1699 Stent Gone Rogue: Endoscopic Removal of a 3-Year-Old Embeded Cystgastrostomy Stent

Abstract

INTRODUCTION: We present a case of endoscopic removal of a delayed SEMS migration into the retroperitoneum, resulting in a perisplenic abscess and embedding of the SEMS into the gastric and retroperitoneal wall. CASE DESCRIPTION/METHODS: A 60-year-old man with idiopathic acute necrotizing pancreatitis complicated by walled-off pancreatic necrosis (WOPN) status post EUS-guided cystgastrostomy 3 years prior, presented with 3 weeks of worsening chronic abdominal pain and fever. Previous cystogastrostomy was performed with a through the scope 18 mm × 60 mm fully covered self-expandable esophageal metal stent (SEMS). Plan was to have SEMS removed after WOPN resolution; however, patient was lost to follow up. Abdominal CT scan revealed fluid collection in pancreatic tail measuring 4.8 × 1.9 cm and cyst-gastrostomy stent in place, splenomegaly measuring 15.5 cm with a perisplenic subcapsular collection along the lateral and superior splenic margin measuring 13.3 × 1.9 cm, thin fluid tract/collection extending from the pancreatic tail with more superior extension to questionably communicate with perisplenic collection. The 3-year-old SEMS was attempted to remove with a new through the scope fully covered 18 mm × 60 mm esophageal SEMS (Taewoong medical) but failed. Following, a new 20 mm lumen-apposing metal stent (LAMS) (Axios, Boston Scientific) stent was deployed within the embedded 3-year-old SEMS and it was secured to the embedded stent with standard clipping (Cook Medical), and CT abdomen 3 weeks after discharge noted improvement of perisplenic fluid collections. Follow up EGD/EUS allowed successful removal of 6F drainage catheter and inner Axios stent with rat tooth. After prolonged efforts, utilizing snare, biopsy, and piecemeal extraction, the embedded 3-year-old SEMS with wire struts and lattice fixed into the gastric wall and retroperitoneum was removed with no fragment remaining that was confirmed multiple times on endoscopy and fluoroscopy. Finally, Patient remained in good health without recurrence of symptoms at 6-months follow up in the outpatient clinics. DISCUSSION: This is the first case report of successful endoscopic removal of a 3-year-old embedded cystgastrostomy stent. Watch the video: http://bit.ly/2Lvc78C.