Adjunct Use of Self-Expanding Covered Stent in the Treatment of Non-Eroded Stenosis By Silatic Gastric Ring

Seiichi Kitahama, MD, Valerie J Halpin, MD FACS, Lee L Swanstrom, MD FACS. Baylor College of Medicine, Michael E. DeBakey Department of Surgery

INTRODUCTION
The silastic ring gastric bypass (SRGB) was introduced by Fobi in 1989, in an effort to combine the advantages of the Roux-en-Y gastric bypass with those of the vertical banded gastroplasty (VBG). A Silastic gastric ring is placed around the vertically constructed gastric pouch above the anastomosis between the pouch and intestinal Roux limb. The ring is intended to control stoma size. Reported percentage of patients necessitating reoperations and band removal are 3%. There are few reports regarding endoscopic removal of dysfunctioning banding after VBG or gastric banding, but no report after SRGB.

CASE
We report a case of endoscopic removal of silastic gastric ring with use of self-expanding stent in the treatment of non-eroded relative stenosis. A 63 year old female 15 years status post SRGB complained of progressive dysphagia and vomiting for 9 months. An Upper GI showed narrowing at the site of gastrojejunostomy with no obstruction of contrast. An Upper GI endoscopy showed no erosion or gastritis, and the gastrojejunostomy was 1.5cm in diameter. An esophageal motility study revealed a high level of esophageal contraction presumed in reaction to the area of relative stenosis. Her symptoms were controllable with medical management, and endoscopic gastric ring removal was performed.

TECHNIQUES
Under the intravenous sedation, a self-expandable fully covered stent (22mm diameter, length 70mm) was placed across the ring. The pursestring at the proximal margin was secured with a clip to the gastric mucosa. The patient was discharged poststent day 1. Three weeks later, the eroded ring was partially seen through the stent. After the removal of the stent, the ring was within the lumen of the gastric pouch, which was retrieved with the grasper. The patient was discharged on the following day without complications.

CONCLUSIONS
With usage of a self-expandable covered stent, endoscopic removal of a ring over the gastrojejunostomy can be safely performed.