|HOW I DO IT
|Year : 2021 | Volume
| Issue : 4 | Page : 148-150
Salvaging migrated lumen apposing metal stent during necrosectomy for walled off pancreatic necrosis in disconnected pancreatic duct syndrome
Shankar Zanwar, Shailesh Chawhare, Akshay Thorat
Department of Gastroenterology, Care Hospital, Nagpur, Maharashtra, India
|Date of Submission||05-Apr-2021|
|Date of Decision||26-May-2021|
|Date of Acceptance||31-May-2021|
|Date of Web Publication||24-Sep-2021|
Department of Gastroenterology, Care Hospital, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
Migration of the lumen apposing stent can be a routine problem during stent placement or necrosectomy and can be a significant source of apprehension for the performing endoscopist. We present our case of walled off necrosis with disconnected pancreatic duct syndrome where the stent migrated during the necrosectomy and was salvaged by replacement. This can be a useful piece of information for endoscopist working in limited resource setting where inserting a new stent could be cost inefficient.
Keywords: Migrated LAMS, necrosectomy, walled of pancreatic necrosis
|How to cite this article:|
Zanwar S, Chawhare S, Thorat A. Salvaging migrated lumen apposing metal stent during necrosectomy for walled off pancreatic necrosis in disconnected pancreatic duct syndrome. Gastroenterol Hepatol Endosc Pract 2021;1:148-50
|How to cite this URL:|
Zanwar S, Chawhare S, Thorat A. Salvaging migrated lumen apposing metal stent during necrosectomy for walled off pancreatic necrosis in disconnected pancreatic duct syndrome. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2022 Aug 18];1:148-50. Available from: http://www.ghepjournal.com/text.asp?2021/1/4/148/326625
We present the case of 50-year-old female who developed acute onset pain and vomiting in the mid of December 2020. She was hospitalized found to have moderately severe acute pancreatitis and etiological evaluation excluded common causes, i.e., alcohol, biliary, hypertriglyceridemia, hyperkalcemia, and malignancy. Computed tomography (CT) scan done on the 3rd day of the illness showed 15%–20% necrosis in the body of the pancreas and with mild amount of peri-pancreatic and para-colic fluid, CT severity index (CTSI) 8. She was managed with analgesics and IV fluids. She remained in the hospital then for 10 days and was discharged with mild residual pain.
She persisted to have mild bearable pain for the next 4 weeks. In the last week of January 2021, i.e., nearly 5 weeks after the onset of illness, she developed recurrent vomiting, fever, and reduced oral intake with increased upper abdominal discomfort. She underwent a repeat CT scan which showed – large necrotic collection with ~50% necrotic debris replacing pancreatic body with a small island of pancreatic parenchyma in the tail still enhancing, along with air foci in the collection – CTSI 10 [Figure 1]. No intra- or peri-cystic aneurysms were seen.
|Figure 1: CT scan showing walled off pancreatic necrosis with disconnected duct syndrome|
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She was started on empirical antibiotics after sending cultures. The patient was taken up for endoscopic ultrasound-guided drainage of the walled off pancreatic necrosis (WOPN). Standard WOPN drainage method was followed with initial assessment for cyst localization, quantifying necrotic content, and exclusion of pancreatic space occupying lesion. Duct was followed from the tail and seen disappearing near the cyst; thus, the diagnosis of disconnected pancreatic duct syndrome (DPDS) was established. Drainage was done in steps as needle (19 G Boston scientific) insertion in the cyst, fluid aspiration for culture, guidewire (0.035” jagwire) coiling, tract dilatation with 6 Fr cystotome and Hanaro Plumber (30 mm × 16 mm) lumen apposing metal stent (LAMS) placement.
Postprocedure day 1, the patient was clinically better with marginally reduced tachycardia, fever spikes reduced. Postprocedure day 2, the patient again had fever, tachycardia, and raised leukocyte count. Endoscopic step-up approach was planned. Relook endoscopy was done de-clogging of the stent was done with snare and nasocystic drain (7Fr) was placed with continuous drainage. Day 5 patient persisted to have fever – necrosectomy was planned and first session of necrosectomy nearly 50%–70% of the visible debris was removed.
Since she persisted to have fever on day 8 session of necrosectomy [Figure 2] was planned. During necrosectomy session, after three debris removal maneuvers, while closing snare with debris near the outer end of the lasso got along the debris and was recognized only as caught when the snare was withdrawn for removing debris. LAMS which was totally migrated [Figure 3] into the lumen (esophagus) now was removed from the mouth. The cavity was entered and remaining debris was cleared.
|Figure 3: Inadvertent LAMS migrated in the esophagus during necrosectomy|
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A recently used and disinfected (with glutraldehyde) esophageal metal stent delivery system was used and migrated LAMS manually compressed [Figure 4] and [Figure 5] and was loaded on this along with the pusher. Guidewire was inserted into the WOPN cavity. Under endoscopic guidance, alongside the stent and delivery system the stent was redeployed in the WOPN cavity. The inner flange was deployed slightly inward which was repositioned using the foreign body forceps.
Nasocystic drain was placed again in the WOPN cavity and drainage continued for 3 more days. After that patient gradually stopped having fever spikes, tachycardia reduced and leukocytosis improved. Nasocystic drain was removed. Four weeks later, a repeat CT scan was done and significantly reduced collection size was noted. LAMS was removed. Clean residual cavity [Figure 4] was noted with no debris. Since the patient had suspected DPDS, a plastic double pigtail plastic stent of 7Fr × 5 cm was placed in the cavity to avoid fluid re-accumulation [Figure 6].
|Figure 6: Loading lumen apposing metal stent on esophageal stent delivery system|
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| Discussion|| |
LAMS placement and necrosectomy is increasingly being used for the treatment of WOPN. Migration of LAMS during and after placement in the WOPN and during necrosectomy is a common occurrence. According to a review by DeSimone et al., the migration of LAMS can be seen ranging variably from 1% to 19% based on different studies. Migration is more common in the lumen then in the cyst cavity. Studies for the management of migrated stent are sparse.
While some endoscopists prefer to place a double pigtail stent through the LAMS to “stabilize” the LAMS, it is currently unknown whether this approach may reduce the risk of LAMS migration. We changed our practice to-not placing a double pigtail plastic stent as it adds to manipulation and increase chances of migration of LAMS during necrosectomy.
If stent migration is recognized during routine imaging or endoscopy, endoscopic removal of the stent should be pursued urgently. In the case of migration into the lumen, retrieval is straightforward if the stent is in the stomach or proximal small bowel. More distal migration of the stent may be managed with a deep enteroscopy attempt at removal, or conservatively with serial abdominal X-rays to confirm passage, and prompt surgical management if bowel obstruction occurs. Migration of the stent into the cyst cavity requires re-establishing the cyst gastrostomy tract with wire passage, dilation, and subsequent re-introduction of the endoscope into the cavity for stent retrieval using a snare or forceps. If stent retrieval is not possible endoscopically, then surgical removal is indicated.
Any instrument used for necrosectomy maneuvered near the ends of the LAMS can cause stent migration. We have had similar instance of stent migration in one of our case when the foreign body forceps was used to remove the debris and one arm of the toothed forceps got stuck into the cell of the LAMS leading to migration of the stent while removing the forceps. Thus, as policy we have been preserving and disinfecting the esophageal, biliary or LAMS stent delivery systems for any such inadvertent situations.
Most studies describing migrated stent management either have inserted new LAMS or replaced it with plastic stent. One of the papers describes replacement of LAMS using snare, which can be used as an alternative method. Our technique is an option to the direct snare-method when it does not help especially when the stent has migrated and an interval has passed before recognition of migration since in these cases the entry site of the cavity tends to shrink over time making endoscope entry in the cavity difficult.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the guardian has given consent for images and other clinical information to be reported in the journal. The guardian understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Endoscopic “step-up approach” using a dedicated biflanged metal stent reduces the need for direct necrosectomy in walled-off necrosis (with videos). Gastrointest Endosc 2017;85:1243-52.
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Muhammad H, Christopher M, Jonathan F. Laura R, Hari S. Internal migration of lumen-apposing, fully covered self-expanding metal stent used for walled off pancreatic necrosis: An approach for retrieval. Am J Gastroenterol 2018;113:S727.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]