Endoscopic retrieval of a lumen-apposing metal stent complicated by inward migration after cystogastrostomy

Abstract

Endoscopic ultrasound (EUS)-guided drainage is well known as an established technique for the treatment of pancreatic pseudocysts [1, 2]. New covered metal stents, known as lumen-apposing metal stents (LAMS), have been designed. Despite their superior antimigration features, these LAMS can migrate inwardly [3, 4]. We report a case of successful endoscopic retrieval of a LAMS with inward migration after cystogastrostomy. A 50-year-old man with a history of alcohol-induced chronic pancreatitis complicated by a large pancreatic pseudocysts at the head of the pancreas (▶ Fig. 1), presented with severe abdominal pain and gastric outlet obstruction. EUS-guided cystogastrostomy was successfully performed with a 15-mm LAMS (▶ Fig. 2). The patient returned for stent removal 2 months later, and the follow-up computed tomography (CT) scan revealed resolution of the cyst. However, during the esophagogastroduodenoscopy to remove the stent, we observed a small orifice at the location of the previously applied stent (▶ Fig. 3 a). Fluoroscopic images confirmed stent migration into the fistulous lumen of the remaining pseudocyst (▶ Fig. 3 b). We proceeded with endoscopic retrieval of LAMS (▶ Video 1). The retrieval procedure was performed under general anesthesia. Carbon diox-▶ Fig. 1 Computed tomography scan demonstrating a large pancreatic pseudocyst (circled) at the head of the pancreas, requiring endoscopic ultrasound-guided drainage. ▶ Fig. 2 Treatment of the pseudocyst. a Endoscopic ultrasound (EUS) image of the cystogastrostomy. b Endoscopic image of successful EUSguided drainage of the pseudocyst with a lumen-apposing metal stent.

Successful retrieval of a lumen-apposing metal stent that had completely migrated into the cavity of a walled-off necrosis

“…Endoscopic ultrasonography (EUS)-guided transgastric drainage of pancreatic fluid collections (PFCs) using a lumen-apposing metal stent (LAMS) is an effective treatment for walled-off necrosis (WON) 1 2 3 . However, misdeployment can occur, which is a severe adverse event 4 5 .…”

“…tive treatment for walled-off necrosis (WON) [1][2][3]. However, misdeployment can occur, which is a severe adverse event [4,5]. EUS-guided transgastric drainage with a LAMS was performed in a 29-year-old woman, for a WON induced by severe idiopathic acute pancreatitis (▶ Fig.…”

Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management

“…The proximal flange of the stent can be grasped with rat-tooth forceps and an attempt can be made to reposition the metallic stent. If only the distal flange is available for grasping, stent retrieval can be tried after inversion of the stent [26-28].…”

Use of a twin‐channel endoscope for removal of a lumen‐apposing metal stent that migrated spontaneously after cystogastrostomy

“…Migration can be classified according to timing (during LAMS deployment or delayed migration) and direction (internal migration [towards the target cavity] or external migration [into the access lumen]). 1,2 Delayed internal migration is rare, but once internal migration occurs, retrieval of the LAMS is often difficult. 3,4 We consider a twin-channel scope useful for retrieval as it enables the LAMS to be grasped and held until the force of the scope can be transferred.…”