a neuroendocrine tumor presented with abdominal pain, chills, and elevated LFTs, and was found to have acute cholangitis. Magnetic resonance imaging showed filling defects in the left and right hepatic ducts extending to the HJ. He underwent an endoscopic retrograde cholangiopancreatography (ERCP) with evidence of cholangitis and stenosis of the HJ, which was dilated with a balloon. A 7 Fr × 5 cm plastic stent was placed across the HJ. Due to a short extrahepatic bile duct, a fully covered self-expandable metal stent (FCSEMS) could not be placed as it would have been <1 cm from the bifurcation. Two months later, he returned for stent exchange and 3 × 7 Fr × 5 cm plastic stents were placed. Repeat ERCP showed migration of 1 stent, and due to improvement in HJ stenosis, the remaining stents were removed. Nine days later he returned with cholangitis and underwent ERCP with placement of 2 × 10 Fr × 5 cm plastic stents. Again, another stent migrated. With his next ERCP, he underwent placement of 4 plastic stents. Two of these stents migrated prior to his next ERCP performed 2 months later. With incomplete resolution of stricture complicated by recurrent stent migration, the decision was made to utilize a LAMS for management. A 10 mm × 10 mm LAMS was placed across the HJ and the patient has done well, without recurrent symptoms. Discussion: This case highlights the complexities in management of HJ anastomotic strictures. Post operative strictures occurs in 2.6% of cases, most often presenting with jaundice by 13 months. Typical endoscopic management includes balloon dilation, plastic stent placement, or FCSEMS. Given his persistent stricture, recurrent stent migration, and anatomy that did not allow for FCSEMS placement, alternative strategies were considered and ultimately a LAMS was used with good treatment response to date. There is a paucity of data on its use for this purpose, and it may be an alternative method for refractory anastomotic strictures; further investigation is needed regarding its long-term outcomes.