Redo-endoscopic ultrasound-guided gastroenterostomy for the management of distal flange misdeployment: trust your orojejunal catheter

A 60-year-old woman developed gastric outlet obstruction (GOO) due to metastatic pancreatic adenocarcinoma. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) was planned using the Wireless Simplified Technique (WEST) [1]. Orojejunal tube (OJT) placement and jejunal instillation of saline and indigo carmine were followed by freehand placement of a 20 × 10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS; Hot Axios, Boston Scientific). Despite jejunal fluid perturbation ([Fig. 1]), suggesting successful jejunal access, we observed the following: (i) no endosonographic confirmation of endojejunal placement of the distal flange after retraction; (ii) no backflow of blue dye after LAMS release; (iii) failed through-the-LAMS aspiration of contrast injected through the OJT; (iv) peritoneum visible through the stent ([Fig. 2 a–d]). Contrast injection through the OJT showed no jejunal leakage, suggesting either a type I or II misdeployment [2].

Fig. 1 Endoscopic ultrasound (EUS) images of the first EUS-guided gastrojejunostomy showing: a electrocautery-assisted advancement of the lumen-apposing metal stent with a challenging visualization of the puncture trajectory and cautery effect visible (arrows), initially suggesting successful jejunal access; b the catheter tip (arrow) at the end of the placement procedure.

Fig. 2 Comparison of the first (misdeployed) and second (correctly deployed) lumen-apposing metal stent (LAMS) placements showing: a–d signs of misdeployment, with a no endosonographic confirmation of intrajejunal flange placement after retraction; b no backflow of blue dye into the stomach; c failure to aspirate contrast injected via the orojejunal tube (OJT) through the LAMS; d peritoneum visible through the LAMS; e–h corresponding signs of correct placement, with; e endosonographic confirmation of intrajejunal flange placement after retraction; f backflow of blue dye into the stomach after release of the proximal flange; g aspiration of contrast injected via the OJT through the LAMS; h the jejunum and OJT visible through the LAMS.

The LAMS was removed and the procedure was repeated using an identical endosonographic position ([Video 1]). Once again, acoustic coupling was challenging, but this time, following LAMS placement, blue-dyed fluid and contrast placed via the OJT were aspirated through the stent into the stomach ([Fig.2 e–h]). Contrast injection through the endoscope working channel, both on the gastric and jejunal side, showed no leakage ([Fig. 3]). The old access point was pre-emptively closed using endoclips. The patient remained asymptomatic, resumed a semisolid diet on postoperative day (POD) 1 and was discharged on POD 3. Amoxicillin/clavulanate was administered for 7 days.

Video 1 Redo-endoscopic ultrasound-guided gastrojejunostomy for management of initial stent misdeployment.

Fig. 3 Radiographic images showing: a after the misdeployment, no jejunal leakage of contrast injected through the orojejunal tube; b at the end of the procedure, no gastric leakage of contrast injected under pressure through the endoscope working channel in front of the gastric defect (inset: endoscopic view); c no jejunal leakage of contrast injected through the lumen-apposing metal stent (inset: endoscopic view) after completion of the redo-gastrojejunostomy.

Misdeployment is one of the most frequent EUS-GE complications [2] [3]. In such cases, it can be challenging to ascertain whether small-bowel integrity is compromised. Fistulas created by electrocautery-enhanced 10.8-Fr catheters might be functionally silent and not always within endoscopic reach [4]. If there is uncertainty regarding small-bowel integrity, surgical exploration should still be considered; however, our case demonstrates that if no leak is demonstrated on both the jejunal (via the OJT) and gastric sides, redo EUS-GE may suffice to complete the procedure uneventfully.

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Competing interests

S. van der Merwe holds co-chairs for the Boston-Scientific Chair in Therapeutic Biliopancreatic Endoscopy and holds consultancy agreements with Boston Scientific, Cook Medical and Pentax. All other authors have no conflict of interest relevant for this article.

• References

• 1 Bronswijk M, Vanella G, Petrone MC. et al. EUS-guided gastroenterostomy: Less is more! The wireless EUS-guided gastroenterostomy simplified technique. VideoGIE 2020; 5: 442
• 2 Ghandour B, Bejjani M, Irani SS. et al. Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy. Gastrointest Endosc 2022; 95: 80-89
• 3 van der Merwe SAW, van Wanrooij JRL, Bronswijk M. et al. Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2022; 54: 185-205
• 4 Colombo M, Fugazza A, Kurihara H. et al. Salvage procedure for double trouble in lumen-apposing metal stent misdeployment during endoscopic ultrasound-guided gastroenterostomy: ready to start again. Am J Gastroenterol 2021; 117: 21-22

Publication History

Article published online:
31 March 2022