Introduction

A 75-year-old female developed nausea and vomiting due to gastric outlet obstruction (GOO) consequent to a duodenal malignancy infiltrating the antrum-duodenal wall and causing stomach enlargement. Moreover, she was considered unfit for surgery due to her performance status and severe cardiopathy

Aims & Methods

To evaluate efficacy and safety of Natural Orifice Transluminal Endoscopic Surgery technique to treat lumen apposing metal stent misdeployment

Results

He underwent a gastroscopy that showed duodenal neoplastic tissue occluding pylorus (tissue was acquired with histological confirmation ), After a multidisciplinary discussion, we scheduled an endoscopic ultrasound (EUS) in order to perform gastro-entero-anastomosis (GEA) to resolve gastric obstruction. EUS-GEA was performed using the single-balloon and free-hands technique with deployment of Lumen Apposing Metal Stent (LAMS). Endoscopic balloon was placed beyond the occluded side of duodenum and endoscopist identified the desired intestinal loop with the instillation of contrast , saline plus methylen blue. LAMS was going to be placed from the stomach into the identified loop through HOT-AXIOS delivery system (20 mm x 10 mm, Boston Scientific), but a a complete intra-peritoneal maldeployment of the LAMS occurred. The first flange of LAMS was deployed out of the jejunum and after that even the second flange was deployed into the peritoneal cavity. In that moment, we immediately had to decide if referring patient to surgery or keeping on performing the procedure with endoscopic retrieval of the LAMS. Considering the use of carbon dioxin (CO2) and patient’s condition, we decided to achieve the EUS-GEA with a second but successful attempt and after that, we moved to endoscopically manage the retrieval of the intra-abdominal LAMS using the NOTES (Natural Orifice Transluminal Endoscopic Surgery) [1]. Therefore, we firstly identified the iatrogenic hole in the gastric wall with insertion of a guidewire through it, and then a dilation of the gastric wall defect to 18 mm of diameter was performed permitting to cross it and performing a trans-gastric peritoneoscopy with the retrieval of the LAMS grasping it using a foreign body forceps. In the end, the iatrogenic gastric leak was closed with three metallic clips and no extra-luminal diffusion of contrast was seen at the fluoroscopy.After 12 hours, patient’s clinical status and laboratory tests were favorable, CT-scan with oral contrast showed regular flow through the GEA with no extra-luminal diffusion. Patient was eventually discharged with liquid diet after further 48 hours of observation and she started administration of chemotherapy at two months of follow up, while feeding with normal diet

Conclusion

Nowadays few reports use NOTES as rescue therapy after LAMS maldeployment [2], but no reports applied NOTES for accessing to the peritoneal space and retrieving a maldeployed LAMS.

References

1. ASGE; SAGES. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005. Gastrointest Endosc. 2006;63(2):199-203. doi:10.1016/j.gie.2005.12.007.
2. Sanchez-Ocana R, Penas-Herrero I, Gil-Simon P, de la Serna-Higuera C, Perez-Miranda M. Natural orifice transluminal endoscopic surgery salvage of direct EUS-guided gastrojejunostomy. VideoGIE. 2017;2(12):346-348. Published 2017 Oct 9. doi:10.1016/j.vgie.2017.08.004