LOST AND FOUND – SPONTANEOUS GASTROINTESTINAL EXPULSION OF A MIGRATED LAMS

Lumen-apposing metal stents (LAMS) are increasingly used for drainage of symptomatic pancreatic walled-off necroses (WON) and pseudocysts. As noted in a growing number of studies, complication rates associated with endoscopic drainage procedures using LAMS are low and, among others, include bleeding, superinfections, stent occlusion and migration. Despite its special anti-migratory design, cases of LAMS migration have been reported both into the cyst cavity and stomach. We describe the first reported case of LAMS migration and spontaneous expulsion through the gastrointestinal tract.

A 61-year-old man with a large symptomatic peripancreatic necrotic collection following an earlier episode of acute necrotic biliary pancreatitis was referred to our Interventional Gastroenterology Unit for evaluation and management. At admission the patient was in a state of chronic sepsis, complained of early satiety and abdominal pain, and computed tomography (CT) revealed a peripancreatic heterogenous necrotic collection measuring 15 × 11.6 cm with bilateral pleural effusions and ascites. Endoscopic ultrasound-guided drainage through the gastric wall was performed using 15-mm cautery enhanced LAMS with a flange diameter of 24 mm (Hot AXIOS, Boston Scientific, USA). Regression of WON size was observed promptly after the procedure and following the clinical improvement the patient was discharged. He was readmitted 7 days later due to fever and abdominal pain. Control CT scan showed LAMS occlusion by necrotic debris and intraabdominal abscess on the left paracolic space. Stent de-occlusion and necrosectomy was performed along with an intraabdominal percutaneous drainage placement under ultrasound guidance. The follow-up CT scan showed nearly complete WON resolution and patient was scheduled for LAMS extraction 31 days after its placement (Video). The LAMS, however, couldn't be visualised the following day on upper endoscopy and was retrieved by the patient after a bowel movement while waiting a fluoroscopy.