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

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]):

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.

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.

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.

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].

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• References

• 1 Sanchez-Ocana R, Penas-Herrero I, Gil-Simon P. et al. Natural orifice transluminal endoscopic surgery salvage of direct EUS-guided gastrojejunostomy. VideoGIE 2017; 2: 346-348
• 2 Ligresti D, Amata M, Barresi L. et al. The lumen-apposing metal stent (LAMS)-in-LAMS technique as an intraprocedural rescue treatment during endoscopic ultrasound-guided gastroenterostomy. Endoscopy 2019; 51: 331-332
• 3 James TW, Grimm IS, Baron TH. Intraperitoneal echoendoscopy for rescue of a gastrojejunal anastomosis. VideoGIE 2019; 4: 528-529
• 4 Tyberg A, Saumoy M, Kahaleh M. Using NOTES to salvage a misdeployed lumen-apposing metal stent during an endoscopic ultrasound-guided gastroenterostomy. Endoscopy 2017; 49: 1007-1008