S5349 Successful Treatment of a Benign Colocolonic Anastomotic Stricture With Freehand Creation of Luminal Patency Using Direct Needle Puncture Technique and Placement of Cautery-Enhanced Lumen Apposing Metal Stent (LAMS)

Introduction: Treatment of colonic anastomotic strictures with LAMS has been described, but is dependent on the ability to pass at least a guidewire across the obstruction. We describe a patient with a benign occlusive colocolonic anastomotic stricture across which there was no contrast or wire passage, where we were able to create a freehand anastomosis across the lumen using a direct needle-puncture and cautery-enhanced lumen-apposing metal stent (LAMS). Case Description: A 33-year-old man with a history of diverticular disease treated with left hemicolectomy and temporary diverting ileostomy presented for endoscopic management of a colocolonic (transverse to sigmoid colon) anastomotic stricture that had recurred despite prior endoscopic therapy and surgical revision. He presented to the operating room for a colonoscopy where a colonoscope was passed through the ileostomy and advanced to the stricture, which was 15 mm (length) and 2 mm (diameter). An endoscope was passed through the rectum by an assisting surgeon. Many guidewires varying in diameter, stiffness and angulation, and contrast did not pass through the tortuous, occluded stricture. A successful direct needle-puncture was done using a 19-gauge endoscopic ultrasound-fine needle aspiration under endoscopic and fluoroscopic guidance; 0.018-inch guidewire was passed through the needle. A cautery-enhanced 15 mm × 15 mm LAMS was deployed over the wire under endoscopic and fluoroscopic guidance. The patient was given 3 days of oral ciprofloxacin, and he tolerated a low-residue diet next day after which he was discharged. At 6-week follow-up, there was improvement in the stricture with luminal diameter to 1.2 cm. A cold LAMS 15 mm × 15 mm was placed until ileostomy reversal. The patient returned after ileostomy reversal and 8 weeks from last colonoscopy and underwent removal of the LAMS with resolution of the stricture. At 4 month follow up, the patient reported no obstructive symptoms. Discussion: In our case, the luminal stenosis was severe, limiting the passage of a wire or contrast. Our case is the first to describe the creation of a freehand anastomosis in a completely occluded colonic stricture using this technique of direct needle puncture and cautery-enhanced LAMS. There was technical and clinical success in restoring luminal patency with this technique using antegrade and retrograde endoscopic and fluoroscopic guidance. Cautious reproducibility in well-selected cases may be possible and further studies are needed to study the safety of this technique.