Emergency endoscopic exploration of a pancreatic pseudocyst to retrieve a migrated pigtail stent

Endoscopic ultrasound (EUS)-guided drainage of pancreatic pseudocyst using double-pigtail plastic stents is a well-established technique with a high success rate (95 % – 100 %). Early adverse events, namely bleeding and perforation, occur in up to 5 % of the procedure [1] [2] [3].

A 38-year-old woman with a history of alcohol abuse was admitted to hospital because of dysphagia, abdominal pain, and vomiting. Computed tomography (CT) scan showed an encapsulated pancreatic fluid collection, and therefore EUS-guided drainage was performed. EUS-guided access to the collection was achieved with a 19-gauge needle ([Fig. 1]) and a first guidewire was inserted. A cystotome was used, followed by hydrostatic dilation up to 8 mm. After insertion of a second guidewire, a double-pigtail 7-Fr, 5-cm plastic stent was delivered, but immediately after deployment the stent spontaneously migrated inside the collection ([Fig. 2]). Blind retrieval was attempted without success with both foreign-body forceps and Dormia basket ([Fig. 3]). Therefore a lumen-apposing metal stent (LAMS) was thendeployed ([Fig. 4]), and a slim gastroscope was advanced inside the pseudocyst ([Fig. 5]). Exploration of the cavity allowed location of the migrated pigtail stent and retrieval using a pediatric biopsy forceps ([Video 1]). Finally, a duodenoscope was used to remove the LAMS and to insert two 10-Fr double-pigtail plastic stents ([Fig. 6]).

Fig. 1 Endoscopic ultrasound (EUS)-guided puncture of a pancreatic pseudocyst using a 19-G needle.

Fig. 2 a Double guidewires inside the pseudocyst. b Deployment of 5-cm 7-Fr double-pigtail plastic stent. c Immediately, the double-pigtail stent spontaneously migrated inside the cavity.

Fig. 3 Attempts at blind retrieval of the migrated double-pigtail stent, using: a foreign-body forceps, and b a Dormia basket.

Fig. 4 a, b Deployment of a lumen-apposing metal stent (LAMS) to allow sustained access to the cavity of the pancreatic pseudocyst.

Fig. 5 A gastroscope was advanced through the lumen-apposing metal stent (LAMS) into the pseudocyst cavity.

Video 1: Endoscopic pseudocyst exploration using a slim gastroscope through a lumen-apposing metal stent (LAMS): fluid aspiration, visualization of migrated double-pigtail stent, and its retrieval using a pediatric biopsy forceps.

Fig. 6 Insertion of two 10-Fr, 5-cm double-pigtail plastic stents to drain the pancreatic pseudocyst.

Inadvertent plastic stent migration inside a cavity is an adverse event that may be difficult to manage. Massive dilation of the tract is not recommended as first-line treatment because of the risk of perforation. Deployment of a LAMS seems a safe and effective option for guaranteeing sustained access to the cavity and allowing the use of a slim endoscope to explore the cavity. In our patient the pseudocyst was not infected; therefore we decided to remove the metal stent in order to allow an early oral diet and reduce the risk of superinfection caused by food stasis. Nonetheless, use of a LAMS might prove very useful in the management of adverse events related to drainage of pseudocysts.

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• References

• 1 Tyberg A, Karia K, Gabr M. et al. Management of pancreatic fluid collections: A comprehensive review of the literature. World J Gastroenterol 2016; 22: 51-53
• 2 Bang JY, Hasan MK, Navaneethan U. et al. Lumen apposing metal stents (LAMS) for drainage of pancreatic fluid collections: When and for whom?. Dig Endosc 20.05.2016; Epub ahead of print.
• 3 Saftoiu A, Vilmann A, Vilmann P. Endoscopic ultrasound-guided drainage of pancreatic pseudocysts. Endosc Ultrasound 2015; 4: 319-323