P1426 - A Novel Case of Utilizing Overlapping Lumen-Apposing Metal Stents for Treatment of Complicated Marginal Ulcers at the Gastrojejunal Anastomosis

Award: ACG Presidential Poster Award

Udit Asija, MD¹, Tejas Nikumbh, MD², Himani Mongia, MBBS³, Sunny Kumar, MD⁴, Aman Ali, MD⁵
1The Wright Center for Graduate Medical Education, Throop, PA; 2The Wright Center for Graduate Medical Education, Dunmore, PA; 3The Wright Center for Graduate Medical Education, Scranton, PA; 4Wright Center for Graduate Medical Education, Scranton, PA; 5The Wright Center for Graduate Medical Education, Edwardswille, PA

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/

Methods: A 57-year-old female with a history of RYGB in 2014, chronic marginal ulcers, and multiple comorbidities presented with four days of worsening left-sided abdominal pain, nausea, and anorexia. CT 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 three large marginal ulcers at the gastrojejunal (GJ) anastomosis: two 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 x 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 Gastrografin upper GI series 24 hours later showed no extravasation, and she was discharged on a liquid diet with instructions for NSAID 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.


Figure: Figure 1:
- Fluoroscopic image showing contrast injection delineating a walled-off abscess cavity, confirming contained perforation extending from the marginal ulcer at the gastrojejunal anastomosis.
- Endoscopic view demonstrating a large marginal ulcer at the gastrojejunal anastomosis, covering over 50% of the luminal circumference with a with a contained perforation cavity.


Figure: Figure 2:
Endoscopic image showing deployment of a fully covered 20 x 10 mm lumen-apposing metal stent (LAMS) across the site of the marginal ulcer with partial overlap for enhanced coverage and perforation sealing.

Disclosures:
Udit Asija indicated no relevant financial relationships.
Tejas Nikumbh indicated no relevant financial relationships.
Himani Mongia indicated no relevant financial relationships.
Sunny Kumar indicated no relevant financial relationships.
Aman Ali indicated no relevant financial relationships.

Udit Asija, MD¹, Tejas Nikumbh, MD², Himani Mongia, MBBS³, Sunny Kumar, MD⁴, Aman Ali, MD⁵. P1426 - A Novel Case of Utilizing Overlapping Lumen-Apposing Metal Stents for Treatment of Complicated Marginal Ulcers at the Gastrojejunal Anastomosis, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.