Endoscopic management of stent displacement after pancreatic pseudocyst drainage

A 50-year-old man who had experienced acute alcoholic pancreatitis 2 years earlier presented with abdominal pain. An abdominal computed tomography (CT) scan revealed a pseudocyst, 16 × 8 cm in size, in the pancreatic tail ([Fig. 1]). After multidisciplinary discussion, the patient was referred for endoscopic pseudocyst drainage.

Fig. 1 Abdominal computed tomography scan showing a well-defined cystic lesion (arrow), 16 × 8 cm in diameter, in the tail of the pancreas.

Transgastric puncture of the pseudocyst was performed using a 19-gauge fine-needle aspiration needle, under endoscopic ultrasound (EUS) guidance. A 0.035-inch guidewire was advanced through the needle and the tract was dilated to 6 mm. A fully covered double-flanged metal stent (40 × 14 mm) was then deployed across the tract under endoscopic, EUS, and fluoroscopic guidance. The deployment was complicated by complete intracystic migration of the stent. We decided to place a fully covered biliary metal stent (60 × 10 mm) in an attempt to save the performed cystogastrostomy, and planned to retrieve the migrated stent at a later time. The patient was discharged with no symptoms.

The patient was readmitted to our department 1 week later with fever and upper abdominal pain. Abdominal CT scan showed complete migration of the two stents into the pseudocyst cavity (12 × 6 cm) ([Fig. 2]).

Fig. 2 Abdominal computed tomography scan in axial view showing complete migration of the first two stents into the pseudocyst cavity.

Under endoscopic, EUS, and fluoroscopic guidance, we placed another fully covered double-flanged metal stent (40 × 14 mm) through the patent cystogastrostomy ([Fig. 3]). The two intracystic migrated stents were then removed through the third stent using a foreign body forceps. Effective drainage of the pseudocyst was observed and the patient became asymptomatic ([Video 1]).

Fig. 3 Fluoroscopic image showing the third stent through the cystogastrostomy and the first two stents in the pseudocyst cavity.

Video 1 Endoscopic management of stent displacement after pancreatic pseudocyst drainage. 1) View of the intragastric portion of double-flanged metal stent. 2) Access to the cystic cavity through the double-flanged metal stent. 3) View of the two intracystic migrated stents. 4) Removal of the biliary and double-flanged metal stents.

At follow-up 1 month later, after an abdominal CT scan showed complete resolution of the pseudocyst ([Fig. 4]), the stent was removed endoscopically ([Fig. 5]).

Fig. 4 Abdominal computed tomography scan. a Coronal view, showing a correctly positioned fully covered double-flanged metal stent. b Axial view, showing complete resolution of the pancreatic pseudocyst.

Fig. 5 Endoscopy image showing collapsed perigastric cavity consistent with complete resolution of the pseudocyst.

Intracystic stent migration is a rare (< 1 %) complication of endoscopic drainage. It seems to be more frequent in transgastric drainage of pseudocysts of the pancreatic tail owing to variable luminal compression during the creation of cystogastrostomy [1].

We propose an alternative endoscopic method to solve intracystic stent migration, avoiding surgery [2].

Endoscopy_UCTN_Code_CPL_1AK_2AG

Competing interests

None

• References

• 1 Varadarajulu S, Christein JD, Wilcox CM. Frequency of complications during EUS-guided drainage of pancreatic fluid collections in 148 consecutive patients. J Gastroenterol Hepatol 2011; 26: 1504-1508
• 2 Wang GX, Liu X, Wang S. et al. Stent displacement in endoscopic pancreatic pseudocyst drainage and endoscopic management. World J Gastroenterol 2015; 21: 2249-2253