Lumen apposing metal stents for pancreatic fluid collections: Recognition and management of complications

Abstract

For patients recovering from acute pancreatitis, the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery, and introduces difficult management decisions with regard to when, whether, and how the collection should be drained. Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction. Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement), and the placement of percutaneous drains. Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients, when local expertise is available. Lumen-apposing metal stents (LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections, and less commonly, for other indications, such as gallbladder drainage. Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding, migration, buried stent, stent occlusion, and perforation. Because of the patient complexity associated with severe pancreatitis, management of pancreatic fluid collections can be a complex and multidisciplinary endeavor. Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques, including how to recognize and manage expected complications.

Endoscopic Interventions in Acute Pancreatitis: What the Advanced Endoscopist Wants to Know

“…One theory is that this observation may be due to the more rapid collapse of the collection when metal stents are used, causing impingement of the stent on blood vessels in the cyst wall, with development of pseudoaneurysm and delayed hemorrhage. Given the lack of robust long-term follow-up data, multiple authors have recommended follow-up CT 3 weeks after LAMS placement to assess for complications, with stent removal once resolution of the collection is achieved (38,61).…”

“…Perforation occurs in less than 5% of cases of ETD and ETN but when present may lead to dissemination of infection into the peritoneal cavity. It may occur during initial cystogastrostomy, with repeat tract dilatation, during débridement, or as a result of separation of the gastric or duodenal wall from the collection (31,61). Perforation is diagnosed at CT by pneumoperitoneum and generalized signs of peritonitis such as interval increase in peritoneal fluid and enhancement of the peritoneum.…”

“…Among these findings, identification of pneumoperitoneum or a new poorly defined collection near the site of intervention is a more reliable indicator of perforation than the presence of peritoneal fluid or enhancement alone. If identified, the size, location, and extent of the perforation should be described, as these factors may affect whether conservative, percutaneous, repeat endoscopic, or surgical management is selected (61).…”

“…Although most studies report the migration rate of LAMSs to be around 5%, some have demonstrated rates as high as 19% (29,61). While a plastic stent that migrates into the gastrointestinal tract often passes spontaneously (Fig 17), bowel obstruction secondary to intraluminal LAMS migration has been reported and may require endoscopic or surgical retrieval (61,63). Migration of a stent into the collection may increase the risk of bleeding if there is erosion into an adjacent blood vessel.…”

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

“…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.…”