Post written by Johannes Maubach, MD, from the Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.

We report a case of an 86-year-old fragile woman who was admitted with painless jaundice and massively congested intrahepatic ducts. An outside MRCP showed a suspicious lesion in the tail of the pancreas, which was confirmed and biopsied in our institution by EUS. Cytology revealed an adenocarcinoma, and the overall diagnosis of a locally advanced pancreatic cancer with hilar lymphadenopathy was made. An endoscopic retrograde cholangiopancreatography (ERCP) was attempted but only pancreatic access could be gained, and a protective 5F stent was placed. A small papillary bleed was successfully treated by adrenaline injection at the end of the procedure. To relieve cholestasis, an EUS-guided HGS was performed by inserting an almost fully covered Boston WallFlex metal stent (SEMS). Overnight, she became hemodynamically unstable, and angiography confirmed the presumed papillary bleed, but angiographic treatment failed. Therefore, a repeat endoscopy was performed, and the bleeding was successfully stopped by applying 3 clips. While retrieving the endoscope, the HGS was still in place. Several hours later the patient vomited heavily and developed acute abdominal discomfort next morning. The CT scan showed a dislodged HGS, and an urgent endoscopy was performed confirming a large gastric defect at the former stent-entry point. The defect could be easily accessed by a slim gastroscope, and the abdominal cavity was examined and extensive biliary fluid aspirated. The SEMS was inserted in the liver, and an attempt to relocate the stent into the stomach with grasping forceps was made. However, during this attempt, the stent totally dislodged. Therefore, the liver entry site was intubated with the gastroscope, and a Jagwire was advanced through the tumor into the duodenum. After changing to a therapeutic scope, another wire was inserted alongside the first one and finally an 80-mm long TaeWoong Gioborstent could be placed. A second SEMS was inserted into the Giobor, extending far into the stomach preventing repeat dislocation. During the whole procedure a water lock in the right flank was used for decompression of the abdominal air. Over the following week, the patient improved continuously and could be discharged home for best supportive care.

A dislodged HGS stent is a rare but potentially dangerous adverse event. Endoscopical rescue is a novel treatment approach that has the potential, if successful, to spare the patient a laparotomy. This is of even greater relevance as those patients are often frail in a palliative setting.

NOTES has been described for almost 20 years but was never implemented into clinical routine. However, our case shows that basic NOTES skills should be in the armamentarium of all invasive endoscopists as it can offer a feasible approach for rescuing a dislodged HGS stent.

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