870 OOPS, THE LUMEN-APPOSING METAL STENT (LAMS) MISDEPLOYED! STAY CALM. NOW LET’S RESCUE IT

Abstract

Reasons for misdeployment of a lumen-apposing metal stent (LAMS) include: Unfamiliarity with the stent, difficult scope position, patient movement and a lack of sufficient space in the lumen being targeted. Consequence of an unaddressed, misdeployed stent can be serious. We present 5 locations and techniques of rescuing misdelpoyed LAMS. Case 1: 56 year old male with severe acute pancreatitis with infected walled off necrosis, undergoing endoscopic necrosectomy. During LAMS deployment, distance of the collection (11mm from duodenum) and patient movement, resulted in duodenal flange almost completely misdeploying into the collection. The last of the tines of the LAMS was grasped with a forcep and repositioned with gentle traction. Case 2: 45 year old male with metastatic pancreatic cancer and a 3rd bout of cholecystitis undergoing cholecystoduodenostomy. Due to patient coughing, the duodenal flange misdeployed into the peritoneum. Unable to reposition this with a forcep, the LAMS was pulled out and access lost. However, using a papillotome and guidewire through the duodenal perforation, access was regained and a new LAMS was placed. Case 3: 38 year old female with Roux-en-Y gastric bypass with choledocholothiasis undergoing EUS-tansgastric fistula for ERCP. The Gastric pouch flange misdeployed in the peritoneum. Balloon dilation allowed us to visualize the LAMS and push it into the gastric remnant. A new LAMS was then deployed allowing for an ERCP. Case 4: 68 year old male with locally advanced pancreatic mass and positive FNA at EUS with a gastric outlet obstruction precluding ERCP, undergoing EUS choledochoduodenostomy. Due to the small bile duct (12mm), the biliary flange misdeployed in the retroperitoneum. After reconstraining the LAMS and redeploying the second time, the LAMS double punctured the bile duct. It was removed and rescued with a 10mm x 10cm biliary FCSEMS. Case 5: 72 year old male admitted with recurrent gastric outlet obstruction post-Whipple, despite dilations, steroids, and stents elected to undergo EUS-gastroenterostomy. After guidewire access into the jejunum, the LAMS was advanced, but instead of penetrating the jejunum, it was pushed it away and deployed in the peritoneum. The LAMS was removed and the gastric perforation closed with an over-the-scope clip. None of the 5 patients needed surgery and were discharged between 1 and 3 days. Prior to procedure, written consent to use a LAMS off-label and a surgeon on standby for a gastroenterostomy should be done. Recognize whether the perforation is on one or both lumenal sides and how can we seal the leak. If spillage of luminal contents has occurred, how will this be managed? Admit the patient, watch for adverse events and communication with providers involved in the patient’s care should follow.