V1 - Takes Two to Tango: Simultaneous Bidirectional Endoscopic Closure of a Gastrocolonic Perforation After Removal of a Misdeployed Lumen-Apposing Metal Stent

A misdeployed lumen-apposing metal stent (LAMS) can lead to luminal perforation. Conventional management of gastric or colonic perforation requires operative interventions. We present a novel method of simultaneous closure of gastric and colonic perforations using contemporaneous, bidirectional, endoscopic dual-sided closure.

Case Description/

Methods:

A 75-year-old male with a pancreatic pseudocyst and an indwelling transcutaneous drain underwent an endosonographic cyst-gastrostomy for drain internalization. After 2 weeks, the patient developed abdominal pain and diarrhea. A subsequent computerized tomogram of the abdomen demonstrated that the drain was abutting the colon wall, and LAMS was deployed into the colon, leading to a gastrocolonic fistula. 

After a multidisciplinary consultation, the decision was made to perform endoscopic interventions to remove the LAMS and treat the consequent gastric and colonic perforations, thus avoiding surgical interventions.

Simultaneous upper endoscopy and colonoscopy were performed by two interventional endoscopists. The upper endoscopy confirmed the LAMS traversing the stomach into the colon (Figure 1). Multiple colon ulcers were identified. A guidewire was passed through the gastroscope, across the LAMS, into the colon, and grasped by the colonoscope to ensure stable access. The LAMS was then removed over the guidewire.
The resulting margins of the gastric and colonic perforations were pretreated with argon plasma coagulation prior to definitive closure. The gastric perforation was closed with a running suture using an over-the-scope suturing system. Closure of the colonic perforation with an over-the-scope clip resulted in partial closure (Figure 2). The remaining colon perforation was closed using a through-the-scope helix tack-and-suture device. Successful closure was confirmed with bidirectional water insufflation. A barium study confirmed the absence of leakage. 

The patient was discharged after 24 hours of observation. Follow-up colonoscopy demonstrated complete healing of colon ulcers. He had no adverse outcomes at his one-year follow-up.

Discussion:

We report the use of simultaneous bidirectional endoscopy as a minimally invasive alternative to surgery for closure of gastric and colonic perforations due to a misdeployed LAMS. Successful closure and the absence of adverse events on follow-up suggest that endoscopic management of perforations can be a viable alternative to surgical intervention for select patients in specific circumstances.