Endoscopic rescue after lumen-apposing metal stent deployment failure during endoscopic ultrasound-guided drainage of a giant pancreatic pseudocyst

A 32-year-old man with a 1-year history of acute pancreatitis presented with obstructive jaundice caused by a large pancreatic body–tail pseudocyst (14.5 × 6.6 × 10.0 cm) compressing the bile duct ([Fig. 1]).

Fig. 1 A pseudocyst located in the body–tail region of the pancreas.

During endoscopic ultrasound-guided HOT-AXIOS lumen-apposing metal stent (LAMS) drainage, proximal flange deployment failed and the stent migrated into the pseudocyst ([Fig. 2] a, b). As the original tract was not identifiable, the pseudocyst was punctured via the gastric wall with a 19-G needle, a guidewire was advanced, and the tract dilated to 12 mm. Due to an unfavorable angle, endoscopic entry failed, so two 7 F × 7cm double-pigtail stents were placed for temporary drainage ([Fig. 2] c).

Fig. 2 a Failed deployment of the proximal flange of the LAMS. b Migration of the LAMS into the pseudocyst cavity. c Placement of double-pigtail stents. LAMS, lumen-apposing metal stent.

The next day, a salvage procedure was performed. Despite right lateral positioning, direct access remained difficult. The tract was dilated with an 18-mm balloon and further enlarged with an insulation-tipped (IT) knife ([Fig. 3] a, b). After removing the pigtail stents, the endoscope entered the pseudocyst, the migrated LAMS was retrieved with forceps ([Fig. 4] a, b), and a nasocystic tube was placed for drainage ([Video 1]).

Fig. 3 a Endoscopic 18-mm balloon dilation. b Endoscopic incision and enlargement using an IT knife. IT, insulation-tipped.

Fig. 4 a LAMS within the pseudocyst. b The LAMS was retrieved from the pseudocyst cavity using grasping forceps. LAMS, lumen-apposing metal stent.

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Endoscopic tract dilation with an 18-mm balloon and IT-knife incision was performed to retrieve the migrated LAMS. IT, insulation-tipped; LAMS, lumen-apposing metal stent.Video 1

Two weeks later, endoscopy showed a narrowed tract with persistent drainage, and computed tomography confirmed significant pseudocyst reduction ([Fig. 5]).

Fig. 5 Marked reduction of the pseudocyst 2 weeks after the procedure.

Stent deployment failure is a challenging complication in endoscopic drainage of pancreatic pseudocysts [1]. Endoscopic salvage provides a feasible treatment option [2], and combined IT-knife incision with balloon dilation allows safe, controlled pseudocyst access, offering a key technical approach for managing LAMS deployment failure.

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Contributorsʼ Statement

Meiru Liu: Writing – original draft. Ziyu Liu: Writing – review & editing. Huihong Zhai: Conceptualization, Methodology, Resources.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Pausawasdi N, Rugivarodom M, Rujirachun P. et al. Effectiveness and Safety of a Single 7-French Plastic Stent for Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage and Long-term Follow-up Outcomes. J Med Ultrasound 2021; 29: 250-257
• 2 Cahen D, Rauws E, Fockens P. et al. Endoscopic drainage of pancreatic pseudocysts: long-term outcome and procedural factors associated with safe and successful treatment. Endoscopy 2005; 37: 977-983

Publication History

Article published online:
28 January 2026