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Brief Report Trans-cavity lumen-apposing metal stent removal: an alternative safe modality
Giacomo Emanuele Maria Rizzo1,2orcid, Ilaria Tarantino1,orcid
Clinical Endoscopy 2023;56(1):129-131.
DOI: https://doi.org/10.5946/ce.2022.105
Published online: January 18, 2023

1Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Palermo, Italy

2Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Italy

Correspondence: Ilaria Tarantino Endoscopy Unit, Department of Diagnostic and Therapeutic Services, IRCCS-ISMETT, Via Tricomi 5, Palermo, 90127, Italy E-mail: itarantino@ismett.edu
• Received: March 18, 2022   • Revised: April 28, 2022   • Accepted: April 29, 2022

Copyright © 2023 Korean Society of Gastrointestinal Endoscopy

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Endoscopic ultrasound (EUS)-guided transluminal drainage through deployment of a lumen-apposing metal stent (LAMS) is a safe and effective technique for pancreatic fluid collections,1,2 even without fluoroscopy.3 The LAMS placement has changed the approach to various diseases, simplifying drainage and necrosectomy techniques to a point that difficult necrosectomies consider the removal and replacement of the same LAMS.4 The removal of LAMS is usually technically safe, and the use of different devices (snare and forceps) can be easily achieved through the gastrointestinal tract. Herein, we present the case of a 67-year-old man with severe acute pancreatitis who developed a huge walled-off pancreatic necrosis (WOPN), which became symptomatic (nausea, vomiting, and gastric outlet obstruction) and infected. Computed tomography scan revealed an 18-cm WOPN (Fig. 1). Therefore, the patient was referred to our institute for EUS-guided drainage. WOPN drainage was achieved with deployment of a LAMS 20×10 mm, with the generation of a gastrocystostomy utilizing the “free-hand” technique with a Hot Axios device (Boston Scientific, Marlborough, MA, USA), followed by endoscopic necrosectomy with partial cleansing of the cavity (Fig. 2). At that point, the patient was critically ill and developed multiorgan failure and septic shock; therefore, he was admitted to the intensive care unit. A computed tomography scan revealed unmodified WOPN. The patient was treated using the multiple transluminal gateway technique, deploying a second LAMS in the duodenum (10×15 mm). Other necrosectomies were performed until complete cleansing of the cavity was achieved and the patient recovered clinically. We then proceeded to remove the distal (duodenal) LAMS three weeks after its placement, but the classical LAMS removal through the duodenum seemed uncomfortable and unsafe. Therefore, it was directly removed from the collection cavity through the proximal (gastric) LAMS, which was also removed after five weeks of indwelling (Supplementary Video 1). Specifically, we decided to remove the distal LAMS with an alternative way for duodenal wall- and technique-related reasons. On one hand, we included the duodenal LAMS location (posterior wall of the duodenal bulb, on the corner between the first and second duodenum), which did not permit a proper grab of the flange, and the severe inflammation of the duodenal mucosa and thinness of the wall contributed to considering the duodenal wall to be too fragile to perform an extreme torsion of the scope with the devices over it. On the other hand, we had a large space and lack of vessels in the cavity, and a larger diameter of the gastric LAMS (20 mm) compared to the duodenal LAMS (15 mm). In the end, the association of the above-mentioned reasons led us to consider trans-duodenal removal to be dangerous, while the trans-LAMS removal was considered safe. In the final analysis, the patient fully recovered without complains of technique-related adverse events. He was discharged after two weeks. In conclusion, WOPN treatment with a multi-gate approach is an effective and safe endoscopic technique when the WOPN is >12 cm.5 In cases of risky trans-duodenal removal, the duodenal LAMS inner removal through the gastric LAMS is a feasible and safe alternative option in patients treated with a multi-gate approach.
Supplementary Video 1. A lumen-apposing metal stent removal in a patient with walled-off pancreatic necrosis was treated with a multiple transluminal gateway technique (https://doi.org/10.5946/ce.2022.105.v001).
Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2022.105.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

Italian Ministry of Health, Ricerca Corrente 2022.

Author Contributions

Conceptualization: GEMR, IT; Data curation: GEMR, IT; Formal analysis: IT; Investigation: GEMR; Methodology: IT; Project administration: IT; Resources: GEMR, IT; Software: GEMR; Supervision: IT; Validation: IT; Visualization: GEMR; Writing–original draft: GEMR; Writing–review & editing: GEMR, IT.

Fig. 1.
Abdominal computed tomography scan showing the huge walled-off pancreatic necrosis (arrow).
ce-2022-105f1.jpg
Fig. 2.
(A) Second lumen-apposing metal stent deployment (duodenal) for the multiple gateway technique. (B) Necrosectomy of the cavity using a device with a basket.
ce-2022-105f2.jpg
  • 1. Garg R, Chaar A, Szpunar S, et al. Efficacy and safety of lumen-apposing stents for management of pancreatic fluid collections in a community hospital setting. Clin Endosc 2020;53:480–486.ArticlePubMedPMCPDF
  • 2. Oh D, Lee JH, Song TJ, et al. Clinical outcomes of EUS-guided transluminal drainage with a novel lumen-apposing metal stent for postoperative pancreatic fluid collection after pancreatic surgery. Gastrointest Endosc 2022;95:735–746.ArticlePubMed
  • 3. Yoo J, Yan L, Hasan R, et al. Feasibility, safety, and outcomes of a single-step endoscopic ultrasonography-guided drainage of pancreatic fluid collections without fluoroscopy using a novel electrocautery-enhanced lumen-apposing, self-expanding metal stent. Endosc Ultrasound 2017;6:131–135.ArticlePubMedPMC
  • 4. Gulati R, Rustagi T. Endoscopic removal and replacement of the same lumen-apposing metal stent for multiple endoscopic necrosectomy sessions. Endoscopy 2021;53:71–74.ArticlePubMed
  • 5. Arvanitakis M, Dumonceau JM, Albert J, et al. Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines. Endoscopy 2018;50:524–546.ArticlePubMed

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      Trans-cavity lumen-apposing metal stent removal: an alternative safe modality
      Image Image
      Fig. 1. Abdominal computed tomography scan showing the huge walled-off pancreatic necrosis (arrow).
      Fig. 2. (A) Second lumen-apposing metal stent deployment (duodenal) for the multiple gateway technique. (B) Necrosectomy of the cavity using a device with a basket.

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