"Cut and Cover”: A case series of dual modality treatment with stricturotomy and stenting for inflammatory bowel disease related strictures

Background: Strictures are common in inflammatory bowel disease (IBD), and are managed medically and endoscopically, if feasible, due to a high rate of post-operative complications after surgery. Endoscopic balloon dilation (EBD) is often successful, but need for repeat dilation and subsequent surgery is common. Endoscopic stricturotomy (ESt) has gained popularity due to improved success but has been limited by frequent post-procedural bleeding. We hypothesized that lumen-apposing metal stent (LAMS) placement after ESt could prevent bleeding and re-stenosis. We aimed to evaluate the feasibility of this "cut and cover" technique.Methods: This is a retrospective study of adults with IBD who underwent endoscopic stricturotomy followed by LAMS placement at Michigan Medicine from July 1, 2023, to June 30, 2024. At the time of procedure, stricture type, location, and dimensions were noted, along with number of incisions required and the deployed LAMS dimensions. Adverse events and follow-up outcomes were recorded.Results: Five patients with Crohn's-related strictures underwent ESt with LAMS placement. Two had prior ulcerative colitis with ileal-pouch anal anastomosis with subsequent Crohn's of the pouch, and two had prior EBD. The mean patient age was 49 years. Strictures were short (<2 cm), and included anastomotic strictures. All patients had a stent in place for at least one month (median 54 days), with average endoscopic follow-up at 170 days post-ESt to assess stricture traversability. Immediate technical success was achieved in all cases, with no procedural complications such as bleeding or perforation, although stent migration was noted in 60% of cases by endoscopic follow-up. One patient was briefly hospitalized for post-procedure abdominal pain. Conclusions: In a small group of patients with IBD-related strictures, ESt followed by LAMS placement was technically feasible and demonstrates potential for high rates of clinical and technical success and few complications. Further multi-center studies are needed to confirm the technique's efficacy and safety.