LAUSR

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) stent dysfunction is uncommon and most often caused by food impaction [1]. We report the use of EUS-guided stent-in-stent bridging to treat a buried gastroenteric lumen-apposing metal stent (LAMS). A 68-year-old woman with an antral gastric cancer underwent EUS-GE with a 20×10-mm LAMS for gastric outlet obstruction (GOO). She developed recurrent GOO 5 months later. A computed tomography scan revealed LAMS tumor ingrowth (▶Fig. 1). A 20×110-mm duodenal metal stent was placed endoscopically across the pylorus to facilitate gastric emptying, but her symptoms failed to improve. Endoscopy showed a barely expanded duodenal stent (▶Fig. 2). An 8.5-Fr oroenteric catheter was placed through the duodenal stent beyond the Treitz angle and into the proximal jejunum. Enteroclysis confirmed an embedded proximal LAMS flange, with a patent distal flange (▶Fig. 3). The gastroscope was removed and a linear echoendoscope was advanced into the stomach parallel to the catheter. Endoscopic ultrasound (EUS) revealed the LAMS buried within tumor overgrowth. The LAMS lumen was punctured using a 19G needle under EUS guidance (▶Fig. 4) and a guidewire was inserted through this into the jejunum, with subsequent balloon dilation being performed. The orojejunal catheter was removed and a 20×100-mm colonic metal stent was placed through the LAMS then expanded using a balloon (▶Fig. 5). The patient was discharged on a soft diet after an uneventful recovery and subsequently restarted chemotherapy. She died 5 months later from tumor progression, with there being no evidence of further stent dysfunction (▶Video 1). EUS-GE is an emerging palliative treatment for malignant GOO [2]. LAMS bypass of the tumor generally decreases the risk of ingrowth [3]. The approach we describe here to address recurrent GOO caused by a late buried LAMS involves a combination of the previously reported EUS-guided removal of a LAMS buried in walled-off necrosis [4], together with stent bridging as used in type I and II acute stent misdeployment [5]. In our case, the technically simpler choice of duodenal stenting that was initially used failed to relieve the GOO; however, EUSguided stent-in-stent bridging was highly effective in both the short and longer term.