Transcolonic lumen-apposing metal stent placement complicating a palliative endoscopic ultrasound-guided gastrojejunostomy

A rare complication associated with an endoscopic ultrasound (EUS)-guided gastroenteroanastomosis (EUS-GE) [1] created using a lumen-apposing metal stent (LAMS) is stent dislocation into the colon with a resulting gastrocolostomy [2] [3] [4]. We report an EUS-GE with stent dislocation and formation of a gastrocolostomy and a colojejunal fistula that was rescued by transcolonic insertion of an intestinal stent ([Video 1]).

Video 1 Endoscopic ultrasound-guided gastrojejunostomy using a lumen-apposing metal stent complicated by stent dislocation and formation of a gastrocolostomy and colojejunal fistula is managed by transcolonic stent insertion.

A 78-year-old patient developed a stenosis at the flexura duodenojejunalis due to advanced pancreatic cancer. A 0.035-inch guidewire and a 7-Fr nasojejunal tube (nasobiliary drainage; Endo-Flex GmbH, Voerde, Germany) were placed across the stenosis to fill the small bowel with fluid. The fluid-filled small bowel was visualized from the stomach with a linear echoendoscope, and a 20-mm LAMS (Hot AXIOS; Boston Scientific, Marlborough, Massachusetts, USA) was directly placed ([Fig. 1 a–c]). Correct positioning of the LAMS was confirmed by the flow of contrast medium and by endoscopic inspection, and abdominal ultrasound assessment showed an optimally positioned stent ([Fig. 1 d]). The patient tolerated oral diet well and was able to be discharged.

Fig. 1 Endoscopic ultrasound (EUS) images showing: a the EUS-guided gastrojejunostomy, with no evidence of colonic interposition seen; b the colonic wall between the two flanges following placement of the lumen-apposing metal stent (LAMS); c the colonic wall highlighted between the two flanges of the LAMS; d ultrasound check showing appropriate stent positioning: on the left side is the stomach with air in it, on the right side is the jejunum and the colonic wall is not recognizable in this image.

He presented again 14 days later with malodorous vomiting and watery diarrhea. Gastroscopy revealed the surprising finding of a LAMS dislocation from the jejunum, with a gastrocolostomy and a fistula from the colon to the jejunum at the lateral border of the LAMS ([Fig. 2]). A fully covered 6-cm duodenal stent (Taewoong Niti-S Duodenal Stent; 20 × 60 mm; Taewoong Medical Co., Ltd., Seoul, South Korea) was inserted through the LAMS via the colon into the small intestine. A functional gastrojejunostomy was recreated through a transcolonic interposition ([Fig. 3]). A postinterventional ultrasound check indicated appropriately positioned stents ([Fig. 4 a]). The patient was discharged 2 days later, with stable oral intake.

Fig. 2 Endoscopic images 14 days later showing: a the dislocated lumen-apposing metal stent (LAMS) with a gastrocolostomy and colonic content visible in the stomach; b a view through the LAMS into the colon, with a colojejunal fistula at the upper edge of the LAMS (black arrow); c the colojejunal fistula at the edge of the LAMS after passage with the endoscope; d the fistula.

Fig. 3 Endoscopic views showing: a the aboral margin of a fully covered (except proximal flange) 6-cm duodenal stent during placement; b the endoluminal view from the stomach after stent placement.

Fig. 4 Final appearances on: a ultrasound scan, with the lumen-apposing metal stent (LAMS) not well recognizable and the distended intestinal stent visible; b a reconstructed computed tomography scan, with both stents in situ: a functioning gastrojejunostomy created by the LAMS between the stomach and colon, and the transcolonic intestinal stent between the stomach and jejunum.

After 1 week, the patient presented with multiple injuries from a car accident. Neither the computed tomography ([Fig. 4 b]) nor the intraoperative findings demonstrated signs of peritonitis. Unfortunately, the patient died a few days later owing to complications from the accident.

Video analysis of the placement of the LAMS demonstrated a completely collapsed colon between the stomach and small intestine, which was detected by image-per-image analysis after stent dislocation. Therefore, when creating a gastroenteroanastomosis, attention should be paid to the avoidance of an unintentional colon interposition. Various approaches have been described to address this problem [2] [3] [4].

Endoscopy_UCTN_Code_CPL_1AL_2AB

Competing interests

Prof. U. Will is a consultant for Boston Scientific. The remaining authors declare that they have no conflict of interest.

• References

• 1 Tyberg A, Perez-Miranda M, Zerbo S. et al. Endoscopic ultrasound-guided gastrojejunostomy: a novel technique. Endoscopy 2017; 49: E252-E253
• 2 Pham KD, Havre RF. Endoscopic management of gastrocolic fistula after endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ). Endoscopy 2019; 51: E169
• 3 Keane MG, Barbouti O, Reffitt D. et al. Removal of a migrated lumen-apposing metal stent and endoscopic closure of a gastrocolonic fistula. Endoscopy 2020; 52: E170-E171
• 4 Laroyenne A, Lafeuille P, Lambin T. et al. Accidental gastrocolonic anastomosis by apposition stent: a one-month healing delay makes it possible to treat a stabilized gastrocolonic fistula rather than a double perforation. Endoscopy 2022; 54: E212-E214

Publication History

Article published online:
16 January 2023