Re: A novel salvage method to recapture the maldeployed distal flange of a lumen-apposing metal stent

We congratulate Prawiradiradja et al. on their novel method to successfully recapture a maldeployed distal flange of a lumen-apposing metal stent (LAMS) [1]. Current literature indicates that maldeployment can occur in 2 %–9 % of cases, even in expert hands [2] [3].

We have two concerns regarding the proposed solution (cutting the plastic safety latch to recapture the distal flange). First, maldeployment of a stent is a stressful situation and, if the endoscopist attempts to cut the safety latch, this poses an additional sharps-related injury risk. Studies have shown that, during stressful situations, fine motor skills are impaired more than gross motor skills [4] [5]. Moreover, removing the safety latch effectively removes the intended brake designed into step 2 of device insertion, which may impact reattempted LAMS deployment, with the step 2 safety latch no longer available to prevent inadvertent distal flange recapture. Instead, we propose a safer alternative (off label) method to help recapture the distal flange, simply by using one’s index finger to push in the lock and recapture the distal flange ([Fig. 1]). This preserves the safety lock, as designed, for any further redeployment attempt.

Fig. 1 Photographs showing: a the deployed distal flange of a lumen-apposing metal stent (LAMS); b an off label method to reverse deployment, which involves pressing down on the safety latch with a finger and sliding the gray handle down (note: the technique is not reliable for LAMSs larger than 10 mm); c a stent that can now be used for a redeployment attempt (the stent dimensions in this example were 15 × 10 mm).

Second, we note that recapture may not work in all situations. In our bench-top model using a 15 × 10-mm LAMS, despite successful reversal of the deployment mechanism, the distal flange could not be fully recaptured. We recognize that a smaller LAMS could possibly be recaptured more easily, as demonstrated by the authors when using a 6 × 8-mm LAMS. We hope to raise awareness of this phenomenon and emphasize the importance of optimal initial deployment technique.

Publication History

Article published online:
26 October 2023

• References

• 1 Prawiradiradja R, Ding M, Yau CC. et al. A novel salvage method to recapture the maldeployed distal flange of a lumen-apposing metal stent. Endoscopy 2023; 55 (Suppl. 01) E438-E439
• 2 Siddiqui A, Adler DG, Nieto J. et al. EUS-guided drainage of peripancreatic fluid collections and necrosis by using a novel lumen-apposing stent: a large retrospective, multicenter U.S. experience (with videos). Gastrointest Endosc 2016; 83: 699-707
• 3 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
• 4 Metz GA, Jadavji NM, Smith LK. Modulation of motor function by stress: a novel concept of the effects of stress and corticosterone on behavior. Eur J Neurosci 2005; 22: 1190-200
• 5 Zink N, Merelman A, Fisher AD. et al. Emergency reflex action drills and the problem with stress. J Spec Oper Med 2023; 23: 54-58