Dislodged lumen-apposing metal stent (LAMS) in EUS–guided gastrojejunostomy salvaged by LAMS-in-LAMS technique

A 61-year-old man with a history of obstructive jaundice from pancreatic head adenocarcinoma, who had undergone placement of a biliary stent 3 months earlier, presented with nausea, vomiting, low-grade fever, and abdominal CT findings concerning for gastric outlet obstruction. An EUS-guided gastrojejunostomy was created with a 20-mm × 10-mm lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Marlborough, Mass, USA) by use of a freehand technique, with flow of contrast material mixed with methylene blue from the jejunum across the LAMS into the stomach. However, the distal end retracted from the jejunal wall, flaring in the peritoneal cavity and partially in the jejunal wall (A), with a resultant small jejunal tear visualized endoscopically. Through a therapeutic forward-viewing endoscope, an angled stiff wire (Dreamwire, Boston Scientific) was advanced under direct vision (B) through the tear into the jejunum aided by fluoroscopy. Over the wire, a second LAMS was deployed with the distal end in the jejunum and the proximal flare inside the distal flare of the previous LAMS (C). An upper GI series showed no evidence of extravasation of contrast material (D). To our knowledge, this is the first successful case of a LAMS-in-LAMS technique to salvage malposition of the LAMS during creation of an EUS-guided gastrojejunostomy.