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 Table of Contents  
IMAGES AND VIDEOS
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 66-68

Endoscopic management of metal stent migration after walled-off necrosis drainage for 3 months (with video)


Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China

Date of Submission29-May-2019
Date of Acceptance10-Jul-2019
Date of Web Publication12-Feb-2020

Correspondence Address:
Dr. Jie Chen
Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai 200433
China
Dr. Zhao-Shen Li
Department of Gastroenterology, Changhai Hospital, Naval 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_58_19

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How to cite this article:
Zhu CP, Guo JF, Wang YF, Han T, Qian YY, Chen J, Li ZS. Endoscopic management of metal stent migration after walled-off necrosis drainage for 3 months (with video). Endosc Ultrasound 2020;9:66-8

How to cite this URL:
Zhu CP, Guo JF, Wang YF, Han T, Qian YY, Chen J, Li ZS. Endoscopic management of metal stent migration after walled-off necrosis drainage for 3 months (with video). Endosc Ultrasound [serial online] 2020 [cited 2020 Jul 13];9:66-8. Available from: http://www.eusjournal.com/text.asp?2020/9/1/66/278199




  Patient and Methods Top


A 34-year-old male patient was admitted with walled-off necrosis (WON) caused by acute pancreatitis. EUS showed that a well-defined cystic lesion measuring 11.3 cm × 13.5 cm was located in the body of the pancreas, which contained liquid and solid components, and the cyst was closely attached to the posterior wall of the stomach [Figure 1]a. The patient was referred for endoscopic transmural drainage, and a double-flanged covered metal stent (40 mm × 14 mm) was deployed across the posterior wall of the stomach under EUS and fluoroscopy guidance [Figure 1]b. The patient was in good condition after the procedure. However, 3 months later, a repeat abdominal computed tomography (CT) scan showed incomplete intracystic migration of the stent [Figure 1]c; therefore, we decided to retrieve the migrated stent.
Figure 1: (a) EUS showing a well-defined cystic lesion in the body of the pancreas, which contained liquid and solid components. (b) Fluoroscopy showing a transgastric double-flanged covered metal stent. (c) A repeat abdominal computed tomography scan showing that the metal stent had incompletely migrated into the pseudocyst

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  Endoscopic Procedure Top


During endoscopy, a fistula covered by a mass of granulation tissue was found on the posterior wall of the stomach and no stent was observed [Figure 2]a. The fistula was narrow and the endoscope could not be advanced. During fluoroscopy, we observed a double-flanged metal stent in the cyst cavity [Figure 2]b.
Figure 2: (a) Endoscopic view showing a nearly closed fistula on the posterior wall of the stomach. (b) Fluoroscopy showing a double-flanged metal stent in the cyst cavity. (c) Fluoroscopy showing the cyst cavity. (d) The fistula tract was dilated to 12 mm with columnar balloon dilators under fluoroscopy. (e) The retrieved metal stent. (f) Endoscopic view showing the gastric end of the double-pigtail plastic stent deployed across the fistula tract. (g) Endoscopic view showing the gastric part of the nasal cyst drainage tube placed in the cyst. (h) The plastic stent and the nasal cyst drainage tube were placed in the cyst under fluoroscopy

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A guidewire (Jagwire™ 0.035 in × 450 cm, Boston Scientific Corporation, MA, USA) was inserted into the cyst cavity through the fistula. A contrast catheter (Tandem™ XL, Boston Scientific Corporation, IN, USA) was introduced through the guidewire, and the cyst cavity was visualized after injection of 10 ml iodixanol [Figure 2]c. Then, the fistula tract was dilated to 12 mm with columnar balloon dilators (ECL, Cook Ireland Ltd, Limerick, Ireland) [Figure 2]d. Under endoscopy and fluoroscopy, the stent was slowly removed successfully by biopsy forceps (JHK-EE, JIUHONG Corporation, Changzhou, China) [Figure 2]e. Finally, we deployed a double-pigtail plastic stent (ZSO 7 Fr × 7 cm, Cook Ireland Ltd, Limerick, Ireland) across the fistula tract [Figure 2]f and [Figure 2]h, and a nasal cyst drainage tube (ENBD-7-NAG-C, Cook Ireland Ltd., Limerick, Ireland) was placed in the pseudocyst [Figure 2]g and [Figure 2]h. Effective drainage of the pseudocyst was observed. The procedure was carried out under fluoroscopy [Video 1].





  Discussion Top


According to the revised Atlanta classification of acute pancreatitis, encapsulated necrotic tissues were defined as WON.[1] About 20%–40% of acute pancreatitis cases progress to WON.[2] EUS-guided drainage has been widely used in WON due to its less invasiveness and effectiveness. Many studies have revealed that lumen-apposing metal stents (LAMSs) have become the standard of care for creation of an endoscopic cystenterostomy in patients with pancreatic WON.[3],[4]

Endoscopic transmural drainage using a LAMS in this patient with acute pancreatitis achieved technical success, and the symptoms were relieved to some extent. However, there is no consensus on when the stents should be removed. In another study, all stents were removed if CT or EUS 4–8 weeks after initial transmural drainage indicated that complete resolution was achieved. The 4A consensus in China recommended that the mean (± standard deviation) time to remove the LAMS was 4.59 ± 1.919 weeks (range, 3–12 weeks). Therefore, we had planned to retrieve the stent 3 months after the initial drainage.

Unfortunately, a repeat CT scan showed incomplete intracystic migration of the stent.

Stent migration is a common complication, and the occurrence rate is about 4.0%–6.5%.[5],[6] According to previous case reports, almost all cases of stent migration were managed successfully through endoscopy.[7],[8],[9] Here, we report a case in which stent migration at 3 months after drainage was resolved by an endoscopic technique without laparotomy. Due to closure of the fistula, it was more difficult to retrieve the stent under endoscopy.

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.

Acknowledgments

We thank all the assistants involved in the operation, including Ting Yang, Ke Qi, Cheng-Li Guo, and En-Dong Song. We also thank Medjaden Bioscience Limited for providing assistance in preparing the manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis – 2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.  Back to cited text no. 1
    
2.
Isayama H, Nakai Y, Rerknimitr R, et al. Asian consensus statements on endoscopic management of walled-off necrosis Part 1: Epidemiology, diagnosis, and treatment. J Gastroenterol Hepatol 2016;31:1546-54.  Back to cited text no. 2
    
3.
Guo J, Saftoiu A, Vilmann P, et al. Amulti-institutional consensus on how to perform endoscopic ultrasound-guided peri-pancreatic fluid collection drainage and endoscopic necrosectomy. Endosc Ultrasound 2017;6:285-91.  Back to cited text no. 3
    
4.
Gornals JB, Consiglieri CF, Busquets J, et al. Endoscopic necrosectomy of walled-off pancreatic necrosis using a lumen-apposing metal stent and irrigation technique. Surg Endosc 2016;30:2592-602.  Back to cited text no. 4
    
5.
Sharaiha RZ, Tyberg A, Khashab MA, et al. Endoscopic therapy with lumen-apposing metal stents is safe and effective for patients with pancreatic walled-off necrosis. Clin Gastroenterol Hepatol 2016;14:1797-803.  Back to cited text no. 5
    
6.
Fabbri C, Luigiano C, Cennamo V, et al. Endoscopic ultrasound-guided transmural drainage of infected pancreatic fluid collections with placement of covered self-expanding metal stents: A case series. Endoscopy 2012;44:429-33.  Back to cited text no. 6
    
7.
Costa JM, Gonçalves BM, Costa RS, et al. Endoscopic management of stent displacement after pancreatic pseudocyst drainage. Endoscopy 2018;50:E304-6.  Back to cited text no. 7
    
8.
Varadarajulu S. EUS-guided retrieval of a migrated transgastric pancreatic stent. Endoscopy 2007;39 Suppl 1:E18-9.  Back to cited text no. 8
    
9.
Guo J, Liu Z, Sun S, et al. Removal of displaced double flanged metal stent in walled-off necrosis by endoscopic ultrasonography. Endosc Ultrasound 2016;5:132-3.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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