Skip to main content

Hybrid gastroenterostomy using a lumen-apposing metal stent: a case report focusing on misdeployment and systematic review of the current literature



Gastric outlet obstruction can result from several benign and malignant diseases, in particular gastric, duodenal or pancreatic tumors. Surgical gastroenterostomy and enteral endoscopic stenting have represented effective therapeutic options, although recently endoscopic ultrasound-guided gastroenterostomy using lumen-apposing metal stent (LAMS) is spreading improving the outcome of this condition. However, this procedure, although mini-invasive, is burdened with not negligible complications, including misdeployment.

Main body

We report the case of a 60-year-old male with gastric outlet obstruction who underwent ultrasound-guided gastroenterostomy using LAMS. The procedure was complicated by LAMS misdeployment being managed by laparoscopy-assisted placement of a second LAMS.

We performed a systematic review in order to identify all reported cases of misdeployment in EUS-GE and their management. The literature shows that misdeployment occurs in up to 10% of all EUS-GE procedures with a wide spectrum of possible strategies of treatment.


The here reported hybrid technique may offer an innovative strategy to manage LAMS misdeployment when this occurs. Moreover, a hybrid approach may be valuable to overcome this complication, especially in early phases of training of EUS-guided gastroenterostomy.


Gastric outlet obstruction (GOO) is a potential complication in malignancies of the upper gastrointestinal tract including gastric, duodenal, pancreatic or biliary tumors [1]. Conventionally, surgical gastroenterostomy (SGE) and endoscopic enteral stenting (ES) are common treatment options. However, SGE has higher complication and mortality rates than ES, which on the other hand demonstrates unsatisfactory patency in patients with life expectancy higher than 6 months [2, 3]. In recent years, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) using lumen-apposing metal stent (LAMS) has been introduced in order to overcome these limitations. Nevertheless, technical success is still suboptimal (around 90%) and complication rates are not negligible (9–17%) [4]. This case report shows a hybrid approach for LAMS deployment, in order to reduce LAMS-associated complications. We further lay focus on recent literature on complications in surgical and endoscopic gastrointestinal anastomosis.

Main text and case presentation

We report the case of a 60-year-old male patient affected by metastatic pancreatic adenocarcinoma who developed symptoms related to GOO (nausea, vomiting). No prior surgical intervention for his oncologic condition or other abdominal problems were performed. During esophagogastroduodenoscopy a duodenal bulb stenosis was diagnosed. Therefore, decision was taken to perform EUS-GE using an electrocautery enhanced (EC)-LAMS 15 × 10 mm (Hot-Axios, Boston Scientific Corp., Marlborough, Massachusetts, USA), which was performed under general anesthesia in the operating theater for logistical reasons.

For stent deployment, endoscopic antegrade freehand technique was used [5]: over a guidewire, a nasocystic tube was passed over the stricture and the jejunum was filled with contrast and methylene blue; under EUS-guidance, the target loop was identified and punctured using a 19 gauge needle, with aspiration of methylene blue confirming correct needle position in the jejunum. While maintaining the target loop in EUS-view, the EC-LAMS was deployed. However, LAMS release was complicated by misdeployment of the first flange which opened in the lesser sac, probably due to lack of penetration by the EC-LAMS cystotome into the jejunum.

As the endoscopic procedure was performed in an operating room, the chance of immediate exploratory laparoscopy was given. Three laparoscopic trocars were placed (one 10 mm supraumbilical trocar and two 5-mm trocars in the right and left upper quadrants), the gastrocolic ligament was sectioned and the lesser sac explored. The first flange of the stent was found open outside of the posterior gastric wall (Fig. 1), leaning against the transverse mesocolon. Jejunal and transvers colonic perforations were excluded.

Fig. 1
figure 1

Misdeployment: view of the EC-LAMS opened on the posterior gastric wall

EC-LAMS was removed endoscopically. Then, laparoscopically, the first jejunal loop after the ligament of Treitz was identified and placed near the stomach. With laparoscopic guidance, we endoscopically released a second EC-LAMS 15 × 10 mm through the previous fistulous gastric tract, performing a laparoscopy-assisted gastroenterostomy (GE). A secure apposition of the LAMS was finally obtained, correct deployment was confirmed both endoscopically and laparoscopically (Fig. 2).

Fig. 2
figure 2

Hybrid technique: laparoscopic view of gastroenteroanastomosis with the EC-LAMS

Procedure time for laparoscopy was 95 min and EUS-guided anastomosis via LAMS deployment needed 6 min. No intraprocedural adverse events occurred (Additional file 1: Video S1).

Seventy-two hours after the procedure oral nutrition was initiated and the patient was discharged on postoperative day 7.

Discussion and conclusions

Establishing gastrointestinal anastomoses is a relatively new endoscopic procedure implemented in 2012 by Binmoeller and Itoi et al. using covered double-anchored metal stents placed via endoscopic ultrasound guidance [6, 7], it rapidly achieved acceptance as a valued alternative for SGE as it was proven to be effective, less invasive and associated with less procedure-related morbidity and mortality. Since 2012, foremost case reports or small case series have been published. Recently, two randomized controlled trials comparing endoscopic vs. surgical GE were published [8, 9] A study by Perez-Miranda et al. study of Perez-Miranda et al. showed that endoscopic GE was associated with fewer postoperative complications and higher technical success than surgical GE (differences non-statistically significant). In a study by Kashab et al. no significant difference was found between endoscopical and surgical GE for adverse events. Technical success was significantly higher in patients treated with surgical GE. Very recently an international multicenter comparison showed that for patients with gastric outlet obstruction EUS-GE and surgical GE have almost identical technical and clinical success; however, reduced time to oral intake, shorter median hospital stay and lower rate of adverse events suggest that the EUS-guided approach might be preferable [10].

Patients with GOO, in which GE becomes necessary, are usually fragile and prone to high morbidity and mortality due to underlying diseases. Therefore, it is necessary to reduce procedure-related mortality as effectively as possible. Use of LAMS for EUS-GE is still considered an off label indication by the American Society of Gastrointestinal Endoscopy [11]. Technical and clinical success rates are reported to be as high as 93 and 90%, respectively [12]. Complications/adverse events associated with LAMS, including misdeployment, are as high as 12% in recent meta-analyses [4].

Various technical endoscopic approaches for EUS-GE exist [5, 13] and so far, it is not clear which one should be favored in order to reduce rate of complications. Chen et al. compared the “direct puncture” with the “balloon assisted” method in a cohort of 77 patients resulting in comparative results concerning complications, technical and clinical success. Only procedure time has been different favoring the direct approach [14]. The “EPASS”-procedure (EUS-guided double-balloon-occluded gastrojejunostomy bypass), which uses a double-balloon-guided occlusion of the jejunal part which will then be connected to the gastric cavity via LAMS, was recently described as one of the safest approaches [15, 16] because of the stable fixation which thereby helps to avoid malpositioning or unsafe LAMS deployment. As for now, it remains in the hands of the endoscopist, which kind of treatment approach to choose, mostly depending on his own experience.

In recent reviews, reported complications associated with EUS-GE are ranging around 12%, including postinterventional pain, bleeding, stent obstruction, stent migration, peritonitis and LAMS misdeployment [4, 12, 17, 18]. A recent multicenter study by Ghandour et al. reported a total of 9.85% (46/467) stent misdeployments counting for one of the most important complications of EUS-GE [19].

Different technical problems can occur during LAMS deployment. Both the proximal or distal flange can be misdeployed, resulting in gastric or jejunal perforation. Also non-target organ puncture can be part of the misdeployment, such as transversing the mesocolon or the transverse colon itself. No standard strategies to overcome LAMS misdeployment exist, its management is up to clinical expertise of each endoscopist.

In order to identify common problems with LAMS deployment/misdeployment and associated problem-solving strategies, we conducted a systematic literature research.

A literature search up to September 2021 among common databases, including PUBMED, SCOPUS, World of Science (WoS), was performed using the following research terms: “axios, lumen-apposing metal stent, gastroenteric anastomosis, gastroenterostomy.”

Publications were accepted in any format, language or publication status. All retrospective, prospective and randomized controlled studies, case reports and case series on humans were included, while studies on animal models were excluded. Studies not mentioning complications related to endoscopic ultrasound-guided gastroenteroanastomosis were excluded.

The initial research identified 323 studies. A total of 75 studies were excluded because of duplicates. Seventy-six were excluded after screening through title and abstract, because not fulfilling the criteria mentioned above. Full text evaluation of 172 studies was fully assessed and included in this systematic review. A total of 151 studies were excluded because of Editorials, review, systematic review with meta-analysis, not reporting misdeployment or duplication of data. Twenty-one studies reported misdeployment (see Fig. 3 and Table 1).

Fig. 3
figure 3

Review flowchart

Table 1 Publications included in the systematic review

We hereby name the most frequently used strategies according to the initial issue of LAMS misdeployment:

  1. A)

    LAMS proximal flange misdeployment: The fistulous tract into the jejunum is already established but the proximal flange is misdeployed into the peritoneum and is not anchored in the gastric wall. Through the gastric puncture site, another LAMS or a fully covered metal stent can be placed in order to bridge the already placed LAMS [8, 20]. Alternatively, LAMS can be removed completely, the gastric puncture site closed with an over-the-scope-clip (OTSC, Ovesco, Tübingen, Germany) and a new LAMS placed via a new access [21, 22].

  2. B)

    LAMS distal flange misdeployment: During puncture of the jejunum, the jejunum dislocates, and the distal flange cannot be opened or is only partially opened into the target site. The distal flange therefore partially remains in the peritoneum creating a free perforation of the gastric wall. Here, either LAMS can be completely removed and a fully covered bridging stent or a second LAMS be inserted [20, 23]. During misdeployment of the distal flange without puncturing the jejunum in two patients reported by Kashab et al., LAMS removal and only conservative treatment were performed. An additional option is to create a NOTES access in which the originally created fistulous tract, created by the LAMS, can be secured endoscopically [20, 24]. In cases where the jejunal wall defect could not be reached by endoscopy, Wannhoff et al. preferred to insert a duodenal fully covered stent to bridge the GOO inducing tumor, whereas the jejunal puncture was not occluded [22]. Interestingly, this did not result in further peritonitis originating from the jejunum.

  3. C)

    Stent misdeployment perforating other organs such as the mesocolon or the transverse colon is a complication which needs surgical intervention [25].

  4. D)

    Stent misdeployment into the peritoneal cavity: in rare cases, when LAMS cannot be retrieved endoscopically from the peritoneal cavity, stent removal by abdominal surgery might be necessary [26].

The hybrid technique described in this case report has several significant advantages. Probability of incorrect deployment of the first flange is up to 27% [17]. Therefore, a laparoscopically assisted procedure outperforms the limitation of a 2-dimensional endoscopic exam, in this case the incorrect visualization of the target loop by endoscopic ultrasound and furthermore the lack of correct cystostome penetration of the jejunal wall.

Furthermore, this hybrid approach may have the ability to considerably shorten overall procedure time while securing success of endoscopic LAMS deployment. Mean procedure time for laparoscopic GE varies widely from 75 to 170 min in the literature [27]. In our case, time for laparoscopy was 95 min, which included the exclusion of jejunal and colonic perforations and recovery of the flange of EC-LAMS. However, procedure time for GE by LAMS was only 6 min.

Another advantage of this hybrid approach may be the possibility of performing anastomoses between the posterior gastric wall and the first jejunal loop, therefore maintaining a maximum of intestinal absorption surface and reducing the risk of malabsorption and malnourishment [28].

However, limitations are mainly related to the availability of infrastructure and medical staff. EUS-GE usually is not performed in an operating theater. Moreover, this hybrid approach requires simultaneous involvement of two teams, surgeons and endoscopists, which is uncommon and more costly.

To our knowledge, this clinical case reported is the first to show a combined endoscopic and surgical treatment approach in order to overcome endoscopic restrictions for GE, in particular LAMS misdeployment. In cases where endoscopic orientation is difficult and LAMS deployment therefore is at risk, we propose a combined endoscopic and surgical approach in order to reduce procedure time and provide higher safety standards. Further studies need to confirm this observation.

Availability of data and materials

All data generated during this study are included in this published article and its supplementary information files. Further minor datasets are available from the corresponding author on reasonable request.



Endoscopic enteral stenting


Endoscopic ultrasound


Endoscopic ultrasound-guided gastroenterostomy




Surgical gastroenterostomy


Gastric outlet obstruction


Lumen-apposing metal stent


  1. Chowdhury A, Dhali GK, Banerjee PK. Etiology of gastric outlet obstruction. Am J Gastroenterol. 1996;91:1679.

    CAS  PubMed  Google Scholar 

  2. Khashab M, Alawad AS, Shin EJ, et al. Enteral stenting versus gastrojejunostomy for palliation of malignant gastric outlet obstruction. Surg Endosc. 2013;27:2068–75.

    Article  Google Scholar 

  3. Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc. 2010;71:490–9.

    Article  Google Scholar 

  4. Iqbal U, Khara HS, Hu Y, et al. EUS-guided gastroenterostomy for the management of gastric outlet obstruction: A systematic review and meta-analysis. Endosc Ultrasound. 2020;9:16–23.

    Article  Google Scholar 

  5. Irani S, Itoi T, Baron TH, et al. EUS-guided gastroenterostomy: techniques from east to west. VideoGIE. 2020;5:48–50.

    Article  Google Scholar 

  6. Binmoeller KF, Shah JN. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy. 2012;44:499–503.

    Article  CAS  Google Scholar 

  7. Itoi T, Itokawa F, Uraoka T, et al. Novel EUS-guided gastrojejunostomy technique using a new double-balloon enteric tube and lumen-apposing metal stent (with videos). Gastrointest Endosc. 2013;78:934–9.

    Article  Google Scholar 

  8. Perez-Miranda M, Tyberg A, Poletto D, et al. EUS-guided gastrojejunostomy versus laparoscopic gastrojejunostomy: an international collaborative study. J Clin Gastroenterol. 2017;51:896–9.

    Article  Google Scholar 

  9. Khashab MA, Bukhari M, Baron TH, et al. International multicenter comparative trial of endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for the treatment of malignant gastric outlet obstruction. Endosc Int Open. 2017;5:E275–81.

    Article  Google Scholar 

  10. Bronswijk M, Vanella G, van Malenstein H et al. Laparoscopic versus EUS-guided gastroenterostomy for gastric outlet obstruction: an international multicenter propensity score-matched comparison (with video). Gastrointest Endosc. 2021;94:526–536 e522.

  11. Committee ASoP, Jue TL, Storm AC et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc. 2021; 93: 309–322 e304

  12. Antonelli G, Kovacevic B, Karstensen JG, et al. Endoscopic ultrasound-guided gastro-enteric anastomosis: a systematic review and meta-analysis. Dig Liver Dis. 2020;52:1294–301.

    Article  Google Scholar 

  13. Marrache MK, Itani MI, Farha J, et al. Endoscopic gastrointestinal anastomosis: a review of established techniques. Gastrointest Endosc. 2021;93:34–46.

    Article  Google Scholar 

  14. Chen YI, Kunda R, Storm AC, et al. EUS-guided gastroenterostomy: a multicenter study comparing the direct and balloon-assisted techniques. Gastrointest Endosc. 2018;87:1215–21.

    Article  Google Scholar 

  15. Tsuchiya T, Sofuni A, Itoi T. Case of successful endoscopic ultrasonography-guided gastrojejunostomy for gastric outlet obstruction caused by gallbladder carcinoma. Dig Endosc. 2019;31(Suppl 1):66–7.

    Article  Google Scholar 

  16. 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;65:193–5.

    Article  Google Scholar 

  17. Carbajo AY, Kahaleh M, Tyberg A. Clinical review of EUS-guided Gastroenterostomy (EUS-GE). J Clin Gastroenterol. 2020;54:1–7.

    Article  Google Scholar 

  18. Tan S, Zhong C, Huang S, et al. Clinical outcomes of lumen-apposing metal stent in the management of benign gastrointestinal strictures: a systematic review and meta-analysis. Scand J Gastroenterol. 2019;54:811–21.

    Article  CAS  Google Scholar 

  19. Ghandour B, Bejjani M, Irani SS, et al. Classification, outcomes, and management of misdeployed stents during EUS-guided gastroenterostomy. Gastrointest Endosc. 2021.

    Article  PubMed  Google Scholar 

  20. Tyberg A, Perez-Miranda M, Sanchez-Ocana R, et al. Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open. 2016;4:E276-281.

    Article  Google Scholar 

  21. Kerdsirichairat T, Irani S, Yang J, et al. Durability and long-term outcomes of direct EUS-guided gastroenterostomy using lumen-apposing metal stents for gastric outlet obstruction. Endosc Int Open. 2019;7:E144–50.

    Article  Google Scholar 

  22. Wannhoff A, Ruh N, Meier B, et al. Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success. Surg Endosc. 2020.

    Article  PubMed  Google Scholar 

  23. Chen YI, James TW, Agarwal A, et al. EUS-guided gastroenterostomy in management of benign gastric outlet obstruction. Endosc Int Open. 2018;6:E363–8.

    Article  Google Scholar 

  24. Chen YI, Haito-Chavez Y, Bueno RP, et al. Displaced endoscopic ultrasound-guided gastroenterostomy stent rescued with natural orifice transluminal endoscopic surgery. Gastroenterology. 2017;153:15–6.

    Article  Google Scholar 

  25. James TW, Greenberg S, Grimm IS, et al. EUS-guided gastroenteric anastomosis as a bridge to definitive treatment in benign gastric outlet obstruction. Gastrointest Endosc. 2020;91:537–42.

    Article  Google Scholar 

  26. 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. Surg Endosc. 2017;31:2946–52.

    Article  Google Scholar 

  27. Manuel-Vazquez A, Latorre-Fragua R, Ramiro-Perez C, et al. Laparoscopic gastrojejunostomy for gastric outlet obstruction in patients with unresectable hepatopancreatobiliary cancers: a personal series and systematic review of the literature. World J Gastroenterol. 2018;24:1978–88.

    Article  Google Scholar 

  28. Reche F, Meyer C. Gastroenteroanastomosi. EMC Tec Chir Addom. 2008;14:1–13.

    Google Scholar 

  29. Bazaga S, Garcia-Sumalla A, Laquente B, et al. Intraperitoneal endoscopic salvage using an enteral stent for a misdeployed lumen-apposing metal stent during endoscopic ultrasound-guided gastroenterostomy. Endoscopy. 2021.

    Article  PubMed  Google Scholar 

  30. Bejjani M, Ghandour B, Subtil JC, et al. Clinical and technical outcomes of patients undergoing EUS-guided gastroenterostomy using 20 mm vs 15 mm LAMS. Endoscopy. 2021.

    Article  PubMed  Google Scholar 

  31. Colombo M, Fugazza A, Kurihara H, et al. Salvage procedure for double trouble in lumen-apposing metal stent misdeployment during endoscopic ultrasound-guided gastroenterostomy: ready to start again. Am J Gastroenterol. 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Martins BC, Ruas JN, Fiuza F, et al. Lessons learned from a salvage procedure for lumen-apposing metal stent misplacement during EUS-guided gastrojejunal bypass. VideoGIE. 2020;5:464–7.

    Article  Google Scholar 

  33. Ge PS, Young JY, Dong W, et al. EUS-guided gastroenterostomy versus enteral stent placement for palliation of malignant gastric outlet obstruction. Surg Endosc. 2019;33:3404–11.

    Article  Google Scholar 

  34. Gornals JB, Consiglieri CF, Maisterra S, et al. Helpful technical notes for intraperitoneal natural orifice transluminal endoscopic surgery (NOTES) salvage in a failed EUS-guided gastroenterostomy scenario. Endoscopy. 2021.

    Article  PubMed  Google Scholar 

  35. Havre RF, Dai C, Roug S, et al. EUS-guided gastroenterostomy with a lumen apposing self-expandable metallic stent relieves gastric outlet obstruction—a Scandinavian case series. Scand J Gastroenterol. 2021;56:972–7.

    Article  CAS  Google Scholar 

  36. Kouanda A, Binmoeller K, Hamerski C, et al. Endoscopic ultrasound-guided gastroenterostomy versus open surgical gastrojejunostomy: clinical outcomes and cost effectiveness analysis. Surg Endosc. 2021.

    Article  PubMed  Google Scholar 

  37. Ligresti D, Amata M, Barresi L, et al. The lumen-apposing metal stent (LAMS)-in-LAMS technique as an intraprocedural rescue treatment during endoscopic ultrasound-guided gastroenterostomy. Endoscopy. 2019;51:E331–2.

    Article  Google Scholar 

  38. Nguyen NQ, Hamerski CM, Nett A, et al. Endoscopic ultrasound-guided gastroenterostomy using an oroenteric catheter-assisted technique: a retrospective analysis. Endoscopy. 2021.

    Article  PubMed  Google Scholar 

  39. Sondhi AR, Law R. Intraperitoneal salvage of an EUS-guided gastroenterostomy using a nested lumen-apposing metal stent. VideoGIE. 2020;5:415–7.

    Article  Google Scholar 

  40. Wannhoff A, Ruh N, Meier B, et al. Endoscopic gastrointestinal anastomoses with lumen-apposing metal stents: predictors of technical success. Surg Endosc. 2021;35:1997–2004.

    Article  Google Scholar 

Download references


Not applicable.


No funding to declare.

Author information

Authors and Affiliations



The manuscript has been read and approved by all the authors; the requirements for authorship have been met; each author believes that the manuscript represents honest work. CF, VA and LA were directly involved in the entire procedure and designed the clinical case. CB, PF and CFMJ screened the literature. MS, MT, CC and EP were responsible for data acquisition and creation of supplementary information files. CB, PF, MS, MT, CC, CFMJ and EP were involved in manuscript preparation. CF and LA were involved in critical revision, editing and reviewing of the paper. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Cecilia Binda.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication


Competing of interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1. Video S1: EUS-GE, confirmation of the misdeployment of the EC-LAMS, laparoscopic procedure of the GE using a second EC-LAMS

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Fabbri, C., Binda, C., Fugazzola, P. et al. Hybrid gastroenterostomy using a lumen-apposing metal stent: a case report focusing on misdeployment and systematic review of the current literature. World J Emerg Surg 17, 6 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: