Post written by Lady Katherine Mejia Perez, MD, and Victoria Gómez, MD, from the Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA.
We describe a case of a 58-year-old man with necrotizing pancreatitis of biliary origin who underwent endoscopic drainage of a large, 12-cm pancreatic collection consistent with walled-off necrosis. A 15-mm diameter fully covered lumen-apposing metal stent (LAMS) was deployed under EUS guidance. After placement of the stent, to enhance drainage of the necrotic contents into the stomach, the LAMS was dilated to 15 mm using a wire-guided dilating balloon. Immediate bleeding was seen at the gastric side of the stent. After a period of endoscopic observation, the bleeding appeared to subside. The patient was hospitalized for overnight observation. Eight hours later, the patient developed melena, with hemodynamic instability. CT angiogram and subsequent arteriogram did not demonstrate the source of bleeding. Clinically, bleeding appeared to resolve, and the patient remained stable. A repeat EGD revealed intermittent active bleeding along the underside of the LAMS on the gastric lumen. Attempts to place a hemoclip were challenging with a forward-viewing gastroscope. This was exchanged for a duodenoscope, and a hemostatic clip was successfully placed at the site of active bleeding. Re-look EGD the following day demonstrated no further bleeding. One month follow-up MRI showed resolution of the WON and the LAMS was removed endoscopically without difficulty.
This case demonstrates that EUS-guided drainage of pancreatic collections is not a risk-free procedure. Although it has become more feasible with the advent of self-expandable lumen-apposing metal stents, severe adverse events such as stent-related bleeding can occur. In this case, dilation of the LAMS likely resulted in erosion into a gastric vessel with serious consequences. Second, exchanging a forward-viewing gastroscope for a side-viewing duodenoscope can assist with optimizing one’s position to allow endoscopic clip placement underneath the stent.
All possible adverse events of LAMS placement should be carefully discussed with patients. It is advisable to observe these patients post-procedure. In addition, in case of bleeding, consider using a duodenoscope for better visualization and deployment of hemostatic hemoclips.
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