This video is titled A Novel Loom in Opposing Mental Stent Fixation Technique Using a Tagged Device. These are the authors. And these are the disclosures. We present the case of a 31-year-old woman with a history of obesity who underwent a Roux-en-Y gastric bypass with paraesophageal hernia repair at our institution. The patient was doing well post-operatively until a month later when she started experiencing progressive intolerance to oral intake. Her symptoms were unfortunately resistant to medical therapy and further workup was needed. Shown here is an upper GI swallow study of our patient that was performed three weeks after the onset of symptoms. An arrow is pointing at the gastrojejunal anastomosis. We can see that there is resistance to the passage of liquid contrast, suggesting a stenosis at this level. Loom in Opposing Metal Stents are widely used for EOS-guided creation of anastomoses and the management of benign anastomotic structures. A relatively new endoscopic device based on a Takin suture model has been reported for use in mucosal closure procedures as well as to secure stents. The fixation of stents prolongs their dwell time and prevents premature migration. Its technique for stent fixation has been described using four helical tacks, one running polypropylene suture and one final plastic cinch. These tacks resemble screw-type fixation anchors commonly used in hernia repair for securing mesh. Therefore, they appear well suited for independently anchoring mesh-like devices including Loom in Opposing Metal Stents, which feature a tighter mesh-like weave. This approach modifies the traditional Takin suture construct by using the tacks without a suture or a cinch. The next day, our patient was consented, evaluated and prepared for a gastroscopy. A new disposable therapeutic channel endoscope was used to perform the procedure. The gastroscope was introduced and advanced to the gastrojejunal anastomosis. Upon examination, the anastomosis was found to be severely stenosed, to the point where it could not be traversed. Given the size of the anastomotic structure and the patient's long distance from home, the decision was made to treat the stenosis with a Loom in Opposing Metal Stent instead of a hydrostatic balloon dilation. Under endoscopic and fluoroscopic guidance, a stent deployment system was introduced over a guide wire and advanced through this structure. A 15 mm diameter Loom in Opposing Stent was deployed slowly through the stenosed GJ anastomosis. The stent was positioned with a distal flange extending into the jejunum and the proximal flange securely placed in the gastric pouch, ensuring coverage beyond the structure margins. The stent was confirmed to be in appropriate position on fluoroscopy. Contrast flowed easily through the anastomosis, confirming its patency. We then proceeded with the fixation of the stent using the tacks from the tack and suture device. The device was then introduced through the scope's working channel. The first tack was advanced firmly through the stent's weave structure. A drilling mechanism, as can be seen here, facilitated the anchoring of the tack in the tissue. Finally, the tack was expelled from the tack driver catheter. The successfully anchored tack can be seen at the bottom of the screen. The catheter was then reloaded and the second tack was introduced. After securing a good position, it was drilled and expelled in the same manner as the first. Finally, a third tack was placed using the same technique. As shown by the arrows, a total of three tacks were placed in three unique areas around the stent, thus completing the procedure. Following the procedure, the patient's symptoms subsided and she was kept on a high-dose proton pump inhibitor. A follow-up endoscopy performed three months later confirmed that the stent remained securely anchored in its original position with the tacks successfully retained. A novel use of the tack and suture device for stent fixation is presented in this case. Our initial pilot experience with this technique has shown it to be safe and effective for LAMPS fixation and may have roles across therapeutic endoscopy and ultrasound techniques using luminoposing metal stents.

metal stents

endoscopic technique

gastrojejunal anastomosis

therapeutic endoscopy

ultrasound applications