- Email: [email protected]
Displaced Endoscopic Ultrasound-Guided Gastroenterostomy Stent Rescued With Natural Orifice Transluminal Endoscopic Surgery
Accepted Manuscript Displaced EUS-guided gastroenterostomy stent rescued with natural orifice transluminal endoscopic surgery Yen-I. Chen, Yamile Haito-Chavez, Renata Pieratti Bueno, Majidah Bukhari, Olaya Brewer Gutierrez, Omid Sanaei, Mouen A. Khashab PII: DOI: Reference:
S0016-5085(17)35594-4 10.1053/j.gastro.2017.04.045 YGAST 61173
To appear in: Gastroenterology Accepted Date: 5 April 2017 Please cite this article as: Chen Y-I, Haito-Chavez Y, Bueno RP, Bukhari M, Gutierrez OB, Sanaei O, Khashab MA, Displaced EUS-guided gastroenterostomy stent rescued with natural orifice transluminal endoscopic surgery, Gastroenterology (2017), doi: 10.1053/j.gastro.2017.04.045. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Displaced EUS-guided gastroenterostomy stent rescued with natural orifice transluminal endoscopic surgery Yen-I Chen, Yamile Haito-Chavez, Renata Pieratti Bueno, Majidah Bukhari, Olaya Brewer Gutierrez, Omid Sanaei, Mouen A. Khashab
RI PT
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA Corresponding Author: Mouen A. Khashab, MD
SC
Johns Hopkins Hospital 1800 Orleans Street
Baltimore, MD 21287 Tel: 443-287-1960 Email: [email protected] Conflict of interest:
M AN U
Sheikh Zayed Tower
TE D
Mouen Khashab is a consultant for Boston Scientific Other authors: None to declare.
AC C
EP
Authors’ contributions: Yen-I Chen: manuscript writing, video editing, video narration; Yamile Haito-Chavez: graphic and animation designer; Renata Pieratti Bueno: video editing; Majidah Bukhari: critical revision of the manuscript and video; Olaya Brewer Gutierrez: critical revision of the manuscript and video; Omid Sanaei: technical support; Mouen A. Khashab: Video concept and critical revision of the manuscript and video
ACCEPTED MANUSCRIPT
RI PT
Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel approach in the treatment of gastric outlet obstruction (GOO)[1-3]. Using a lumen apposing metal stent (LAMS), a bypass can be created between the stomach and the small bowel distal to the
SC
obstruction. One of the major potential adverse events with EUS-GE is the misdeployment or displacement of the LAMS, which can lead to severe clinical
M AN U
consequences and possibly the need for surgical intervention. We describe a case of EUSGE complicated by stent displacement salvaged with natural orifice transluminal endoscopic surgery (NOTES) technique (Figure 1).
Description of Technology: The concept of endoscopic bypass is to provide sustained
TE D
palliation for GOO similarly to a surgical bypass through a minimal invasive approach. Although lumen apposing stents have been developed for drainage of pancreatic fluid
EP
collections, their anti-migration properties and generous luminal diameter are ideal for endoscopic bypass[4]. Data from retrospective and prospective series on EUS-GE have
AC C
shown promising results with technical and clinical success rates of greater than 90% and 85%, respectively. A recent comparative study suggested that EUS-GE may lead to fewer stent obstructions from tumor tissue ingrowth and overgrowth as compared to the traditional enteral stenting approach[5-7]. Currently, endoscopic bypass can be performed through EUS guidance or the NOTES technique. The major adverse event associated with EUS-GE is the risk for stent misdeployment or displacement leading to spillage of
ACCEPTED MANUSCRIPT
luminal content into the peritoneum and an iatrogenic perforation, which may require surgical intervention[6].
RI PT
Video Description: A 68-year old male patient with a history of unresectable cholangiocarcinoma was referred for symptoms of GOO (Video 1). A gastroscopy showed an obstruction in the second portion of the duodenum due to extrinsic
SC
compression from advanced cancer. After discussion with patient and his family a decision was taken to palliate with EUS-GE given the potential for a decreased risk of
M AN U
stent obstruction and need for re-intervention[5].
A gastroscope was advanced across the obstruction and fluid (methylene blue, normal saline, and contrast) was infused to optimize small bowel distension. Using fluoroscopy
TE D
and EUS, a small bowel loop close to the stomach was punctured with a 19-gauge needle (Video 2). Blue tinged fluid was aspirated confirming the correct location of the puncture. A LAMS was then inserted directly using cautery-assistance and deployed
EP
successfully forming the GE. A wire-guided dilating balloon was then inserted across the stent and inflated to 15 mm. Unfortunately, during dilation the patient retched displacing
AC C
both the distal flange of the LAMS and the guidewire from the small bowel into the peritoneal space. A therapeutic gastroscope was advanced through the LAMS and peritoneoscopy performed using CO2 insufflation. The puncture defect in the peritoneum was located and cannulated with an ERCP catheter preloaded with a 0.035 inch guidewire, which was advanced into the small bowel under fluoroscopy. The displaced LAMS was removed with a biopsy forceps over the wire. A LAMS was then advanced
ACCEPTED MANUSCRIPT
over the wire into the small bowel through the established puncture site with the assistance of a quick burst of cautery and the distal flange deployed. The stent was then pulled back approximating the small bowel to the stomach followed by deployment of the
RI PT
proximal flange. Contrast injection showed excellent stent position without evidence of a leak. Note that cautery assistance was needed to facilitate the passage of the second LAMS through the small bowel defect given the free flowing nature of the small bowel
SC
and difficulty of pushing the stent through without cautery. The patient was hospitalized with moderate abdominal pain due to focal peritonitis. He was placed on broad-spectrum
tolerating a full low-residue diet.
M AN U
antibiotics and improved rapidly. He was discharged 4 days later with minimal pain while
Take home message: EUS-GE is a novel treatment modality for GOO; however, stent
TE D
misdeployment/displacement is a feared complication with possible severe clinical consequences. This case demonstrates that by using NOTES, rescue of a displaced GE stent is feasible and may potentially avoid the need for surgery. Although preliminary
EP
data on EUS-GE are encouraging, published studies are small and there are currently no prospective data comparing its efficacy and safety with enteral stenting or surgical
AC C
bypass. In addition, EUS-GE is technically challenging and should only be performed by experienced endoscopists with extensive therapeutic EUS and fluoroscopy experience and practicing at centers with appropriate surgical and interventional radiology backup. As such, EUS-GE should not be considered the standard of care for the management of GOO until further validation.
ACCEPTED MANUSCRIPT
Figure 1: EUS-guided gastroenterostomy stent displaced during dilation salvaged with the NOTES technique. A) Peritoneoscopy through displaced lumen apposing metal stent. Peritoneal
defect,
from
initial
cautery-assisted
stent
insertion,
identified
RI PT
B)
endoscopically. C) ERCP catheter and guidewire inserted through the peritoneal defect and advanced deep into the small bowel. D-E) Deployment of a lumen apposing stent
SC
over the wire. F) Contrast injection confirming proper location of the lumen apposing
M AN U
stent.
Video 1: General overview of EUS-guided gastroenterostomy and case presentation
Video 2: Technical description of EUS-guided gastroenterostomy complicated by stent
2.
3.
REFERENCES
Itoi T, Ishii K, Tanaka R et al. Current status and perspective of endoscopic ultrasonography-guided gastrojejunostomy: endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy (with videos). J Hepatobiliary Pancreat Sci 2015; 22: 3-11 Khashab MA, Baron TH, Binmoeller KF et al. EUS-guided gastroenterostomy: a new promising technique in evolution. Gastrointestinal endoscopy 2015; 81: 1234-1236 Khashab MA, Kumbhari V, Grimm IS et al. EUS-guided gastroenterostomy: the first U.S. clinical experience (with video). Gastrointestinal endoscopy 2015; 82: 932-938
AC C
1.
EP
technique.
TE D
displacement salvaged with the natural orifice transluminal endoscopic surgery
ACCEPTED MANUSCRIPT
RI PT
SC M AN U
7.
TE D
6.
EP
5.
Binmoeller KF, Shah JN. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503 Chen YI, Itoi T, Baron TH et al. EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surgical endoscopy 2016, DOI: 10.1007/s00464-016-5311-1: Itoi T, Ishii K, Ikeuchi N et al. Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut 2016; 65: 193-195 Tyberg A, Perez-Miranda M, Sanchez-Ocana R et al. Endoscopic ultrasoundguided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open 2016; 4: E276-281
AC C
4.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0016-5085(17)35594-4 10.1053/j.gastro.2017.04.045 YGAST 61173
To appear in: Gastroenterology Accepted Date: 5 April 2017 Please cite this article as: Chen Y-I, Haito-Chavez Y, Bueno RP, Bukhari M, Gutierrez OB, Sanaei O, Khashab MA, Displaced EUS-guided gastroenterostomy stent rescued with natural orifice transluminal endoscopic surgery, Gastroenterology (2017), doi: 10.1053/j.gastro.2017.04.045. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Displaced EUS-guided gastroenterostomy stent rescued with natural orifice transluminal endoscopic surgery Yen-I Chen, Yamile Haito-Chavez, Renata Pieratti Bueno, Majidah Bukhari, Olaya Brewer Gutierrez, Omid Sanaei, Mouen A. Khashab
RI PT
Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, MD, USA Corresponding Author: Mouen A. Khashab, MD
SC
Johns Hopkins Hospital 1800 Orleans Street
Baltimore, MD 21287 Tel: 443-287-1960 Email: [email protected] Conflict of interest:
M AN U
Sheikh Zayed Tower
TE D
Mouen Khashab is a consultant for Boston Scientific Other authors: None to declare.
AC C
EP
Authors’ contributions: Yen-I Chen: manuscript writing, video editing, video narration; Yamile Haito-Chavez: graphic and animation designer; Renata Pieratti Bueno: video editing; Majidah Bukhari: critical revision of the manuscript and video; Olaya Brewer Gutierrez: critical revision of the manuscript and video; Omid Sanaei: technical support; Mouen A. Khashab: Video concept and critical revision of the manuscript and video
ACCEPTED MANUSCRIPT
RI PT
Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is a novel approach in the treatment of gastric outlet obstruction (GOO)[1-3]. Using a lumen apposing metal stent (LAMS), a bypass can be created between the stomach and the small bowel distal to the
SC
obstruction. One of the major potential adverse events with EUS-GE is the misdeployment or displacement of the LAMS, which can lead to severe clinical
M AN U
consequences and possibly the need for surgical intervention. We describe a case of EUSGE complicated by stent displacement salvaged with natural orifice transluminal endoscopic surgery (NOTES) technique (Figure 1).
Description of Technology: The concept of endoscopic bypass is to provide sustained
TE D
palliation for GOO similarly to a surgical bypass through a minimal invasive approach. Although lumen apposing stents have been developed for drainage of pancreatic fluid
EP
collections, their anti-migration properties and generous luminal diameter are ideal for endoscopic bypass[4]. Data from retrospective and prospective series on EUS-GE have
AC C
shown promising results with technical and clinical success rates of greater than 90% and 85%, respectively. A recent comparative study suggested that EUS-GE may lead to fewer stent obstructions from tumor tissue ingrowth and overgrowth as compared to the traditional enteral stenting approach[5-7]. Currently, endoscopic bypass can be performed through EUS guidance or the NOTES technique. The major adverse event associated with EUS-GE is the risk for stent misdeployment or displacement leading to spillage of
ACCEPTED MANUSCRIPT
luminal content into the peritoneum and an iatrogenic perforation, which may require surgical intervention[6].
RI PT
Video Description: A 68-year old male patient with a history of unresectable cholangiocarcinoma was referred for symptoms of GOO (Video 1). A gastroscopy showed an obstruction in the second portion of the duodenum due to extrinsic
SC
compression from advanced cancer. After discussion with patient and his family a decision was taken to palliate with EUS-GE given the potential for a decreased risk of
M AN U
stent obstruction and need for re-intervention[5].
A gastroscope was advanced across the obstruction and fluid (methylene blue, normal saline, and contrast) was infused to optimize small bowel distension. Using fluoroscopy
TE D
and EUS, a small bowel loop close to the stomach was punctured with a 19-gauge needle (Video 2). Blue tinged fluid was aspirated confirming the correct location of the puncture. A LAMS was then inserted directly using cautery-assistance and deployed
EP
successfully forming the GE. A wire-guided dilating balloon was then inserted across the stent and inflated to 15 mm. Unfortunately, during dilation the patient retched displacing
AC C
both the distal flange of the LAMS and the guidewire from the small bowel into the peritoneal space. A therapeutic gastroscope was advanced through the LAMS and peritoneoscopy performed using CO2 insufflation. The puncture defect in the peritoneum was located and cannulated with an ERCP catheter preloaded with a 0.035 inch guidewire, which was advanced into the small bowel under fluoroscopy. The displaced LAMS was removed with a biopsy forceps over the wire. A LAMS was then advanced
ACCEPTED MANUSCRIPT
over the wire into the small bowel through the established puncture site with the assistance of a quick burst of cautery and the distal flange deployed. The stent was then pulled back approximating the small bowel to the stomach followed by deployment of the
RI PT
proximal flange. Contrast injection showed excellent stent position without evidence of a leak. Note that cautery assistance was needed to facilitate the passage of the second LAMS through the small bowel defect given the free flowing nature of the small bowel
SC
and difficulty of pushing the stent through without cautery. The patient was hospitalized with moderate abdominal pain due to focal peritonitis. He was placed on broad-spectrum
tolerating a full low-residue diet.
M AN U
antibiotics and improved rapidly. He was discharged 4 days later with minimal pain while
Take home message: EUS-GE is a novel treatment modality for GOO; however, stent
TE D
misdeployment/displacement is a feared complication with possible severe clinical consequences. This case demonstrates that by using NOTES, rescue of a displaced GE stent is feasible and may potentially avoid the need for surgery. Although preliminary
EP
data on EUS-GE are encouraging, published studies are small and there are currently no prospective data comparing its efficacy and safety with enteral stenting or surgical
AC C
bypass. In addition, EUS-GE is technically challenging and should only be performed by experienced endoscopists with extensive therapeutic EUS and fluoroscopy experience and practicing at centers with appropriate surgical and interventional radiology backup. As such, EUS-GE should not be considered the standard of care for the management of GOO until further validation.
ACCEPTED MANUSCRIPT
Figure 1: EUS-guided gastroenterostomy stent displaced during dilation salvaged with the NOTES technique. A) Peritoneoscopy through displaced lumen apposing metal stent. Peritoneal
defect,
from
initial
cautery-assisted
stent
insertion,
identified
RI PT
B)
endoscopically. C) ERCP catheter and guidewire inserted through the peritoneal defect and advanced deep into the small bowel. D-E) Deployment of a lumen apposing stent
SC
over the wire. F) Contrast injection confirming proper location of the lumen apposing
M AN U
stent.
Video 1: General overview of EUS-guided gastroenterostomy and case presentation
Video 2: Technical description of EUS-guided gastroenterostomy complicated by stent
2.
3.
REFERENCES
Itoi T, Ishii K, Tanaka R et al. Current status and perspective of endoscopic ultrasonography-guided gastrojejunostomy: endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy (with videos). J Hepatobiliary Pancreat Sci 2015; 22: 3-11 Khashab MA, Baron TH, Binmoeller KF et al. EUS-guided gastroenterostomy: a new promising technique in evolution. Gastrointestinal endoscopy 2015; 81: 1234-1236 Khashab MA, Kumbhari V, Grimm IS et al. EUS-guided gastroenterostomy: the first U.S. clinical experience (with video). Gastrointestinal endoscopy 2015; 82: 932-938
AC C
1.
EP
technique.
TE D
displacement salvaged with the natural orifice transluminal endoscopic surgery
ACCEPTED MANUSCRIPT
RI PT
SC M AN U
7.
TE D
6.
EP
5.
Binmoeller KF, Shah JN. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503 Chen YI, Itoi T, Baron TH et al. EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction. Surgical endoscopy 2016, DOI: 10.1007/s00464-016-5311-1: Itoi T, Ishii K, Ikeuchi N et al. Prospective evaluation of endoscopic ultrasonography-guided double-balloon-occluded gastrojejunostomy bypass (EPASS) for malignant gastric outlet obstruction. Gut 2016; 65: 193-195 Tyberg A, Perez-Miranda M, Sanchez-Ocana R et al. Endoscopic ultrasoundguided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open 2016; 4: E276-281
AC C
4.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT