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Iatrogenic perforation during lumen-apposing metal stent deployment closed using an over-the-scope stent fixation clip device

Open AccessPublished:January 20, 2023DOI:https://doi.org/10.1016/j.vgie.2022.11.002

      Video

      (mp4, (135.72 MB)

      Endoscopic closure of an iatrogenic perforation caused during EUS-guided gastrojejunostomy for malignant gastric outlet obstruction treated with an over-the-scope stent fixation clip device.

      Abbreviations:

      EUS-GJ (EUS-guided gastrojejunostomy), LAMS (lumen-apposing metal stent), OTS (over-the-scope)

      Background

      EUS–guided gastrojejunostomy (EUS-GJ) has emerged as a safe and effective alternative for the palliative management of malignant gastric outlet obstruction.
      • Khashab M.
      • Alawad A.S.
      • Shin E.J.
      • et al.
      Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction.
      ,
      • Boghossian M.B.
      • Funari M.P.
      • De Moura D.T.H.
      • et al.
      EUS-guided gastroenterostomy versus duodenal stent placement and surgical gastrojejunostomy for the palliation of malignant gastric outlet obstruction: a systematic review and meta-analysis.
      Although rare, perforation is a known adverse event of EUS-GJ seen in 1.6% of patients.
      • Krishnamoorthi R.
      • Bomman S.
      • Benias P.
      • et al.
      Efficacy and safety of endoscopic duodenal stent versus endoscopic or surgical gastrojejunostomy to treat malignant gastric outlet obstruction: systematic review and meta-analysis.
      We present a case of endoscopic closure of an iatrogenic perforation caused while performing EUS-GJ using an over-the-scope (OTS) stent fixation clip device (Video 1, available online at www.giejournal.org).

      Case Presentation

      A 78-year-old man with a history of diverting end colostomy for a complex sacral wound presented to the emergency department with severe peroral intolerance. On examination, he was hemodynamically stable with a soft, distended, and nontender abdomen and a left-lower-quadrant colostomy without gas or output in the stoma bag. CT imaging showed severe distension of the stomach and duodenum (Fig. 1). An obstructing mass with a tight stricture was visualized endoscopically in the second part of the duodenum (Fig. 2). Biopsy of this mass revealed moderate to poorly differentiated duodenal adenocarcinoma. The patient was deemed a poor surgical candidate; therefore, the decision was made to perform EUS-GJ for symptomatic relief.
      Figure thumbnail gr1
      Figure 1CT scan of the abdomen and pelvis with contrast showing severe distension of the stomach and the duodenum (yellow arrows).
      Figure thumbnail gr2
      Figure 2Endoscopic view of the second part of the duodenum. A, Obstructing mass. B, Tight stricture.

      Endoscopic Methods

      A standard EUS-GJ was successfully performed using a 15-mm cautery-enhanced lumen-apposing metal stent (LAMS). However, because of the mild resistance felt on initial deployment, the decision was made to evaluate stent positioning using fluoroscopy. Contrast injection through the LAMS showed a tiny leak around the jejunum on fluoroscopy, which was further confirmed by endoscopically visualizing a 10-mm full-thickness tear (Fig. 3). Potential contributing factors for perforation are device malfunction and small-bowel peristalsis, which may have resulted in less-than-optimal apposition and led to inadvertent catheter passage too far into the jejunum. To close this perforation, we initially used a 12/6-mm OTS clip (maximum diameter of 17.5 mm) as we wanted to achieve full-thickness closure, which cannot be achieved using through-the-scope clips. However, despite the dilation of the LAMS tract to 20 mm, this clip could not pass through the tract. Thus, we elected to use an OTS stent fixation clip device (outer diameter 15.9 mm) (Fig. 4). This device was mounted on the tip of the endoscope and was then successfully passed through the LAMS tract. Care was taken to ensure that the perforation was central in location, and then under suction, the stent fixation device was released by rotating the handwheel in a clockwise direction (Fig. 5). Repeat fluoroscopy confirmed the absence of a leak. Prophylactic ampicillin and sulbactam were prescribed for 3 days to reduce the risk of infection. The patient had no postprocedure adverse events and tolerated a soft diet on day 2 postprocedure. CT imaging 2 months later showed no evidence of perforation with the LAMS and the appropriate position of the stent fixation clip (Fig. 6). At the 6-month follow-up, the patient was doing well and was able to tolerate peroral intake without undergoing any reinterventions.
      Figure thumbnail gr3
      Figure 3Perforation of the jejunal wall. A, Fluoroscopic image of a small contrast leak (yellow arrow) confirming the presence of a perforation. B, Endoscopic view of a 10-mm full-thickness jejunal wall tear.
      Figure thumbnail gr4
      Figure 4Over-the-scope stent fixation clip device.
      Figure thumbnail gr5
      Figure 5Endoscopic view of the deployed over-the-scope stent fixation clip at the site of the jejunal tear.
      Figure thumbnail gr6
      Figure 6CT scan of the abdomen and pelvis with contrast obtained 2 months postprocedure showing the lumen-apposing metal stent (yellow arrows) and over-the-scope stent fixation clip (red arrow) in appropriate position without any evidence of a leak or perforation.

      Discussion

      The OTS stent fixation clip is a useful device in our toolbox for the closure of smaller diameter perforations, especially when encountering limitations because of large-caliber scope passage.

      Disclosure

      Dr Khashab is a consultant for Boston Scientific, Olympus America, Pentax, Apollo Endosurgery, Medtronic, GI Supply, and Triton, and receives royalties from UpToDate and Elsevier. All other authors disclosed no financial relationships.

      Supplementary data

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