LAUSR

A 60-year-old woman developed gastric outlet obstruction (GOO) due to metastatic pancreatic adenocarcinoma. Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) was planned using the Wireless Simplified Technique (WEST) [1]. Orojejunal tube (OJT) placement and jejunal instillation of saline and indigo carmine were followed by freehand placement of a 20×10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS; Hot Axios, Boston Scientific). Despite jejunal fluid perturbation (▶Fig. 1), suggesting successful jejunal access, we observed the following: (i) no endosonographic confirmation of endojejunal placement of the distal flange after retraction; (ii) no backflow of blue dye after LAMS release; (iii) failed through-the-LAMS aspiration of contrast injected through the OJT; (iv) peritoneum visible through the stent (▶Fig. 2 a–d). Contrast injection through the OJT showed no jejunal leakage, suggesting either a type I or II misdeployment [2]. The LAMS was removed and the procedure was repeated using an identical endosonographic position (▶Video 1). Once again, acoustic coupling was challenging, but this time, following LAMS placement, blue-dyed fluid and contrast placed via the OJTwere aspirated through the stent into the stomach (▶Fig.2 e–h). Contrast injection through the endoscope working channel, both on the gastric and jejunal side, showed no leakage (▶Fig. 3). The old access point was preemptively closed using endoclips. The patient remained asymptomatic, resumed a semisolid diet on postoperative day (POD) 1 and was discharged on POD 3. Amoxicillin/clavulanate was administered for 7 days. Misdeployment is one of the most frequent EUS-GE complications [2, 3]. In such cases, it can be challenging to ascertain whether small-bowel integrity is compromised. Fistulas created by electrocautery-enhanced 10.8-Fr catheters might be functionally silent and not always within endoscopic reach [4]. If there is uncertainty regarding small-bowel integrity, surgical exploration should still be considered; however, our case demonstrates that if no leak is demonstrated on both the jejunal (via the OJT) and gastric sides, redo EUS-GE may suffice to complete the procedure uneventfully. ▶ Fig. 1 Endoscopic ultrasound (EUS) images of the first EUS-guided gastrojejunostomy showing: a electrocautery-assisted advancement of the lumen-apposing metal stent with a challenging visualization of the puncture trajectory and cautery effect visible (arrows), initially suggesting successful jejunal access; b the catheter tip (arrow) at the end of the placement procedure. Video 1 Redo-endoscopic ultrasound-guided gastrojejunostomy for management of initial stent misdeployment. E-Videos