The possibilities of performing endoscopic gastroenteral bypass and entero-enteral
bypass have been explored recently in patients with Roux-en-Y reconstruction after
subtotal gastrectomy or biliary anastomosis; however, data are still scant and based
on limited follow-up. The main adverse events described in the available literature
are displacement or migration of the enteral stents, enteral perforations, and early
bleeding [1]
[2]
[3]. We here describe the occurrence and our management of an intramural gastric partial
migration of a lumen-apposing metal stent (LAMS), a rare adverse event of endoscopic
gastroenteral bypass that has not yet been reported.
A 72-year-old man underwent endoscopic retrograde cholangiopancreatography (ERCP)
via an endoscopic enteral bypass [4], with double metal stenting to treat an anastomotic stricture of the hepaticojejunostomy
on the Roux-en-Y loop (previously performed because of a lesion of the common bile
duct found during cholecystectomy). He failed to present for removal of the stents
at 6 months; however, he presented to the Emergency Department because of acute cholangitis
13 months after the endoscopic procedure. An abdominal computed tomography (CT) scan
showed correct positioning of both the biliary and enteral stents (partially obstructed
by stones and sludge); however, the gastric flare of the enteral LAMS seemed to be
“buried” in the gastric wall.
An ERCP was scheduled to remove the stents. During the endoscopy, performed using
an operative gastroscope (EG-216; Pentax), the gastric side of the bypass was recognized
as a small (around 5 mm) ulcerated orifice ([Video 1]). The scope could not be passed through the small residual opening, so a guidewire
(0.035-inch Jagwire; Boston Scientific) was pushed through the orifice until it reached
the connected biliary jejunal loop. A 15-mm dilation balloon (CRE 12 – 15 mm; Boston
Scientific) was inflated and left within the LAMS to channel back the bypass for 24
hours.
Video 1 The video shows the endoscopic management of a rare adverse event following endoscopic
gastroenteral bypass: the flare of the lumen-apposing metal stent buried at the gastric
side of the endoscopic bypass.
At the second-look endoscopy, the gastric orifice of the bypass was now larger and
clearly visible. The operative gastroscope was pushed through the endoscopic gastroenteral
bypass and the biliary stents were removed, although the procedure proved difficult
because one of the stents was entrapped in an anastomotic recess of the hepaticojejunostomy.
A cholangiography performed at the end of the procedure showed no residual defect
in the biliary tree and no evidence of bile leakage. Removal of the enteral LAMS appeared
to carry a risk of perforation because the gastric flare was located in the deep layers
of the gastric wall. Therefore, a biflanged fully covered metal stent (Nagi Stent,
16 mm × 2 cm; EuroMedical Inc.) was placed into the LAMS to guarantee the patency
of the bypass.
The patient experienced a self-limited episode of fever (due to transient bacteremia),
but both his symptoms and blood tests improved in 12 hours and he was discharged 48
hours after the procedure.
Endoscopy_UCTN_Code_CPL_1AL_2AB
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
