69-year-old female with history of hypertension, Parkinson's disease and newly diagnosed pancreatic head mass, cytology with poorly differentiated carcinoma, status post ERCP twice with failed cannulation of the bile duct and subsequent placement of percutaneous external biliary catheter. The patient was found to have gastric and duodenal distension on a recent CAT scan at an outside hospital concerning for gastric outlet obstruction. He was transferred to our hospital for further workup of surgical slash chemotherapy candidacy. Patient was deemed not a surgical candidate and underwent endoscopic ultrasound guided gastrointestinal. Ten days later, the patient was brought back to the endoscopy suite for internalization of the percutaneous strain. Trials at reaching the papilla and retrograde through the gastrointestinal therapeutic scope were not successful. The therapeutic scope was switched to a colonoscope and while trying to reach the papilla, the lamp stent was dislodged separating the gastric wall from the jejunal wall with the lamp stent still attached to the jejunal wall. A wire was left in place through the lamps and the scope was exchanged out. The scope was exchanged to a double channel scope which was advanced into the peritoneum through the gastric opening. The lamp stent was attached to the jejunal wall. Under fluoroscopic guidance, the grabbers were used to pull the lumen opposing metal stents towards the stomach. A second set of grabbers were used to grab the small bowel to help ensure this would not migrate off the stent. The small bowel loop was brought into the stomach and the grabbers were exchanged out for the X-TAC suturing system. The X-TAC was then used to place a tag on the jejunal wall next to the lumen opposing metal stents and the jejunal wall with the lumen opposing metal stent were pulled into the gastrostomy. Another attack was placed using the X-TAC to fix the gastric wall and jejunal walls together in place. The previously placed lumen opposing metal stent was removed entirely. The gastric defect and small bowel defect were cannulated with a wire and the scope was driven into the small bowel where a previously placed tattoo was visualized. In you, lumen opposing metal stent 20 centimeters by 10 centimeters were placed through the gastro-jejunostomy into this loop of bowel with the distal flange and the jejunum and the proximal flange and the stomach. This case highlights using a novel method of utilizing the through-the-scope suturing system to allow us to secure a small bowel in place while deploying rescue stent. The use of through-the-scope suturing system avoids the need of exchanging the scope as opposed to over-the-scope suturing systems and clips. This also prevents loss of position and maintains fixation of small bowel. This case also highlights a new method of salvage of mis-deployed transmural stents, which helps avoid surgery. And according to the classification previously described for mis-deployment of lumen-opposing mental stents, our case demonstrates type 3 mis-deployment that was salvaged. In conclusion, this video demonstrates novel fixation method as salvage therapy for mis-deployed and migrated lumen-opposing mental stents using through-the-scope suturing system.

pancreatic head mass

endoscopic procedure

X-TAC suturing system

lumen-opposing metal stent

stent mis-deployment