New deployment techniques of the lumen‐apposing metal stent in walled‐off necrosis filled with necrotic tissue: Chick opening its mouth (with video)

Abstract

The lumen‐apposing metal stent (LAMS) on an electrocautery‐enhanced delivery system for endoscopic ultrasound‐guided transluminal drainage has been widely used for the treatment of walled‐off necrosis (WON). However, deployment of the LAMS can be technically difficult in WON, which contains a large amount of necrotic tissue and a low liquid component, owing to insufficient space for expansion of the distal stent flange. It has been recommended that the LAMS is placed in WON containing necrotic tissue, because additional endoscopic necrosectomy can be readily performed via the lumen of the LAMS. Here we introduce two new deployment techniques of the LAMS for WON filled with necrotic tissue, namely, the two‐step puncture technique and the back‐and‐forth technique, which enable the distal stent flange to be expanded like a chick opening its mouth. These techniques are expected to further improve the clinical outcomes of refractory WON.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges

“…How could endoscopists deal with complicated deployments of LAMS? Several novel techniques have been reported, among which the two-step puncture technique is recommended for IPN patients with massive solid necrosis and little fluid content, and the back-and-forth technique is intended for insufficient expansion of the distal flange[ 69 ].…”

Retrieval of a misdeployed lumen‐apposing metal stent in walled‐off necrosis by a parallel withdrawal technique using a double‐channel endoscope

“…First, we identified the WON cavity on contrast‐enhanced EUS. Then, we deployed an additional 20 mm LAMS (AXIOS‐EC; Boston Scientific) using back‐and‐forth technique to create an approach route 5 . Seven days later, we inserted a forward‐viewing endoscope through the additional LAMS into the WON cavity and could see the misdeployed LAMS blocked by necrotic tissue.…”

“…Then, we deployed an additional 20 mm LAMS (AXIOS-EC; Boston Scientific) using back-and-forth technique to create an approach route. 5 Seven days later, we inserted a forward-viewing endoscope through the additional LAMS into the WON cavity and could see the misdeployed LAMS blocked by necrotic tissue. There was limited space to open a snare to extract the misdeployed LAMS, and retrieval using a single grasping forceps was also difficult due to insufficient force and the risk of injury to the surrounding tissue.…”

Placement of a lumen‐apposing metal stent using the water‐filling technique from an endoscopic nasocystic drainage catheter to walled‐off necrosis with less liquid component

“…Lumen‐apposing metal stents (LAMS) are frequently used for draining pancreatic fluid collection, including walled‐off necrosis (WON) 1–4 . However, it is technically quite challenging to treat WON with rich necrotic tissue, and some techniques of endoscopic ultrasound‐guided transluminal drainage (EUS‐TD) have been reported 5 . The present case aimed to demonstrate safe deployment and placement of a LAMS by increasing the proportion of the liquid component of WON through the water‐filling technique (WFT) using an endoscopic nasocystic drainage catheter (NDC).…”