S2090 Rare Terminal Ileum Migration of Lumen-Apposing Metal Stent Used for Pancreatic Pseudocyst Drainage

Abstract

INTRODUCTION: Pancreatic fluid collections, including pseudocysts, can occur as complications of pancreatitis. Endoscopic ultrasound-guided transluminal drainage with a lumen-apposing metal stent (LAMS) is the standard of care for symptomatic pseudocysts. Migration of these stents can occur into the cyst cavity or GI tract. Here we describe a case of LAMS migration into the terminal ileum which was successfully removed during colonoscopy. CASE DESCRIPTION/METHODS: A 51 year old male presented with right lower quadrant (RLQ) pain for one week. No other symptoms or changes in bowel habits were reported. His prior history includes polysubstance use disorder, alcohol-induced pancreatitis (multiple episodes), chronic kidney disease, diabetes, hypertension, and hyperlipidemia. His most recent episode of pancreatitis, complicated by pseudocyst formation required an endoscopic cystogastrostomy and LAMS placement for drainage of a large, symptomatic pseudocyst. On initial examination, the patient was well appearing but had tenderness to palpation in the RLQ without rebound or guarding. Laboratory tests were notable for a normocytic anemia and a mild AKI. Liver tests, lipase, and electrolytes were unremarkable. CT imaging showed an Axios stent within the terminal ileum with adjacent inflammation, but no obstruction. The patient was evaluated by both gastroenterology and surgery. An endoscopic approach was preferred and a colonoscopy was completed after bowel prep. The terminal ileum was reached and the migrated stent was visualized just proximal to the ileocecal valve. The stent was successfully removed utilizing a 2.4mm raptor grasping device (manufacturer-US Endoscopy). The terminal ileum was inspected post removal and was healthy-appearing with some residual congestion. The patient’s symptoms improved and he was discharged. DISCUSSION: Estimates regarding rates of stent migration have been varied across different reports, ranging from 1% to 19%. The cumulative rate of migration over a period of two years has been estimated to be as high as 31.4%. Previously reported migration of LAMS has been within the esophagus, small bowel, and colon. We report a case of migration of a LAMS in the terminal ileum and subsequent retrieval. Removal of these stents via endoscopic intervention can be difficult and requires adequate surgical support should endoscopic removal be unsuccessful. In our case, the stent was successfully removed during colonoscopy, preventing the morbidity and cost associated with surgical intervention.Figure 1.: Image 1: CT imaging with LAMS in the terminal ileum.Figure 2.: Image 2: LAMS in the terminal ileum, proximal extent.Figure 3.: Image 6: LAMS retrieved and raptor grasping device used.