Gastric leak closure after the misdeployment of a lumen-apposing metal stent

Endoscopic ultrasound-guided cystogastrostomy (EUS-CG) represents the main therapeutic modality for treatment of pancreatic fluid collections [1] [2]. While much has been written regarding technical advantages of lumen-apposing metal stents (LAMSs), there are limited data on the complications, which range from 7 % to 15 % [3] [4].

A 66-year-old woman had post-endoscopic retrograde cholangiopancreatography necrotizing pancreatitis and symptomatic pancreatic fluid collection that caused compression and dislodgment of both the stomach and duodenum. She underwent EUS-CG with placement of a 20 × 10 mm LAMS, followed by placement of a plastic double-pigtail stent inside the LAMS.

The day after the procedure, she experienced progressive epigastric pain and vomiting with abdominal tenderness. A computed tomography scan confirmed the suspicion of LAMS dislocation ([Fig. 1]).

Fig. 1 Computed tomography scan showed the lumen-apposing metal stent and the pigtail stent close to the hepatic hilus.

Once in our hospital, an upper endoscopy showed the proximal flange of the LAMS located just above the gastric cardia while the distal flange was displaced in the peritoneal space close to the hepatic hilus ([Fig. 2]). The stents were removed, revealing a gastric parietal defect of 20–25 mm, surrounded by ulcerated tissue. The defect was immediately sutured using the OverStitch endoscopic suturing system (Apollo Endosurgery, Austin, Texas, USA) mounted on a single-channel gastroscope. Given the narrow space and the poor distensibility, four continuous running stitches were placed around the edge of the leak; however, a residual orifice of 3–4 mm was observed and an 11 mm over-the-scope clip, traumatic-type, was applied ([Video 1]). Both endoscopic and fluoroscopic check showed no contrast extravasation outside the stomach.

Fig. 2 Endoscopic view, showing malposition of the lumen-apposing metal stent and pigtail stent in the abdominal cavity.

Video 1 Gastric defect after lumen-apposing metal stent misdeployment sutured using the OverStitch system (Apollo Endosurgery, Austin, Texas, USA).

The patient showed rapid clinical improvement and a new EUS-CG was performed a few days later.

LAMS misdeployment and migration are serious adverse events [3]. In most cases the diagnosis is immediate, but sometimes the instability and malposition toward the target lesion can lead to delayed migration, resulting in continuous passage of corrosive gastric fluid into the abdomen. After stent removal, the wall defect can be difficult to treat with either through-the-scope or over-the-scope clips, especially if a 20 mm LAMS has been used [4] [5]. As in the current case, the prompt application of a suturing device allows the closure, or at least the reduction of the parietal leak, avoiding further and more invasive intervention.

Endoscopy_UCTN_Code_TTT_1AO_2AI

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Bang JY, Wilcox CM, Navaneethan U. et al. Impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic drainage of pancreatic fluid collections. Dig Endosc 2023;
• 2 Anderloni A, Fabbri C, Nieto J. et al. The safety and efficacy of a new 20-mm lumen apposing metal stent (LAMS) for the endoscopic treatment of pancreatic and peripancreatic fluid collections: a large international, multicenter study. Surg Endosc 2021; 35: 1741-1748
• 3 Rana SS, Shah J, Kang M. et al. Complications of endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections and their management. Ann Gastroenterol 2019; 32: 441-450
• 4 Bemelman WA, Baron TH. Endoscopic management of transmural defects, including leaks, perforations, and fistulae. Gastroenterology 2018; 154: 1938-1946
• 5 Ge PS, Thompson CC. The use of the Overstitch to close perforations and fistulas. Gastrointest Endosc Clin N Am 2020; 30: 147-161

Publication History

Article published online:
30 August 2023