Endoscopy 2022; 54(06): E287-E289
DOI: 10.1055/a-1519-6401
E-Videos

Helpful technical notes for intraperitoneal natural orifice transluminal endoscopic surgery (NOTES) salvage in a failed EUS-guided gastroenterostomy scenario

1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
2   Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Catalonia, Spain
,
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
Sandra Maisterra
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
Julio G. Velasquez-Rodriguez
1   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), University of Barcelona, Catalonia, Spain
,
Carme Loras
2   Faculty of Health Sciences, Universitat Oberta de Catalunya, Barcelona, Catalonia, Spain
3   Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari Mutua de Terrassa, Fundacio per la Recerca Mutua de Terrassa, CIBERehd, Terrassa, Catalonia, Spain
› Author Affiliations
 

The main reasons for dislodgement of the distal flange of a lumen-apposing metal stent (LAMS) into the peritoneum during endoscopic ultrasound (EUS)-guided gastroenterostomy are that the delivery catheter pushes away the small bowel without entering it, or else that advancement of a preloaded guidewire tents away the jejunal loop (in both cases, the EUS window is lost).

The main question is: Is the guidewire still in place? If yes, the action of choice is coaxial insertion of a second (coaxial) stent (LAMS, enteral self-expandable metal stent) through the misdeployed LAMS. If not, three options have been reported: LAMS-in-LAMS rescue with -intraperitoneal EUS guidance; natural orifice transluminal endoscopic surgery (NOTES); or surgery.

We offer some helpful technical notes for intraperitoneal NOTES salvage ([Fig. 1], [Fig. 2], [Fig. 3]; [Video 1]):

Zoom Image
Fig. 1 a Balloon dilation of a lumen-apposing metal stent (LAMS) to allow scope passage; b, c jejunal loop seen through the misplaced LAMS; d suctioning of small bowel into the transgastric LAMS before cutting with a needle-knife.
Zoom Image
Fig. 2 a–d Peritoneoscopy: accessing a jejunal loop. a, b Avoid an acute angle like this (the liver is seen). c, d Try to maintain the LAMS and the scope in the same plane.
Zoom Image
Fig. 3 a, b The second LAMS delivery catheter with its distal flange deployed inside the jejunal loop is pulled into the misplaced LAMS. c, d The second LAMS in position within the first LAMS, creating a bridge between the small bowel and the stomach.

Video 1 Helpful technical notes for intraperitoneal natural orifice transluminal endoscopic surgery (NOTES) salvage in the scenario of a failed endoscopic ultrasound-guided gastroenteroanastomy with a misdeployed lumen-apposing metal stent.


Quality:
  1. Do not remove the transgastric misplaced LAMS! Use it as an internal trocar for intraperitoneal NOTES.

  2. Exchange the echoendoscope for a therapeutic gastroscope (single or double-channel). After balloon expansion of the LAMS up to 15 mm, the scope is ready for NOTES through the misplaced LAMS.

  3. NOTES: From the stomach, (i) suction a jejunal loop into the distal LAMS flange and access it by cutting with a needle-knife, or (ii) access the peritoneal cavity and incise the bowel wall with a needle-knife. After this, advance a guidewire through the needle-knife and coil it in the jejunum. (If a double-channel scope is used, the jejunal loop can be grasped with a rat-tooth forceps and the needle-knife can be advanced through the second channel).

  4. Under endoscopic/fluoroscopic guidance, deploy a second coaxial rescue stent within the misplaced stent to create a bridge between the small bowel and the stomach. A LAMS-in-LAMS option may be preferred, given that the cautery system will help to gain access through the jejunum wall.

Relevant technical aspects during NOTEs are to: limit CO2 insufflation; maneuver carefully; stabilize the guidewire; ensure meticulous fluoroscopic monitoring to help advancement of the second LAMS delivery catheter into the small bowel [1] [2] [3] [4].

Endoscopy_UCTN_Code_CPL_1AL_2AB

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Competing interests

J. B. Gornals is a consultant for Boston Scientific.


Corresponding author

Joan B. Gornals, MD, PhD
Endoscopy Unit, Department of Digestive Diseases
Hospital Universitari de Bellvitge – IDIBELL
Feixa Llarga s/n
08907 L’Hospitalet de Llobregat
Barcelona
Catalonia
Spain   

Publication History

Article published online:
02 July 2021

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Zoom Image
Fig. 1 a Balloon dilation of a lumen-apposing metal stent (LAMS) to allow scope passage; b, c jejunal loop seen through the misplaced LAMS; d suctioning of small bowel into the transgastric LAMS before cutting with a needle-knife.
Zoom Image
Fig. 2 a–d Peritoneoscopy: accessing a jejunal loop. a, b Avoid an acute angle like this (the liver is seen). c, d Try to maintain the LAMS and the scope in the same plane.
Zoom Image
Fig. 3 a, b The second LAMS delivery catheter with its distal flange deployed inside the jejunal loop is pulled into the misplaced LAMS. c, d The second LAMS in position within the first LAMS, creating a bridge between the small bowel and the stomach.