Endoscopic exchange of a lumen-apposing metal stent after endoscopic ultrasound-guided gastroenterostomy in severe acute pancreatitis
07 November 2018 (eFirst)
Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has been an effective and safe alternative to surgery for the palliation of symptoms of gastric outlet obstruction (GOO) due to benign or malignant conditions   . The lumen-apposing metal stent (LAMS) is a necessary device for EUS-GE because of its anti-migration role and long-term patency . However, there is no clear in vivo evidence of the duration of LAMS efficacy. There is still no evidence on when the LAMS should be exchanged especially when used in benign GOO. We report a case of endoscopic exchange of LAMS after EUS-GE in severe acute pancreatitis.
A 49-year-old man experienced severe acute pancreatitis after excessive alcohol intake. Although his condition greatly improved with active treatment, he presented 3 months later with progressive nausea, vomiting, and poor oral food intake. Upper gastrointestinal imaging (UGI) and gastroscopy revealed duodenal obstruction due to distortion of the descending part of the duodenum. A nasojujunal feeding tube was implanted deeply beyond the ligament of Treitz and exchanged every 3 months. However, the symptoms had not improved significantly 9 months later. The patient could no longer tolerate the nasogastric nutrition but strongly refused surgery. Ultimately, he accepted treatment with EUS-GE, performed according to the reported method , and could tolerate a semi-liquid oral diet after the procedure ([Fig. 1], [Video 1]).
Video 1 Endoscopic exchange of a lumen-apposing metal stent after endoscopic ultrasound-guided gastroenterostomy in acute pancreatitis.
Unfortunately, the initial symptoms recurred and worsened 6 months later. UGI revealed no improvement in the duodenal obstruction. Gastroscopy found fractures in some of the steel wires of the stent ([Fig. 2 a]). Gastroscopy and fluoroscopy showed that the inner diameter of the stent had decreased significantly ([Fig. 2 b, c]). The stent might have been ineffective due to corrosion by gastric juice. A new LAMS was deployed into the gastrojejunal anastomosis ([Video 1]), and the patient resumed a semi-liquid diet after the procedure.
This case suggests that LAMS could be effective for about 6 months but needs to be exchanged periodically in patients requiring long-term treatment.
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