Lumen apposing metal stents for pancreatic fluid collections: Recognition and management of complications

Abstract

For patients recovering from acute pancreatitis, the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery, and introduces difficult management decisions with regard to when, whether, and how the collection should be drained. Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction. Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement), and the placement of percutaneous drains. Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients, when local expertise is available. Lumen-apposing metal stents (LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections, and less commonly, for other indications, such as gallbladder drainage. Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding, migration, buried stent, stent occlusion, and perforation. Because of the patient complexity associated with severe pancreatitis, management of pancreatic fluid collections can be a complex and multidisciplinary endeavor. Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques, including how to recognize and manage expected complications.

Keywords: Cystgastrostomy; Endoscopic necrosectomy; Lumen apposing metal stent; Pancreatic fluid collection.

Figure 1

Delayed bleeding after lumen apposing metal stent placement, which required angiographic embolization.

Figure 2

Pulsatile pseudoaneurysm seen on left of screen after endoscopic entry into cyst cavity, several weeks after initial lumen apposing metal stent placement for walled off necrosis.

Figure 3

Endoscopic removal of lumen apposing metal stent that migrated into gastric lumen.

Figure 4

Closure of a perforation in the stomach after lumen apposing metal stents maldeployment and removal (a second gastric location was subsequently chosen for successful lumen apposing metal stents placement).

Figure 5

Food debris occluding lumen apposing metal stent lumen.

Figure 6

Necrotic debris occluding lumen apposing metal stent lumen.