Unanticipated buried endoscopic ultrasound-guided lumen-apposing metal stent for gastroenterostomy concerning for potential dehiscence

A 55-year old man presented with a gastric outlet obstruction from metastatic duodenal cancer. Given his poor performance status from malnutrition, we decided to perform an endoscopic ultrasound (EUS)-guided gastroenterostomy with a lumen-apposing metal stent (LAMS). The procedure was performed successfully utilizing nasojejunal water irrigation and free-hand deployment of a 15-mm cautery-enhanced LAMS through the antrum ([Fig. 1]). The patient was discharged the following day tolerating oral intake. He developed a biliary obstruction 1 month later and EUS-guided choledochoduodenostomy was performed. During this endoscopy, the previously placed LAMS was noted to be completely buried within the gastric wall with purulent material oozing from the embedded margin ([Video 1], [Fig. 2], [Fig. 3]). Given the concern for separation between lumens, a through-the-scope 18 mm × 6 cm long, fully covered metal stent was placed through the LAMS and oriented along the jejunal lumen. Three months later, the patient remains asymptomatic, maintaining weight and undergoing chemotherapy.

Fig. 1 Initial placement of lumen-apposing metal stent during endoscopic ultrasound-guided gastroenterostomy.

Video 1 A previously placed lumen-apposing metal stent (LAMS) was buried within the gastric wall. Given the concern for separation between lumens, a fully covered metal stent was placed through the LAMS.

Fig. 2 Lumen-apposing metal stent (LAMS) 30 days post-placement; buried LAMS with purulent discharge at the proximal edge (arrow).

Fig. 3 Computed tomography scan 1 month after placement demonstrating lumen-apposing metal stent within the gastric wall (red circle).

EUS-guided gastroenterostomy with LAMS is a novel and disruptive alternative procedure that may offer long-lasting patency with less stent failure [1]. Retrospective series report stent dwell and patency ranging from 126 days for malignant disease to 319 days in benign scenarios [2]. Premature buried LAMS as early as 5 weeks has also been described when placed for drainage of pancreatic fluid collections [3].

We report a case of premature buried LAMS with a potential for lumen separation, supporting the need for prospective data for this technique.

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• References

• 1 Khashab MA, Kumbhari V, Grimm IS. et al. EUS-guided gastroenterostomy: the first U.S. clinical experience (with video). Gastrointest Endosc 2015; 82: 932-938
• 2 Kerdsirichairat T, Irani S, Yang J. et al. Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction. Endosc Int Open 2019; 07: E144-E150
• 3 Bang JY, Hasan M, Navaneethan U. et al. Lumen-apposing metal stents (LAMS) for pancreatic fluid collection (PFC) drainage: may not be business as usual. Gut 2017; 66: 2054-2056