A tent-like sign during endoscopic ultrasound-guided gastroenterostomy: an indication of a misdeployed stent in the peritoneum

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with the use of a lumen-apposing metal stent (LAMS) is an established alternative technique for patients with malignant gastric outlet obstruction [1]. Although single-step delivery systems for LAMSs significantly reduce the risk of adverse events (AEs), stent misdeployment during EUS-GE remains the most common cause for technical failure and AEs. This report describes the case of a patient who underwent EUS-GE with deployment of the distal flange of the LAMS occurring in the peritoneum (type 1 stent misdeployment) [2].

A 57-year-old man with advanced pancreatic cancer with multiple liver metastases attended our hospital because of early satiety and post-prandial vomiting for several weeks. After admission, he underwent esophagogastroduodenoscopy, which confirmed pancreatic cancer with duodenal bulb invasion. EUS-GE with the direct technique was performed using a 20-mm cautery-enhanced LAMS (Hot AXIOS; Boston Scientific, Marlborough, Massachusetts, USA). After a suitable location for a gastroenterostomy had been identified, direct puncture with the LAMS was performed from the gastric wall into the target jejunum; however, the tip of the delivery system of the LAMS caused the bowel wall to deform into a shape that produced a tent-like sign owing to incomplete penetration of the bowel wall. This sign warrants caution as it indicates misdeployment of the distal flange of the LAMS in the peritoneum ([Fig. 1], [Fig. 2]; [Video 1]).

Fig. 1 Endoscopic ultrasound (EUS) image showing the tent-like sign of the bowel wall (arrow) that resulted from the tip of the delivery system of the lumen-apposing metal stent incompletely penetrating the targeted jejunum during EUS-guided gastroenterostomy.

Fig. 2 Fluoroscopic image showing the misdeployment of the lumen-apposing metal stent, with the distal flange seen, after contrast injection, in the peritoneum and the proximal flange in the stomach.

Video 1 An attempted endoscopic ultrasound-guided gastroenterostomy results in misdeployment of the distal flange of a lumen-apposing metal stent in the peritoneum, which was managed by removal of the misdeployed stent and endoscopic closure of the subsequent gastrotomy using through-the-scope clips. A second attempt during the session proved successful.

The complication was managed by removal of the misdeployed LAMS followed by endoscopic closure of the gastrotomy using through-the-scope (TTS) clips ([Fig. 3]). A subsequent EUS-GE using a second new 20-mm cautery-enhanced LAMS was performed successfully during the same session. No obvious pneumoperitoneum was observed after these procedures ([Fig. 4]) and the patient’s symptoms subsequently resolved.

Fig. 3 Endoscopic images showing: a the gastrotomy left after removal of the misdeployed lumen-apposing metal stent; b through-the-scope clips placed to close the gastrotomy endoscopically.

Fig. 4 Radiographic image after a second endoscopic ultrasound-guided gastroenterostomy, using a new 20-mm cautery-enhanced lumen-apposing metal stent, had been successfully performed in the same session showing no obvious pneumoperitoneum.

Caution should be taken in the event of the rare and dangerous tent-like sign, which indicates incomplete puncture through the bowel wall, during EUS-GE with LAMS deployment.

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Publication History

Article published online:
27 July 2023

• 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
• 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