Overtube-mediated luminoposing metal stent placement for removal of a capsule endoscope pertained proximal to an ileal stricture. The submitting author is Alexis Bayoudin. Additional authors are Kenneth Bindmuller, Chris Hammersky, Rabindra Watson, and Andrew Nett. Our case involves a 61-year-old female with a history of cervical cancer treated with chemotherapy and radiation therapy in 2010. She suffered from chronic intermittent bloating, nausea, and abdominal pain, for which she received a motility capsule endoscopy at an outside institution. The capsule endoscopy was complicated by retention within the ileum, documented on multiple imaging studies over the subsequent one and a half years. In addition to persistent chronic symptoms, she began having bouts of symptomatic recurrent iron deficiency anemia, requiring transfusions following capsule retention. Most recently, an abdominal x-ray showed evidence of persistent capsule retention. A CT scan performed had also shown capsule retention within the ileum. The capsule was present within a dilated loop of ileum with downstream relative narrowing, suggestive of a chronic ileal stricture as the etiology of capsule retention. A previous outside colonoscopy with intubation of the terminal 20 centimeters of the ileum had failed to reach the site of capsule retention or identify an ileal stricture. As such, device-assisted retrograde enteroscopy was performed at our center for therapy of the suspected stricture and capsule extraction. Double balloon enteroscopy was initially performed with successful advancement to a short-segment ulcerated severe ileal stricture located approximately 50 centimeters from the ileocecal valve. Through the stricture lumen, the retained capsule could be visualized upstream with surrounding normal ileal mucosa. The stricture was dilated sequentially to a maximum diameter of 10 millimeters using a through-the-scope dilating balloon passed across the stricture over a guide wire. Despite dilation, the enteroscope was unable to traverse the stricture. Stricture biopsies were taken which showed changes consistent with radiation enteritis. A repeat enteroscopy was performed three days later. Single-balloon rather than double-balloon assisted enteroscopy was performed this time so that the enteroscope could be removed with the balloon overtube left in place to use as a conduit for catheter devices too large or short to pass through the enteroscope working channel. Just three days later, there was partial restenosis of the ileal stricture. Dilation was performed with a through-the-scope dilating balloon to a maximum size of 12 millimeters. The enteroscope was advanced across the stricture and the retained capsule was fully visualized a few centimeters approximately. There was pre-stenotic dilation of the ileal lumen. A retrieval net was used to grasp the capsule, but the capsule, which measures 26.8 mm in length and 11.7 mm in diameter, could not be extracted across the ileal stricture despite prolonged manipulation. Given the rapid restenosis of the ileal stricture and anticipated need for multiple additional procedures for sequential dilation to facilitate capsule extraction, an ileal stent was instead placed. To accomplish this, the enteroscope was removed from within the single balloon overtube with careful force. The segment of the overtube external to the patient's body was then cut shorter such that a pediatric endoscope could be advanced through the overtube and fully reach the ileal stricture. Alongside the pediatric endoscope, a 0.035 inch stiff guide wire was placed through the overtube and advanced across the ileal stricture under direct visualization. A 15 mm by 10 mm lumen-opposing metal stent was then placed over the guide wire and across the stricture under direct visualization. Since the stent conformation mitigates against stent migration, the stent was then left in place for three months for prolonged stricture therapy. Just prior to follow-up enteroscopy, an abdominal x-ray showed spontaneous complete migration of the previously retained capsule. A single balloon enteroscope was again advanced to the site of the ileal stricture. Visualization through the stent confirmed passage of the retained capsule. The stricture was marked with submucosal tattoo injection in case of symptomatic recurrence and need for future surgical therapy. The stent was then grasped with a rat-toothed forceps and extracted through the ileum with careful manipulation. This case demonstrates why a history of pelvic irradiation is a contraindication to capsule endoscopy due to the risk of iliitis and associated stricturing. If capsule endoscopy is performed with resultant obstruction, serial endoscopic dilation may not successfully enable capsule extraction. Enterostent placement for stricture dilation can potentially facilitate stricture therapy and successful capsule removal in fewer cases or in cases of stricture poorly responsive to dilation. A lumen-opposing metal stent catheter is too short and wide to pass through an enteroscope working channel and too short to pass through a colonoscope working channel. Following single balloon enteroscopy, the balloon overtube may be used as a working conduit for lumen-opposing metal stent catheter deployment under direct visualization through a broad span of the GI tract. Lumen-opposing metal stents may be successfully placed across ileal strictures. Lumen-opposing metal stent placement is a method to achieve removal of a capsule chronically retained above small bowel strictures. Lumen-opposing metal stent placement within the ileum may be successfully performed under direct endoscopic visualization through a single balloon enteroscopy overtube. www.ottobock.com

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