Post written by Ilaria Tarantino, MD, from the Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS–ISMETT, and Giacomo Emanuele Maria Rizzo, MD, from the Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS–ISMETT, and the Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Italy.

A 75-year-old woman with malignant gastric outlet obstruction unfit for surgery underwent an EUS-guided gastroenteroanastomosis (EUS-GEA).

Unfortunately, a complete intraperitoneal maldeployment of the lumen-apposing metal stent (LAMS) occurred, so we performed a second but successful EUS-GEA with deployment of another LAMS (20 × 10 mm, Hot AXIOS; Boston Scientific, Marlborough, Mass, USA). We retrieved the maldeployed LAMS using the natural orifice transluminal endoscopic surgery (NOTES) technique through the balloon–dilated gastric wall defect. At the end, the gastric defect was closed by applying 3 metallic clips.

We think it is fundamental to show how to manage intraprocedural adverse events (AEs) while performing EUS-GEA, mainly because it is an advanced endoscopic technique, and only a few endosonographers have performed it, so safety also depends on the development of skills.

Surely, this technique will spread as a result of encouraging data on its outcomes, so all endoscopists should know how to manage any intraprocedural AE, even applying NOTES as rescue therapy in case of complete LAMS maldeployment.

Our experience will certainly help colleagues be prepared to manage AEs before performing EUS-GEA in order to make fast but wise intraprocedural decisions and keep calm when an AE occurs because we showed that most of the time AEs can be endoscopically managed.

A, Endoscopic view of the intraperitoneal LAMS rescue. The white arrow indicates the LAMS, and the red arrow indicates the peritoneal tissue. B, Radiologic view after EUS-guided gastroenteroanastomosis and natural orifice transluminal endoscopic surgery showing normal placement of the LAMS and the 3 metallic clips applied to close the gastric defect. LAMS, Lumen-apposing metal stent.

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