NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) SALVAGE OF PARTIAL MISPLACEMENT OF LUMEN-APPOSING METAL STENT (LAMS) DURING EUS-GUIDED GALLBLADDER DRAINAGE

EUS-Guided Gallbladder Drainage (EUS-GBD) is an emerging procedure. Lumen-Apposing Metal Stents (LAMS) are increasingly used for EUS-GBD. Misplacement of either de distal or proximal LAMS flange during EUS-GBD may have serious consequences. We present a novel endoscopic approach to manage proximal flange misplacement during EUS-GBD.

Case Report: An elderly patient with multiple comorbidities had septic shock secondary to acute cholecystitis. A percutaneous cholecystostomy (PC) was performed. The patient was deemed a definitive non-surgical candidate. EUS-GBD with a 10 × 10 cautery-enabled LAMS was chosen for permanent internal drainage. A cautery-enable LAMS delivery catheter was advanced over-the-wire (OTW) into the gallbladder following 19G needle access under EUS. The distal LAMS flange was deployed inside the gallbladder. Excessive friction during the final stages of LAMS deployment resulted in uncontrolled release with the proximal flange eventually lying beyond the gastric wall. OTW 18-mm balloon dilation of the tract was performed to create a NOTES access. A therapeutic gastroscope was passed into the peritoneal cavity. The proximal LAMS flange was identified. Retraction of the proximal flange into the stomach across the NOTES access site risked dislodgment of the distal LAMS flange from the gallbladder. A second LAMS 15 × 10-mm was passed OTW through the gastroscope into the misplaced LAMS aiming to bridge the gap. During transgastric deployment of the second LAMS, the distal flange slipped out of the first LAMS. Using the second LAMS as trocar for peritoneoscopy, the proximal flange of the first LAMS could eventually be retracted with a foreign body forceps inside the second LAMS. Cholecystography showed no leakage. The PC catheter was removed and the patient was uneventfully discharged within 72 hours.

Our case shows successful salvage of LAMS misplacement during EUS-GBD by means of NOTES and the “stent in stent” technique, thus avoiding the need for emergency surgery.