a technique for leaving permanent double pigtail plastic stents after resolution of pancreatic fluid collections. Additional authors include Jorge Machicado and Eric John Wamstecker. These are our disclosures. Symptomatic pancreatic fluid collections are commonly treated with transmural placements of lumen-opposing metal stents, also called LAMs. Permanent placements of double pigtail plastic stents has been shown to be safe and beneficial in preventing pancreatic fluid collection recurrence. However, exchanging of LAMs to double pigtail plastic stents after pancreatic fluid collection resolution can be technically challenging due to collapse of the cyst cavity. As a result, technical success of such approach has been suboptimal in prior studies, an approximating 70%. In this presentation, we describe two cases that highlight an endoscopic method that has the potential to improve technical success for permanent double pigtail plastic stent placement. Our first case is a 23-year-old gentleman with Goldstone necrotizing pancreatitis, complicated by recurrent 13-centimeter pancreatic fluid collection, and suspected disconnected pancreatic duct syndrome. He underwent EUS-guided cyst gastrostomy with LAMs, in addition to placement of two coaxial 10-fringe-by-3-centimeter double pigtail plastic stents within the LAMs. At four weeks, repeat upper endoscopy showed complete resolution of the pancreatic fluid collection without necrotic debris. Given the history of prior pancreatic fluid collection recurrence and disconnected pancreatic duct, the decision was made to leave the double pigtail plastic stents indefinitely after LAMs removal. Upper endoscopy four weeks after cyst gastrostomy confirmed complete resolution of the pancreatic fluid collection. Using a rat-tooth forceps, the proximal flange of the lumen-opposing metal stent is grasped and then carefully pulled out of the cyst gastrostomy tract into the gastric lumen. The LAMs is then further pulled using the rat-tooth forceps by applying scope-tip manipulation with the dials and rotational body movements, until the LAMs is entirely pulled around the external plastic pigtails. Afterwards, the LAMs is placed in the LAMs chamber. Lastly, the cyst gastrostomy site is then inspected to confirm adequate position of the double pigtail plastic stents. Afterwards, the LAMs can be removed through the therapeutic scope channel or removed entirely with the scope. Lastly, the cyst gastrostomy site is then inspected to confirm adequate position of the double pigtail plastic stents. Our second case is a 46-year-old gentleman with post-ERCP necrotizing pancreatitis, complicated by 12-centimeter pancreatic fluid collection and disconnected pancreatic depth. He underwent EUS-guided cyst gastrostomy using LAMs with a placement of two coaxial 10-french-by-3-centimeter double pigtail plastic stents within the LAMs. Afterwards, he underwent four necrosectomies followed by complete resolution of his pancreatic fluid collection at six weeks. Given the high risk of pancreatic fluid collection recurrence in this patient, the double pigtail plastic stents were left in place indefinitely after LAMs removal. Upper endoscopy six weeks after cyst gastrostomy confirmed complete resolution of the pancreatic fluid collection. In a similar fashion, a rat tooth forceps is used to grasp the proximal flange of the lumen opposing metal stent, which is then carefully pulled out of the cyst gastrostomy tract and into the gastric lumen. The LAMs is then further pulled using the rat tooth forceps by applying similar scope tip manipulation and rotational body movements, until the LAMs is entirely pulled around the external plastic pigtails. Afterwards, the LAMs was removed entirely with the scope. Lastly, the cyst gastrostomy site is inspected to confirm adequate position of the double pigtail plastic stents. This is a summary of the endoscopic method steps performed in our two cases. These are the post-procedure fluoroscopic images of the two patients showing the appropriate positioning of the double pigtail plastic stents after the removal of the lumen opposing metal stents. Placement of double pigtail plastic stents within lumen opposing metal stents during index cyst gastrostomy procedures should be considered for patients at high risk of pancreatic fluid collection recurrence, as this approach can increase the likelihood of long-term transfemoral drainage after pancreatic fluid collection resolution. We highlight a simple endoscopic technique that facilitates leaving permanent double pigtail plastic stents while LAMs is removed at time of pancreatic fluid collection resolution. Compared to conventional LAMs exchange for new double pigtail plastic stents, this method may be more technically feasible, less time-consuming, and potentially more cost-effective.

permanent double pigtail plastic stents

pancreatic fluid collections

transmural placements

lumen-opposing metal stents

endoscopic method