Post written by Prabhleen Chahal, MD, FACG, FASGE, and C. Roberto Simons-Linares, MD, MSc, from the Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
We present a case of a delayed spontaneously migrated lumen-apposing metal stent (LAMS) that was placed in a patient with a history of Roux-en-Y gastric bypass (RYGB) to facilitate endoscopic retrograde cholangiopancreatography (ERCP). The patient presented with multiple episodes of recurrent acute pancreatitis (RAP) and was diagnosed with pancreas divisum. In our video, we demonstrate a unique technique for the rescue of the migrated LAMS in order to perform transluminal ERCP.
The video is particularly important because spontaneous migration of LAMS has been reported during management of pancreatic fluid collections. Spontaneous delayed migration has not been reported in the context of transluminal access. This adds another layer of complexity to the highly complex and technically demanding procedure. It is important to ensure that we have all the necessary tools in the tool kit to manage this possible complication.
What endoscopists can learn from this experience:
- Be aware and prepared for this complication.
- Ensure that the endoscopist has all the necessary technology and accessories to manage this complication.
- Demonstrate the technique to safely perform transluminal ERCP with fistula track dilation, placement of through-the-scope fully covered stent and safe retrieval of migrated stent.
- Technique of fistula closure
- Importance of follow-up imaging to demonstrate the jejunogastrostomy fistula closure
Even though we were successfully able to manage the above described complications, we are sorely in need of innovative traction, anchoring, suturing tools, and modified and improved stent design to minimize these complications.
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