S2352 A Tale of Two Stents: Rescue of a Migrated Lumen-Apposing Stent During EUS-Guided Cystogastrostomy

Abstract

INTRODUCTION: Pancreatic pseudocysts are a common complication of pancreatitis. Both percutaneous and endoscopic therapeutic avenues have been developed for the drainage of symptomatic cysts. Surgical management is associated with higher rates of morbidity and, therefore, trans-gastric and trans-duodenal endoscopic drainage have become widely utilized treatments for the definitive management of pancreatic pseudocysts. Following tract creation and dilation, plastic pigtail stents, self-expanding metal stents, and now lumen-apposing covered self-expanding metal stents (LAMS) are used to maintain patency of the tract and allow for drainage of cysts. Though LAMS reduce the risk of stent migration, we report a case of a 28-year old female undergoing endoscopic ultrasound (EUS)-guided trans-gastric cystogastrostomy complicated by intra-procedural stent migration. CASE DESCRIPTION/METHODS: The patient had a two year history of abdominal pain that began after a cholecystectomy for gallstone disease. Computerized tomography (CT) imaging from May of 2019 demonstrated a large, thin-walled cyst within the head of the pancreas (Figure 1). The patient was scheduled to undergo EUS-guided drainage. A trans-gastric approach was utilized for tract creation. A 10 mm × 10 mm LAMS stent was deployed across the tract. The distal flange opened appropriately, however the proximal flange did not completely open. Because the tract was slightly longer than the length of the stent, while attempting to retract and reposition the stent, the proximal end migrated into the tract. To ensure maintained patency of the tract, a 10 mm × 80 mm covered metal biliary stent was placed inside of the LAMS stent to completely and securely bridge the cyst and the stomach. Final stent position was confirmed with fluoroscopy (Figure 2). The patient remained asymptomatic in the time between discharge and follow-up visit. The stents were removed without complication and no necrosis or bleeding was noted at the tract site. DISCUSSION: The use of lumen-apposing covered metal stents for pancreatic fluid collection drainage is a relatively novel technique offering a convenient, single step method of deployment. Though these large-lumen, dumbell-shaped devices reduce the risk of stent migration, we report a unique complication of the procedure in which, during stent deployment, one end of the LAMS stent migrated into the tract. Placement of a biliary metal stent proved to be an effective and safe rescue technique in this patient.Figure 1.: Large, thin-walled fluid-filled cyst in head of pancreas.Figure 2.: Fluoroscopic image demonstrating biliary metal stent contained within lumen-apposing metal stent bridging cyst to stomach.