A 72-year-old male (American Society of Anesthesiologists [ASA] II) presented with symptoms of vomiting and inability to eat since several weeks. Upper endoscopy revealed a large circular gastric carcinoma in the distal antrum, causing an outlet obstruction. Computed tomography (CT) revealed loco-regional lymphadenopathy and multiple small bilateral liver metastasis. There were no curative options. Based on the limited extent of metastasis and a reasonable life expectancy of the patient at that time, duodenal stenting was deemed unsuitable due to the risk of re-obstruction over time. As the patient did not prefer undergoing a surgical gastroenterostomy, an EUS-GE was performed to palliate the obstructive symptoms. The direct puncture technique was performed [4]. From the proximal antrum, a 15-mm LAMS (Hot AXIOS™ Stent and Electrocautery-Enhanced Delivery System; Boston Scientific Co., Marlborough, MA, USA), the standard-diameter LAMS that was used at that moment, was successfully deployed (Fig. 1A). The patient was discharged the next day.

After three weeks, the patient returned with symptoms of early satiety. A second upper endoscopy was performed and it revealed a LAMS obstructed by food impaction (Fig. 1B). The food bolus was extracted endoscopically, and the patient was discharged. Six weeks after the LAMS placement, the patient presented again with recurrent symptoms of GOO. A third upper endoscopy revealed that the LAMS had become stenotic due to hyperplastic tissue overgrowth (Fig. 1C), and the distal flange was buried in the jejunal wall (Fig. 1D). Dilation with a 12-mm controlled radial expansion (CRE)-balloon was performed, but the patient’s symptoms hardly improved. The persisting hyperplastic tissue, covering and obstructing the distal end of the stent, was partly treated by argon plasma coagulation, but a 9.8-mm endoscope still could not pass through the LAMS. The patient was rescheduled for a stent change. The original 15-mm LAMS was removed and replaced by a new 20-mm LAMS (Fig. 1E), ten weeks after the first LAMS placement. Palliative chemotherapy was started four days later. Because of vomiting, upper endoscopies were repeated twice, two days after and one month after initiating the chemotherapy. During both endoscopic examinations, a patent LAMS and an empty stomach were noted. Therefore, the complaints were respectively attributed to chemotherapy (which was discontinued after one cycle, following patient’s wish to stop due to side effects), and to a short and transitory period of food impaction (as the patient was able to eat again spontaneously, after the last upper endoscopy). The patient suffered from a rapidly progressive disease and passed away 4.5 months after the initial LAMS placement.

A 31-year-old female (ASA I) with a history of melanoma in situ, presented with postprandial nausea and vomiting since 6 weeks. Upper endoscopy revealed external compression of the horizontal part of the duodenum. CT revealed a 55×38-mm mass, originating from the uncinate process, with circular encasement of the proximal superior mesenteric artery and tumor progression in the left para-aortic region. Histological examination confirmed the diagnosis of a locally advanced pancreatic adenocarcinoma. Patient’s condition was good, her life expectancy was reasonable, and induction chemotherapy with additional surgery (when tumor regression allowed this) was planned. Therefore, duodenal stenting and surgical gastrojejunostomy were not preferred. Rather, direct EUS-GE was performed, with successful placement of a 20-mm diameter LAMS (Hot AXIOS™ Stent) between the antrum and the small intestine.

Two days later, the patient complained of postprandial epigastric cramps. Upper endoscopy revealed a patent and well-positioned LAMS, which could easily be passed with the pediatric gastroscope. Analgesics were administered for reducing pain, and induction chemotherapy was initiated 16 days after LAMS placement. One day after the first chemotherapy, the patient was readmitted to the hospital because of postprandial vomiting. Upper endoscopy, three weeks after LAMS placement, revealed a patent, but suboptimally expanded LAMS, with the opposite side of the enteral wall blocking the distal end of the LAMS (Fig. 2A). In addition, pressure ulcers were seen at the distal flange of the LAMS (Fig. 2B). As the stent was not fully expanded to its maximal size, the subsequent lengthening of the LAMS was probably the cause of the ulcerations. CRE-balloon dilation up to 20 mm was performed (Fig. 2C), and the patient’s symptoms improved. Two months later, however, the 5th chemotherapy cycle had to be postponed because of epigastric pain associated with worsening postprandial nausea and vomiting. A third repeat endoscopy revealed regenerative tissue overgrowth (biopsy proven) obstructing the distal end of the LAMS. Ulcerations were not visible; however, when the LAMS was passed, two small openings were identified (Fig. 2D): one to the jejunum, and a second opening suspected to be a gastro-colonic fistula (since colonic haustrae were identified after exploring the opening with the endoscope). Because the primary tumor regressed after neoadjuvant chemotherapy, a Whipple procedure (pancreaticoduodenectomy) was performed 17 weeks after the LAMS placement. During this procedure, the LAMS was identified, positioned in the stomach and attached to the transverse colon and to a jejunal loop. A right hemicolectomy, combined with a partial jejunal resection and resection of the greater curvature of the stomach, was performed to remove both the LAMS and the fistula. The surgical specimen of the resected LAMS showed the LAMS with tissues of the transverse colon and jejunum (Fig. 2E). Further pathological evaluation of the jejunum revealed the presence of gastric mucosa and ulcerations. Tissue around the stent (colon, jejunum, and distal stomach) was tumor-free. The patient experienced a complicated recovery, and was discharged after two months. Because of R1 tumor resection, adjuvant chemotherapy was indicated; however, the patients’ physical condition did not allow this. Seven months after the LAMS placement (four months after surgery), the patient developed an ileus of the small intestine and was diagnosed with peritoneal carcinomatosis. She was discharged home with best supportive care.