Hybrid Gastroenterostomy Using A Lumen-Apposing Metal Stent: A Case Report Focusing On Misdeployment.

Abstract BackgroundGastric outlet obstruction can result from several benign and malignant diseases, in particular gastric, duodenal or pancreatic tumors. Historically, surgical gastroenterostomy and enteral endoscopic stenting have represented effective therapeutic options. However, surgery is burdened by high complication and mortality rates, while endoscopic stenting demonstrates unsatisfactory patency after six months. Lately, endoscopic ultrasound-guided gastroenterostomy using lumen apposing metal stent (LAMS) is spreading in order to improve the outcome of this condition, but still complication rate remains not negligible. Our case report shows a hybrid (endoscopic and surgical) technique for LAMS deployment, reviews current literature on potential complications and demonstrates problem solving strategies. Case presentationA 60 year-old male patient, affected by metastatic pancreatic adenocarcinoma, developed gastric outlet obstruction due to a duodenal bulb stenosis. Endoscopic ultrasound-guided gastroenterostomy was performed in an operating room, but the first flange of LAMS was misdeployed opening in the epiploon retrocavity. Immediate diagnostic laparoscopy was carried out, LAMS was removed endoscopically and the first jejunal loop was identified by laparoscopy. The jejunal loop was placed near the stomach, allowing for endoscopic release of a second LAMS through the previous fistulous gastric tract, performing a laparoscopy-assisted gastroenterostomy.ConclusionsThis hybrid technique may offer an innovative strategy to overcome misdeployment of LAMS, which represents the most troubling complication of endoscopic ultrasound-guided approach. There are several significant advantages, such as the easy visualization of target loop and cystostome penetration, nevertheless the ability to considerably shorten overall procedure time.