Endoscopic retrieval of a dislocated AXIOS stent from the peritoneal cavity

Introduction Endoscopic ultrasound guided gastroenterostomy (EUS-GE) is a new technique of placing a lumen-apposing metal stent (LAMS)/Hot AXIOS stent from the stomach to a proximal jejunal loop for the treatment of gastric outlet obstruction (GOO). Benign GOO can be caused by peptic ulcer disease, as well as acute and chronic pancreatitis, whereas gastric, pancreatic, and duodenal cancer can lead to malignant GOO (1). We present a case of a patient with malignant GOO, who received a gastroenterostomy with subsequent unintended stent dislocation into the peritoneal cavity, followed by an endoscopic stent retrieval procedure.

Clinical background A 77-year-old man with a history of pancreatic papillary adenocarcinoma who had been diagnosed 11 months earlier and had undergone pylorus-preserving pancreaticoduodenectomy as well as adjuvant chemotherapy, presented to our department of gastroenterology. On the day of admission, he showed symptoms of reflux and vomiting following ingestion for 4 weeks. CT-scan was notable for thickening of the wall in the area of the anastomosis without a clear indication of a recurrence. To further assess his symptoms, we performed an esophagogastroduodenoscopy, which showed a delayed gastric emptying with a short segment jejunal stenosis. Endoscopic ultrasound showed an impassable pyloric stenosis, which was analyzed using a fine needle biopsy. Histopathology revealed infiltrates of a micropapillary adenocarcinoma. Therefore, the clinical hypothesis was impassable pyloric stenosis due to a local recurrence of an infiltrative carcinoma of the pancreatic papillary adenocarcinoma.

Endoscopic ultrasound guided gastroenterostomy We successfully performed an endoscopic ultrasound guided gastroenterostomy with a Hot AXIOS stent. In the following days, the patient developed severe abdominal pain and increasing inflammation markers. Consequently, we performed an EGD to rule out small bowel perforation. EGD showed the Hot AXIOS in correct position. Balloon dilatation of the AXIOS was performed to allow endoscopic passage to the small bowel. During this endoscopic passage through the AXIOS stent into the small bowel, the stent dislocated from the stomach into the peritoneum with its distal flange still attached to the small bowel. The patient developed a temporary severe capnoperitoneum, that we released by inserting a 21-G Vasofix into the lower abdomen. The patient developed respiratory instability, which was relieved upon intubation. Afterwards, we marked the gastric stoma with a clip and explored the peritoneal cavity with the endoscope, searching for the AXIOS stent ([Fig. 1]).

Fig. 1 Endoscopic view after entering the peritoneal cavity through the gastric stoma.

We aspirated the ascites and rinsed the abdomen with gentamycin. After finding the proximal jejunal loop with the inlaying AXIOS stent in the lower abdomen ([Fig. 2]), multiple trials to reposition the proximal flange of the stent into the stomach failed.

Fig. 2 Abdominal X-ray with endoscope and dislocated AXIOS stent (marked with red arrows)

The stent with the attached bowel loop was approximated to the gastric stoma using a forceps. A wire was inserted through the AXIOS stent into the small bowel (Figure 3) and a fully covered 10 cm long, 2 cm diameter esophageal stent (with its proximal flange in the stomach and the distal flange in the small bowel) was positioned into the inlaying AXIOS stent (Figure 4, Figure 5).

Publication History

Article published online:
29 March 2022