Endoscopic ultrasound-guided stent-in-stent bridging for a late buried gastroenteric lumen-apposing metal stent

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) stent dysfunction is uncommon and most often caused by food impaction [1]. We report the use of EUS-guided stent-in-stent bridging to treat a buried gastroenteric lumen-apposing metal stent (LAMS).

A 68-year-old woman with an antral gastric cancer underwent EUS-GE with a 20 × 10-mm LAMS for gastric outlet obstruction (GOO). She developed recurrent GOO 5 months later. A computed tomography scan revealed LAMS tumor ingrowth ([Fig. 1]). A 20 × 110-mm duodenal metal stent was placed endoscopically across the pylorus to facilitate gastric emptying, but her symptoms failed to improve. Endoscopy showed a barely expanded duodenal stent ([Fig. 2]). An 8.5-Fr oroenteric catheter was placed through the duodenal stent beyond the Treitz angle and into the proximal jejunum. Enteroclysis confirmed an embedded proximal LAMS flange, with a patent distal flange ([Fig. 3]). The gastroscope was removed and a linear echoendoscope was advanced into the stomach parallel to the catheter. Endoscopic ultrasound (EUS) revealed the LAMS buried within tumor overgrowth. The LAMS lumen was punctured using a 19G needle under EUS guidance ([Fig. 4]) and a guidewire was inserted through this into the jejunum, with subsequent balloon dilation being performed. The orojejunal catheter was removed and a 20 × 100-mm colonic metal stent was placed through the LAMS then expanded using a balloon ([Fig. 5]). The patient was discharged on a soft diet after an uneventful recovery and subsequently restarted chemotherapy. She died 5 months later from tumor progression, with there being no evidence of further stent dysfunction ([Video 1]).

Fig. 1 Computed tomography image showing gastric retention and the buried proximal flange of the lumen-apposing metal stent, with the distal flange in position.

Fig. 2 Endoscopic view of barely expanded duodenal stent.

Fig. 3 Fluoroscopic view during enteroclysis using an orojejunal catheter passed through the duodenal stent, which allows better identification of the buried distal flange of the lumen-apposing metal stent after filling with contrast.

Fig. 4 Endoscopic ultrasound view showing the 19G needle puncturing the lumen of the lumen-apposing metal stent, which has been obstructed by tumor ingrowth.

Fig. 5 Endoscopic view showing the deployed colonic metal stent placed in stent-in-stent fashion through the lumen-apposing metal stent, below the proximal end of the duodenal metal stent, which is also visible.

Video 1 Repermeabilization of a gastroenteric fistula, after attempted duodenal stenting failed, with views showing endoscopic ultrasound-guided puncture of the lumen-apposing metal stent (LAMS), followed by balloon dilation and eventual stent-in-stent placement of a colonic metal stent through the LAMS, adjacent to the barely expanded duodenal stent.

EUS-GE is an emerging palliative treatment for malignant GOO [2]. LAMS bypass of the tumor generally decreases the risk of ingrowth [3]. The approach we describe here to address recurrent GOO caused by a late buried LAMS involves a combination of the previously reported EUS-guided removal of a LAMS buried in walled-off necrosis [4], together with stent bridging as used in type I and II acute stent misdeployment [5]. In our case, the technically simpler choice of duodenal stenting that was initially used failed to relieve the GOO; however, EUS-guided stent-in-stent bridging was highly effective in both the short and longer term.

Endoscopy_UCTN_Code_CPL_1AL_2AB

Competing interests

M. Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic, and M. I.Tech.

• References

• 1 Kastelijn JB, Moons LMG, Garcia-Alonso FJ. et al. Patency of endoscopic ultrasound-guided gastroenterostomy in the treatment of malignant gastric outlet obstruction. Endosc Int Open 2020; 8: E1194-E1201
• 2 McCarty TR, Garg R, Thompson CC. et al. Efficacy and safety of EUS-guided gastroenterostomy for benign and malignant gastric outlet obstruction: a systematic review and meta-analysis. Endosc Int Open 2019; 7: E1474-E1482
• 3 Tyberg A, Perez-Miranda M, Sanchez-Ocaña R. et al. Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open 2016; 4: E276-E281
• 4 Biedermann J, Zeissig S, Brückner S. et al. EUS-guided stent removal in buried lumen-apposing metal stent syndrome: a case series. VideoGIE 2020; 5: 37-40
• 5 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

Publication History

Article published online:
30 March 2023