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CC BY 4.0 · Endoscopy 2024; 56(S 01): E327-E328
DOI: 10.1055/a-2288-5076
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Lotus sign: The lumen-apposing metal stent that failed to bloom

Gabriel Liu Yuan Cher
1   Division of Gastroenterology, Department of General Medicine, Khoo Teck Puat Hospital, Singapore, Singapore (Ringgold ID: RIN150819)
2   Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan (Ringgold ID: RIN38006)
,
Yu-Ting Kuo 
2   Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan (Ringgold ID: RIN38006)
3   Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan (Ringgold ID: RIN38005)
,
Chen-Ling Peng
2   Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, Taipei, Taiwan (Ringgold ID: RIN38006)
,
Hsiu-Po Wang
3   Department of Internal Medicine, National Taiwan University College of Medicine, Taipei, Taiwan (Ringgold ID: RIN38005)
4   Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan (Ringgold ID: RIN38006)
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Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with the use of a lumen-apposing metal stent (LAMS) has emerged as a promising modality for the treatment of a malignant gastric outlet obstruction (MGOO) [1]. The design of single-step delivery systems of LAMSs can significantly reduce the risk of adverse events. However, the process of stent deployment is the crucial step in determining the success of EUS-GE. This report describes the case of a patient who underwent EUS-GE with the deployment of the proximal flange of the LAMS failing to open.

A 54-year-old man with advanced pancreatic adenocarcinoma presented with vomiting due to MGOO. After admission, EUS-GE with the wireless simplified technique [2] was performed using a 20-mm LAMS (Hot AXIOS stent; Boston Scientific, Marlborough, Massachusetts, USA). The distal flange of the LAMS deployed successfully. However, on deployment of the proximal portion, the most proximal end of the LAMS failed to open, resulting in a lotus-shaped flange in the stomach ([Fig. 1], [Video 1]). Despite gentle manipulation of the internal sheath and allowing some time for the flange to expand, it still failed to bloom. A 20-mm extraction balloon catheter was passed through the narrow opening of the proximal end and inflated carefully to dilate the flange ([Fig. 2], [Video 1]). This was followed by gushing of methylene-blue colored saline that had been previously irrigated into the jejunum. Fluoroscopy confirmed successful placement of the LAMS ([Fig. 3]). A follow-up abdominal X-ray the next day revealed the stable position of the LAMS and the patient progressed uneventfully from a liquid to a regular diet. Caution should be taken in the event of a rare incomplete blooming of a LAMS flange, which indicates that the lumen-apposing force may be reduced and stent migration can occur. Early recognition and intervention may prevent stent misdeployment [3].

Zoom Image
Fig. 1 Endoscopy showed lotus sign of the proximal flange of the lumen-apposing metal stent (LAMS) resulting from the failure of the proximal end of LAMS to bloom.
Zoom Image
Fig. 2 A 20-mm extraction balloon catheter was passed through the narrow opening of the proximal end of LAMS and inflated carefully to dilate the flange.
Zoom Image
Fig. 3 The proximal flange of LAMS satisfactorily opened after repeated balloon inflation.

Quality:
Unexpected failure of the proximal flange of lumen-apposing metal stent to open and rescue management to prevent stent misdeployment.Video 1

Endoscopy_UCTN_Code_CPL_1AL_2AG

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Conflict of Interest

The authors declare that they have no conflict of interest.

  • References

  • 1 van der Merwe SW, van Wanrooij RLJ, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205
    Search in Google Scholar
  • 2 Bronswijk M, van Malenstein H, Laleman W. et al. EUS-guided gastroenterostomy: Less is more! The wireless EUS-guided gastroenterostomy simplified technique. VideoGIE 2020; 5: 442
    CrossrefPubMedSearch in Google Scholar
  • 3 Ghandour B, Bejjani M, Irani S. et al. Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy. Gastrointest Endosc 2022; 95: 80-89
    CrossrefPubMedSearch in Google Scholar

Correspondence

Yu-Ting Kuo, MD
Department of Integrated Diagnostics & Therapeutics, National Taiwan University Hospital, National Taiwan University College of Medicine
No. 7, Chung-Shan South Road
Taipei 100
Taiwan   

Publication History

Article published online:
09 April 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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  • References

  • 1 van der Merwe SW, van Wanrooij RLJ, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205
    Search in Google Scholar
  • 2 Bronswijk M, van Malenstein H, Laleman W. et al. EUS-guided gastroenterostomy: Less is more! The wireless EUS-guided gastroenterostomy simplified technique. VideoGIE 2020; 5: 442
    CrossrefPubMedSearch in Google Scholar
  • 3 Ghandour B, Bejjani M, Irani S. et al. Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy. Gastrointest Endosc 2022; 95: 80-89
    CrossrefPubMedSearch in Google Scholar

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Zoom Image
Fig. 1 Endoscopy showed lotus sign of the proximal flange of the lumen-apposing metal stent (LAMS) resulting from the failure of the proximal end of LAMS to bloom.
Zoom Image
Fig. 2 A 20-mm extraction balloon catheter was passed through the narrow opening of the proximal end of LAMS and inflated carefully to dilate the flange.
Zoom Image
Fig. 3 The proximal flange of LAMS satisfactorily opened after repeated balloon inflation.