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 Table of Contents  
IMAGES AND VIDEOS
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 61-63

An unusual complication of cardia occlusion with lumen-apposing metal stent therapy for pancreatic pseudocyst


Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China

Date of Submission09-Aug-2017
Date of Acceptance16-Sep-2017
Date of Web Publication15-Feb-2018

Correspondence Address:
Dr. Yiqi Du
Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai 200433
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/eus.eus_99_17

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How to cite this article:
Chen Y, Zhu H, Jin Z, Li Z, Du Y. An unusual complication of cardia occlusion with lumen-apposing metal stent therapy for pancreatic pseudocyst. Endosc Ultrasound 2018;7:61-3

How to cite this URL:
Chen Y, Zhu H, Jin Z, Li Z, Du Y. An unusual complication of cardia occlusion with lumen-apposing metal stent therapy for pancreatic pseudocyst. Endosc Ultrasound [serial online] 2018 [cited 2020 Apr 2];7:61-3. Available from: http://www.eusjournal.com/text.asp?2018/7/1/61/225433

Yan Chen, Huiyun Zhu
These authors contributed equally to this work.




A 44-year-old male patient (body mass index [BMI], 21.22 kg/m 2) was admitted to our hospital with intermittent severe epigastric pain radiating to the left shoulder for 2 months. He had a history of acute pancreatitis 4 months prior when his BMI was 32.65 kg/m 2. Magnetic resonance cholangiopancreatography revealed two cystic lesions, one at the pancreatic tail measuring approximately 7.5 cm × 7.0 cm × 3.5 cm and the other within the splenic capsule measuring approximately 13.0 cm × 10.0 cm × 5.5 cm [Figure 1]. The patient was diagnosed with pancreatic pseudocyst (PP) and splenic subscapular collection (SSC) complicated by moderately severe acute pancreatitis.
Figure 1: Images of the two cystic lesions. (a) Magnetic resonance cholangiopancreatography shows a splenic fluid space attached to the pancreatic tail and pancreatic pseudocyst at the pancreatic tail. (b) Computed tomography-guided percutaneous drainage of the splenic subcapsular collection

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After admission, computed tomography-guided percutaneous drainage of the SSC was performed with a 10-Fr pigtail tube. The amylase level of the brown fluid was 5641 U/L. The tube was removed 8 days later when the drainage volume decreased to 10 mL/day. An EUS-guided cystogastrostomy was performed 4 days after percutaneous puncture in the upper gastric body, adjacent to the cardia. The lumen of the lumen-apposing metal stent (LAMS) showed an opening toward the esophagus and complete coverage of the gastric cardia with anchor flange, which is supposed to be in the stomach [Figure 2]. A nasogastric feeding tube was deployed instantaneously, by passing the stent, under endoscopic control [Figure 3]. The amylase level of the cyst fluid was 66,096 U/L.
Figure 2: Drainage of the pancreatic pseudocyst. (a) EUS-guided puncture. (b) Fluoroscopic image immediately after deployment of lumen-apposing metal stent within the pseudocyst. (c) Endoscopic view of lumen-apposing metal stent immediately after deployment as viewed from the lower esophagus

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Figure 3: Imaging 3 days after drainage. Nasogastric feeding tube ensures adequate intake (arrowhead). (a) Computed tomography showing lumen-apposing metal stent and percutaneous drainage tube with resolution of lesions. (b) Fluoroscopy showing lumen-apposing metal stent and iodixanol flowing into the pseudocyst

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By day 3, the patient reported complete resolution of pain and requested oral intake. Upper gastrointestinal contrast fluoroscopy revealed iodinated contrast media flowing into the PP cavity along the lumen of the LAMS [Figure 3]. The nasogastric tube was then used for enteral nutrition. The patient experienced rapid improvement and complete resolution of the PP upon imaging at the 3-week follow-up. The LAMS was retrieved endoscopically. An abdominal radiography was performed 60 h after removal to ensure the absence of gastric fistula [Figure 4]. Oral eating was then permitted and the patient remains asymptomatic 3 months later.
Figure 4: Stent removal. (a) Mucosal overgrowth at the gastric end of the stent after 27 days. (b) Safe removal using a snare. (c) Endoscopic view of fistula after removal (arrowhead). (d) Fluoroscopy confirmed healing of the gastric fistula

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Splenic complications can be expected in acute pancreatitis, especially with an inflammatory process originating from the tail of the pancreas into the hilum of the spleen, which likely occurred in our case. Percutaneous drainage is the recommended treatment option for these complications.[1],[2] EUS-guided cystogastrostomy of a PP is a well-established procedure.[3],[4],[5] Recently, the introduction of the novel LAMS has made transmural intervention more effective.[6],[7],[8] In our case, the cystogastrostomy process was imperfect because the cardia was blocked because of the upper puncture position. Fortunately, the large stent diameter allowed rapid adequate drainage and the nutrition tube was just placed for 27 days. We recommend choosing the lower part of the stomach as the puncture point, or designing a shorter LAMS, to avoid this complication.

Acute pancreatitis complicated simultaneously by PP and SSC is not uncommon. We treated both conditions during the initial hospitalization. Cardia occlusion by LAMS during the EUS-guided procedure retarded oral administration; we are the first to report this complication associated with LAMS.[9],[10] This was successfully solved by placement of a nasogastric feeding tube.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Malka D, Hammel P, Lévy P, et al. Splenic complications in chronic pancreatitis: Prevalence and risk factors in a medical-surgical series of 500 patients. Br J Surg 1998;85:1645-9.  Back to cited text no. 1
    
2.
Tseng CW, Chen CC, Chiang JH, et al. Percutaneous drainage of large subcapsular hematoma of the spleen complicating acute pancreatitis. J Chin Med Assoc 2008;71:92-5.  Back to cited text no. 2
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3.
Wiersema MJ. Endosonography-guided cystoduodenostomy with a therapeutic ultrasound endoscope. Gastrointest Endosc 1996;44:614-7.  Back to cited text no. 3
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4.
Vilmann P, Hancke S, Pless T, et al. One-step endosonography-guided drainage of a pancreatic pseudocyst: A new technique of stent delivery through the echo endoscope. Endoscopy 1998;30:730-3.  Back to cited text no. 4
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5.
Lopes CV, Pesenti C, Bories E, et al. Endoscopic-ultrasound-guided endoscopic transmural drainage of pancreatic pseudocysts and abscesses. Scand J Gastroenterol 2007;42:524-9.  Back to cited text no. 5
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6.
Talreja JP, Shami VM, Ku J, et al. Transenteric drainage of pancreatic-fluid collections with fully covered self-expanding metallic stents (with video). Gastrointest Endosc 2008;68:1199-203.  Back to cited text no. 6
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7.
Rodrigues-Pinto E, Baron TH. Evaluation of the AXIOS stent for the treatment of pancreatic fluid collections. Expert Rev Med Devices 2016;13:793-805.  Back to cited text no. 7
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8.
Zhu H, Lin H, Jin Z, et al. Re-evaluation of the role of lumen-apposing metal stents (LAMS) for pancreatic fluid collection drainage. Gut 2017;66:2192.  Back to cited text no. 8
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9.
Shah RJ, Shah JN, Waxman I, et al. Safety and efficacy of endoscopic ultrasound-guided drainage of pancreatic fluid collections with lumen-apposing covered self-expanding metal stents. Clin Gastroenterol Hepatol 2015;13:747-52.  Back to cited text no. 9
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10.
Rinninella E, Kunda R, Dollhopf M, et al. EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: A large retrospective study (with video). Gastrointest Endosc 2015;82:1039-46.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


This article has been cited by
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Nan Ge,Si-Yu Sun
World Journal of Clinical Cases. 2019; 7(23): 4157
[Pubmed] | [DOI]



 

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