Management Of Pancreatic Pseudocysts Research Articles

Non-Operative Management of Pancreatic Pseudocyst in Paediatric Population: A Case Report

Non-Operative Management of Pancreatic Pseudocyst in Paediatric Population: A Case Report

The Surgical Management of Pancreatic Pseudocysts: A Narrative Review.

Pancreatic pseudocysts, commonly arising as a complication of acute or chronic pancreatitis, present a significant clinical challenge. This narrative review explores the surgical management of pancreatic pseudocysts, emphasizing advancements, techniques, and outcomes. We examine the indications for surgical intervention, including symptomatic pseudocysts, complications such as infection or hemorrhage, and pseudocysts resistant to conservative treatment. Various surgical approaches are discussed, including open surgery, laparoscopic techniques, and endoscopic interventions. The review highlights the evolution of surgical strategies, from traditional cystogastrostomy to minimally invasive methods, and assesses their efficacy and safety. Additionally, we address patient selection criteria, preoperative assessment, and postoperative care. By synthesizing current evidence and clinical experiences, this review aims to provide a comprehensive overview of the best practices in the surgical management of pancreatic pseudocysts, offering valuable insights for clinicians in optimizing patient outcomes.

SP4.6 - Endoscopic versus laparoscopic management of pancreatic pseudocyst - A systematic review and meta-analysis

Abstract Objective The aim of this meta-analysis is to compare the postoperative surgical outcomes of endoscopic versus laparoscopic management of pancreatic pseudocyst. Methods Two randomised control trials (RCTs) and four comparative trials reporting postoperative outcomes for patients undergoing treatment with endoscopic transgastric or transduodenal drainage versus laparoscopic cyst-gastrectomy or cyst-jejunostomy for the pancreatic pseudocyst were selected from medical electronic databases and meta-analysis was conducted by the guidelines of the Cochrane Collaboration using statistical software RevMan version 5.4. Results Two RCTs and four comparative trials on 401 patients reporting postoperative outcomes were included. In the random effect model analysis, the overall success rate [odds ratio (OR) 0.81, 95%, CI (0.38, 1.72), Z = 0.54, P = 0.59] was comparable between the two groups with no heterogeneity among the included studies. Adverse events after the procedure was also comparable between the two groups [OR 0.72, 95%, CI (0.34, 1.50), Z = 0.89, P = 0.37] with no heterogeneity among the included studies. Hospital stay was shorter in the endoscopic group [Mean difference -2.71, 95%, CI (-4.14, -1.27), Z = 3.69, P = 0.0002] with high statistical heterogeneity among the included studies. Conclusion The patients managed with endoscopic procedures had shorter hospital stay, but the incidence of adverse post-procedure outcomes and overall success rate were comparable between the two groups. Due to the paucity of the RCTs, a major multi-centre RCT is needed to strengthen the findings of this systematic review.

Pancreatic pseudocyst: The past, the present, and the future.

A pancreatic pseudocyst is defined as an encapsulated fluid collection with a well-defined inflammatory wall with minimal or no necrosis. The diagnosis cannot be made prior to 4 wk after the onset of pancreatitis. The clinical presentation is often nonspecific, with abdominal pain being the most common symptom. If a diagnosis is suspected, contrast-enhanced computed tomography and/or magnetic resonance imaging are performed to confirm the diagnosis and assess the characteristics of the pseudocyst. Endoscopic ultrasound with cyst fluid analysis can be performed in cases of diagnostic uncertainty. Pseudocyst of the pancreas can lead to complications such as hemorrhage, infection, and rupture. The management of pancreatic pseudocysts depends on the presence of symptoms and the development of complications, such as biliary or gastric outlet obstruction. Management options include endoscopic or surgical drainage. The aim of this review was to summarize the current literature on pancreatic pseudocysts and discuss the evolution of the definitions, diagnosis, and management of this condition.

Endoscopic intramural cystogastrostomy for treatment of peripancreatic fluid collection: A viewpoint from a surgeon.

Percutaneous or endoscopic drainage is the initial choice for the treatment of peripancreatic fluid collection in symptomatic patients. Endoscopic transgastric fenestration (ETGF) was first reported for the management of pancreatic pseudocysts of 20 patients in 2008. From a surgeon's viewpoint, ETGF is a similar procedure to cystogastrostomy in that they both produce a wide outlet orifice for the drainage of fluid and necrotic debris. ETGF can be performed at least 4 wk after the initial onset of acute pancreatitis and it has a high priority over the surgical approach. However, the surgical approach usually has a better success rate because surgical cystogastrostomy has a wider outlet (> 6 cm vs 2 cm) than ETGF. However, percutaneous or endoscopic drainage, ETGF, and surgical approach offer various treatment options for peripancreatic fluid collection patients based on their conditions.

Minimally Invasive Open Cystogastrostomy for Giant Pancreatic Pseudocyst in Pediatric Patients.

Open cystogastrostomy is the standard treatment for the operative management of pancreatic pseudocysts. We describe our technique of minimally invasive open cystogastrostomy for giant pediatric pancreatic pseudocyst. Preoperative incision marking on the most prominent part of the pseudocyst was done by ultrasound guidance. A transverse incision of approximately 3-4 cm was made, and a minilaparotomy was performed. Stay sutures were applied on the anterior wall of the stomach. The anterior wall was exteriorized; transverse gastrotomy was performed, and superior and inferior flaps were made. Deaver's retractor was placed inside the lumen, and cystogastrostomy was completed. We employed this technique in five male patients without any complications. All patients were allowed clear liquids on postoperative day 4 or 5; and gradually shifted to a soft diet. The mean duration of postoperative stay was 7 days. The size of the scar ranged from 3 to 5 cm. All patients were doing well on follow-up. Our technique of minimally invasive open cystogastrostomy is a viable option for pancreatic pseudocyst in pediatric patients.

A Retrospective Study on Comparison Between Surgical and Endoscopic Management of Pancreatic Pseudocyst and Walled-off Pancreatic Necrosis

BACKGROUND: Surgical management is the standard approach for pancreatic pseudocyst and walled off pancreatic necrosis. With newly evolving procedures and a comprehensive approach, management of walled off pancreatic necrosis and pancreatic pseudocyst is taking a new turn. A multi-centric study comparing surgical and endoscopic management of pancreatic pseudocyst and walled off pancreatic necrosis was performed. METHODS: Data was collected retrospectively from multiple centers and patients were followed up till date since the time of intervention. The outcomes were therapeutic success, post-operative complications, recurrence rate, mortality and duration of hospitalization. RESULTS: At the end of the follow-up period, none of the patients who received endoscopic intervention had a recurrence, compared to 2 patients in the surgical group. There was 16.67% mortality in the surgical group and only 3.33% mortality in the endoscopic group. Significantly high mortality was seen in the patients with Walled-Off Pancreatic Necrosis treated surgically, compared to no mortality in the patients treated endoscopically. 86 % of the patients in the endoscopic group had resolution of the disease following intervention compared to 70% in the other group. There were no statistically significant differences in mortality, resolution or recurrence of disease following intervention between the two groups. However, the length of hospital stay was significantly shorter for patients who underwent endoscopic intervention than open surgery. CONCLUSION: Endoscopic drainage of Pancreatic Pseudocysts and Walled off Pancreatic necrosis have demonstrated a therapeutic success rate, mortality and recurrence statistically comparable to that seen in surgical treatment, but with reduced time of hospitalization, supporting its use as the preferred initial modality for drainage.

PSEUDO-KYSTE DU PANCREAS CHEZ LA PERSONNE AGEE

Introduction: Pancreatic pseudocysts (PKP) are fluid collections without their own epithelium, developed at the expense of or in contact with the pancreas, containing pure pancreatic juice or mixed with necrotic debris, following pancreatitis or trauma, or of undetermined cause. Treatment of PKP usually requires drainage. We discuss the diagnostic and therapeutic aspects of a case of pseudocyst of the pancreas drained by conventional surgery in an elderly patient with a good post-operative course. Observation: We admitted an 80-years-old patient with epigastric abdominal mass, pain, physical asthenia and anorexia evolving for 1 year. She had no previous medical history. Examination revealed a painful epigastric abdominal mass, more or less mobile in relation to the deep plane, with a smooth surface and irregular, matt edges. Pelvic touch was unremarkable. CT scan showed a large intra-abdominal cystic mass (pancreatic cyst? mesenteric cyst?). Biology revealed anemia and hyperleukocytosis. After laparotomy, we found a voluminous, firm cystic mass, about 10x5x8 cm in size, at the expense of the body of the pancreas. We proceeded to internal drainage of the cyst by retrogastric cysto gastrostomy according to JEDLICKA. The patient was followed up for one year without any particularities. Conclusion: In our case, a symptomatic pancreatic pseudocyst was drained by surgical retrogastric cystogastrostomy with a favorable outcome. The management of pancreatic pseudocysts requires a multidisciplinary approach and an adequate technical platform.

Increasing trend of endoscopic drainage utilization for the management of pancreatic pseudocyst: insights from a nationwide database.

The pancreatic pseudocyst (PP) is a type of fluid collection that typically develops as a delayed complication of acute pancreatitis. Drainage is indicated for symptomatic patients and/or associated complications, such as infection and bleeding. Drainage modalities include percutaneous, endoscopic, laparoscopic, and open drainage. This study aimed to assess trends in the utilization of different drainage modalities for treating PP from 2016 to 2020. The trends in mortality, mean length of hospital stay, and mean hospitalization costs were also assessed. The National Inpatient Sample database was used to obtain data. The variables were generated using International Classification of Diseases-10 diagnostic and procedural codes. Endoscopic drainage was the most commonly used drainage modality in 2018-2020, with an increasing trend over time (385 procedures in 2018 to 515 in 2020; p=0.003). This is associated with a decrease in the use of other drainage modalities. A decrease in the hospitalization cost for PP requiring drainage was also noted (29,318 United States dollar [USD] in 2016 to 18,087 USD in 2020, p<0.001). Endoscopic drainage is becoming the most commonly used modality for the treatment of PP in hospitals located in the US. This new trend is associated with decreasing hospitalization costs.

Comparison of Conservative Management versus Drainage in Patients with Pancreatic Pseudocyst

Objective: To compare the conservative management of pancreatic pseudocyst with active surgical intervention.Study Design: Case series study.&#x0D; Place and Duration of Study: Department of General Surgery Combined Military Hospital, Rawalpindi Pakistan, from Jan 2020 to Apr 2021.&#x0D; Methodology: A total of 40 patients with pancreatic pseudocysts were included. The size of the pseudocysts, patients’ age,gender, lifestyle risk factors and possible aetiology were recorded. Conservative management was offered initially. The nonregressing and complicated pseudocysts were treated surgically via radiology-assisted external drainage or surgical drainage. Relevant data via close follow-up was recorded.&#x0D; Results: The mean age of the patients was 61±8.89 years. The pseudocyst size ranged from 4-17cm (median 10cm). Conservative treatment was efficacious in 15(37.5%) with shorter hospital stays (p-value&lt;0.001). All remained pain-free during the one-year follow-up. Surgical intervention was required in 25(62.5%). Radiology-assisted external drainage employed in 15(60%), proved advantageous in 14(93.4%) patients. Recurrence was seen in one patient (6.6%). Other complications included abscess and sepsis. Surgical drainage was used in 10(40%) individuals. Complications included sepsis, abscess and intractable pain. Cumulative intervention-related complications were far higher than conservative management (14,56%, p-value 0.01).The thirty-day mortality in the study patients was 5%, all following surgical intervention.&#x0D; Conclusion: Conservative management can be successfully employed to avoid the adverse sequelae associated with active interventions.Keywords: Complications, Conservative management, Pancreatic pseudocyst, Radiological intervention, Surgical intervention

Laparoscopic vs Endoscopic Management of Pancreatic Pseudocysts: A Scoping Review.

Pancreatic pseudocyst (PPC) and walled-off necrosis (WON) develop as late complications of acute pancreatitis that have been historically managed surgically. With the advancement in endoscopic equipment and the evolution of endoscopic surgery, the management of PPC has evolved considerably in recent years from surgical drainage to transmural endoscopic drainage. Till the end of the 20th century, a limited number of surgeons performed laparoscopic drainage of PPCs. Due to the steep learning curve needed for performing advanced laparoscopic suturing, a majority of studiesconducted during this period have compared open surgical drainage with endoscopy.The efficacy of these modalities has largely been evaluated using retrospective studies and a few meta-analysesparticularly due to the low-volume caseload of individual centres. Also, these studies include PPC and WON together in data analysis despite WON being a distinct entity. There are limited prospective well-designed clinical trials comparing endoscopic and laparoscopic management of pure PPCs. There is also a lack ofspecific recommendations for the management of PPCs. Considerable overlap of indications between these two modalitiesexists. The efficacy of endoscopic transmural drainage as an index intervention when compared to laparoscopy has not been proven in the research literature. Previous studies have not considered multiple endoscopic interventions within a four-week period of index intervention as a failure.We reviewed the literature using appropriate MeSH terms on the PubMed search engine for articles comparing laparoscopic and endoscopic transmural management of PPCs according to our inclusion and exclusion criteria. Seven articles were identified for inclusion in the qualitative synthesis. This scoping review was conducted to answer some pertinent unanswered questions, identify gaps in knowledge regarding the laparoscopic vs endoscopic management of PPCs, and guide further research.

S378 EUS-Guided Cyst Gastrostomy for Treatment of a Pancreatic Pseudocyst Extending Into the Mediastinum Resulting in Acute Respiratory Failure

Introduction: Mediastinal pseudocysts are the result of a rare drainage tract formation that develops more often in patients with a history of alcohol related chronic pancreatitis. The current evidence suggests favorable outcomes using endoscopic transmural drainage in the management of pancreatic pseudocysts. Here, we present a challenging approach to an unusual complication of a pancreatic pseudocyst extending into the mediastinum using EUS guided creation of a cyst gastrostomy. Case Description/Methods: A 50-year-old female with a history of alcohol related chronic pancreatitis presented to our hospital in severe respiratory distress requiring intubation for acute hypoxemic respiratory failure. A CT scan demonstrated a pseudocyst extending through the esophageal hiatus into the mediastinum and right lower lung where it measured 69.7mm. Multidisciplinary consensus between gastroenterology and interventional radiology was to proceed with EUS assisted creation of a cyst gastrostomy with placement of a metal stent. A curvilinear echoendoscope was passed and advanced into the proximal stomach. Here, a 55mm anechoic cystic cavity with layering debris was brought into stable view. Using standard endo cut settings, a 10mm x 10mm lumen apposing axios metal stent was successfully placed using a cauterized technique. The echoendoscope was then exchanged for the gastroscope and the stent was seen to be in good position draining cystic fluid. Four days after the procedure, a CT scan showed the stent extending from the proximal stomach to the pseudocyst, which had decreased in size from 69.7mm to 43.6mm. One week following the initial procedure, the patient underwent upper endoscopy, which showed the lumen-apposing metal stent in the cardia along with an empty cavity and scant fluid drainage when suction was applied through the stent. A CT scan performed 8 weeks later showed complete resolution of the pseudocyst. The patient then underwent upper endoscopy with EUS, which confirmed resolution of the pseudocyst and the stent was removed using rat tooth forceps. Discussion: In this case, we have demonstrated the utility of EUS in the creation of a cyst gastrostomy to successfully treat a patient with acute respiratory failure secondary to pancreatic pseudocyst extension into the mediastinum and right lower lung. Further studies are needed to evaluate for pseudocyst recurrence following this procedure to determine its long-term efficacy in the management of mediastinal pseudocysts. Watch the video at https://tinyurl.com/ACGAbstractS378Figure 1.: (A) CT scan showing a pseudocyst extending through the esophageal hiatus into the right lower lobe of the lung where it measured 69.7 mm and appeared to contain gas. (B) CT scan showing a stent extending from the stomach to the pseudocyst which decreased in size to 43.6 mm and an enlarging moderate right pleural effusion. (C) CT scan demonstrating the stent placed on prior admission with interval resolution of the previously demonstrated large pseudocyst.

The surgical management of pancreatic pseudocysts – outcomes on a group of seven patients

The pancreatic pseudocyst represents the main complication that occurred 3 to 6 weeks after an outbreak of acute or chronic pancreatitis represented by a collection containing pancreatic enzymes without their own epithelial wall. In the present paper, we present a study performed on 7 patients admitted to the Surgical Department of Sibiu County Emergency Clinical Hospital who were diagnosed with pancreatic pseudocyst between 2016 and 2020, and the drainage of the mini-invasive pancreatic pseudocyst by an incision in the right lumbar area, in the case of a 53-year-old patient known to have a history of multiple cardiac defects, the pancreatic pseudocyst being discovered approximately 6 months before, for which the patient underwent conservative treatment, and who had 5 resuscitated cardio-respiratory arrests throughout the evolution.

Laparoscopic Cystogastrostomy in Children with Pancreatic Pseudocysts: A Preliminary Experience of Eight Cases.

Introduction:Pancreatic pseudocysts (PPCs) and walled-off necrosis (WON) in children following acute pancreatitis are uncommon. The various modalities of therapy possible are conservative treatment, external drainage, endoscopic stenting, and internal surgical drainage procedures. There are no existing guidelines for the management of PPC in children. We evaluate the outcomes of laparoscopic cystogastrostomy (LCG) performed at our center.Materials and Methods:Eight children (median age: 10 years) underwent LCG for large PPC (median size: 12.5 cm). There were seven patients with PPC and one with WON. Seven underwent LCG by a transgastric approach and one underwent LCG by a retrogastric approach.Results:Seven out of the eight patients had complete resolution of symptoms and the PPC. The median follow-up period was 32 months (interquartile range: 9.5–55.5 months). There were no conversions. There was one patient with a WON who developed a recurrence.Conclusion:LCG is a safe and effective treatment option for large PPC/WON in children. A posterior retrogastric approach, when indicated, is a safe approach with a comparable outcome.

Laparoscopic Intragastric Cystgastrostomy: A Technical Report.

Background: Management of symptomatic pancreatic pseudocysts poses a unique challenge to minimally invasive surgeons. Despite the predominance of endoscopic management of pancreatic pseudocysts, the laparoscopic approach remains a critical skill in the armamentarium of surgeons. Methods: This report details a laparoscopic intragastric approach to create a pancreatic cystgastrostomy using intraoperative ultrasound and endoscopy. Conclusion: Laparoendoscopic techniques for pancreatic pseudocysts are still required in selective cases when endoscopic management is not available or fails. Using this technique provides patients with same clinical benefits of an endoscopic approach.

Cystocolostomy as an unusual approach to recurrent pancreatic pseudocyst in a Ugandan male with dense hepatogastroduodenal adhesions: A case report.

Introduction and importancePancreatic pseudocyst is one of the most frequent late complications of acute pancreatitis with increasing prevalence in chronic pancreatitis. Other causes include abdominal trauma, biliary tract disease, and other idiopathic causes. 85% resolve spontaneously within 4–6 weeks. Interventions are required for persistently symptomatic, large and complicated pancreatic pseudocysts. Cystocolostomy is a rarely reported pancreatic pseudocyst drainage option.Case presentation20-year-old male with large recurrent pancreatic pseudocyst following trauma underwent 2 exploratory laparotomies from a peripheral hospital, before referral to Lubaga hospital. Ultrasound-guided cyst drainage was performed. He was readmitted two weeks later with features of cyst recurrence. Re-laparotomy was done and the stomach, duodenum and proximal jejunum were inaccessible due to extensive dense non-obstructive adhesions. Therefore, we performed a transverse cystocolostomy. Patient improved and was discharged on 5th post-operative day. Review was unremarkable at 6 weeks and 3 months post-surgery.Clinical discussionCurrent management of pancreatic pseudocyst is percutaneous, endoscopic or laparoscopic drainage. However in cases of large recurrent cysts despite the above interventions, open surgery still has a role. Cystogastrostomy, cystoduodenostomy or cystojejunostomy are the commonly performed drainage options. These 3 options were not possible in this patient due to dense adhesions, hence we performed a transverse cystocolostomy with no post-operative complications. Possible complications from the procedure might include recurrent pancreatitis, pancreatic abscess and stool leak into the pancreatic duct.ConclusionIn cases of inaccessibility to the stomach, duodenum and jejunum due to non-obstructing dense adhesions, a pancreatic cystocolostomy can be performed with equally good outcomes.

51-Year-Old Man With Ascites and Abdominal Pain

51-Year-Old Man With Ascites and Abdominal Pain

Use of lumen-apposing metal stents (LAMS) in the management of gastro jejunostomy stricture following Roux-en-Y Gastric Bypass for obesity: a prospective series

BackgroundChronic strictures following Roux-en-Y Gastric Bypass (RYGB) are a troublesome complication that can lead to significant morbidity. The use of stents has been described but the need for X-ray and risk of migration have meant limited use in the management of these strictures. Lumen apposing metal stents (LAMS) have traditionally been used for management of pancreatic pseudocysts. They don’t require X-ray and are easy to deploy with a short learning curve. This paper explores the use of LAMS to treat post RYGB strictures and explores their safety and efficacy.MethodsA prospective study over a 4-year period looking at 14 patients with post RYGB strictures. These patients were privately insured patients operated within a tertiary Private facility. The patients were followed up for between 1 and 3 years. We have prospectively collected data on the efficacy and safety of LAMS in these patients. Patients were followed up until stent removal or definitive surgery to correct a stricture.Results421 patients underwent RYGB in the study period. 14 (3.3%) of these patients developed a stricture that resulted in insertion of LAMS. There was no immediate complications and 12 patients had complete resolution of their stricture. There were no reoperations due to migration related issues although a migration rate of 19% was noted. 2 patients required surgery to correct refractory strictures not relieved by a LAMS stent, both of these were strictures associated with marginal ulceration of the gastro jejunostomy.ConclusionLAMS are a safe and effective method to manage post RYGB strictures. They have a high rate of resolution of strictures and can be safely deployed across strictures with no immediate complication. Migration does still appear to be a problem, however, does not appear to affect patient outcome or increase morbidity. Insertion is straightforward and doesn’t appear to be associated with a long learning curve.

Pancreatic pseudocyst: Dilemma of its recent management (Review).

Advances in radiological techniques have led to an increase in the number of diagnoses of pancreatic pseudocyst, which is the most common pancreatic cyst lesion disease, accounting for two-thirds of all pancreatic cyst lesions. Historically, the management of pancreatic pseudocyst has been achieved through the use of conservative treatments and surgery; however, due to the complications and recurrence rate associated with these techniques, the management of pancreatic pseudocyst is challenging. Surgeons and gastroenterologists have attempted to determine the optimal management technique to treat pancreatic pseudocyst to reduce complications and the recurrence rate. From these investigations, percutaneous catheter, surgical and endoscopic drainage with ultrasonography guidance have become promising management techniques. The present review aimed to summarize the diagnostic and therapeutic methods used for the management of pancreatic pseudocyst and to compare percutaneous catheter, surgical and endoscopic drainage.

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

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.