esophageal stent salvage for twice maldeployed lumen opposing metal stent and pancreatic walled off necrosis. These are our disclosures. Here is a 56 year old female with a history of a motor vehicle accident in 2016 resulting in the pancreatic leak status post distal pancreatectomy. Four years later she developed recurrent acute pancreatitis due to pancreatic ductal stone blockage not amenable to endoscopic therapy and required a second distal pancreatectomy about four months ago. She presented from an outside institution with projectile non-bloody non-biliary vomiting and abdominal pain. Here is a CT scan taken at the outside institution demonstrating the walled off necrosis within the distal pancreatectomy site. It is about 21.7 centimeter by 13.5 centimeter by 6.8 centimeter. Patient underwent an EOS guided cyst gastrostomy. Once an appropriate position the stomach was identified a channel was created and a guide wire was carefully navigated into the wall of necrosis. Shown in these fluoroscopic images a 20 millimeter by 10 millimeter lumen opposing metal stent or LAMS was deployed into the targeted location with the phalanges in close approximation to the walls of the walled off necrosis and stomach. Here's an endoscopic view of the stomach showing the copious purulent fluid pouring through the stent approximately 1.3 liters in total. After closer inspection the length of the LAMS was deemed too short and mispositioned despite purulent fluid coming out. From this endoscopic view the phalanges of the LAMS on the distal side was actually positioned at the exterior wall of the walled off necrosis. Rat tooth forceps were utilized to carefully remove the LAMS prime it and then redeploy under fluoroscopic guidance. This time the distal end of the LAMS reached closer but the luminal side of the stent still could not be completely traversed into the walled off necrosis. So we additionally placed a 10 French by 4 centimeter double pigtail plastic stent into the LAMS and walled off necrosis. We obtained a post endoscopic CT scan to assess for any perforation. It shows interval decrease in size of the fluid collection to 19.2 centimeter by 8.5 centimeter by 14.1 centimeter with evidence of gas in the walled off necrosis as well as a tiny volume of pneumoperitoneum. The next day the patient reports significant symptomatic relief with minimal abdominal pain with no peritoneal signs and return of her appetite. She was monitored clinically over the next couple of days with serial abdominal exams given the pneumoperitoneum findings. General surgery was consulted and recommended continuing endoscopic treatment because the patient is stable. Two days later she was taken back to the endoscopy unit for reassessment of the stent. In this endoscopic view the previously placed LAMS was found halfway out into the cardiac of the stomach. A guide wire was reinserted through the LAMS and a thru-the-scope balloon dilator was passed through the endoscope to dilate the tract up to 12 millimeters. Afterwards we attempted to remove only the double pigtail plastic stents with rat tooth forceps but the LAMS was also removed. Under fluoroscopic guidance a 16 millimeter by 18 millimeter fully covered esophageal stent was placed due to the long tract of the channel. Afterwards the cavity of the walled off necrosis was lavaged with 1 to 4 ratio of hydrogen peroxide and saline and then two 10 French by 7 centimeter double pigtail plastic stents were placed within the esophageal stent. The patient had no immediate or acute complications from the procedure. Here is an endoscopic view of the two double pigtail plastic stents within the esophageal stent. One month later the patient presented for her first direct endoscopic necrosectomy. She was unable to be scheduled sooner due to cancellation and frequent rescheduling. On initial inspection the esophageal stent with the two double pigtail plastic stents migrated into the stomach cavity with tissue overgrowth on the gastric side. Here's an endoscopic view showing the large tissue overgrowth in the gastric side covering the esophageal stent. The tissue overgrowth was carefully dissected and the necrosectomy was performed for two hours. Afterwards cavity was lavaged and suctioned and the esophageal stent and double pigtail plastic stents were replaced back in its position. Patient presented for a second direct endoscopic necrosectomy one month later. During this visit she endures mild abdominal pain. In this endoscopy view looking through the esophageal stent purulent fluid was seen pouring out of the wall of necrosis. The patient underwent another two-hour necrosectomy. Afterwards she was admitted for concern for infected pancreatic necrosis. She was afebrile and hemodynamically stable with blood work significant for leukocytosis. Post necrosectomy CT scan demonstrated decreasing heterogeneous fluid collection in the wall of necrosis but more inflammatory fat stranding around the collection. Patient received empiric IV antibiotics with gradual resolution of the leukocytosis and negative blood cultures. Due to the complexity of the wall of necrosis the patient underwent two more direct endoscopic necrosectomies during her hospital stay. During these necrosectomies an endoscopic mucosal resection system was utilized to assist with the debridement. Post direct endoscopic necrosectomy CT scan demonstrates further interval decrease in size of the heterogeneous fluid collection. Patient clinically improved during the remainder of her hospital stay and was discharged home with oral antibiotics. Here we have a side-by-side coronal view of the CT scan showing the initial size of the wall of necrosis and the one two months later. Since the second hospitalization the patient underwent three more direct endoscopic necrosectomies about every 10 days. Each subsequent necrosectomy demonstrated interval resolution of the necrotic debris and reassuring signs of vitalized tissue. Here is the endoscopic view looking into the wall of necrosis after the seventh and final direct endoscopic necrosectomy. Before the conclusion of the procedure the esophageal stem with the two previous double pigtail plastic stents were removed and two brand-new 10 French by 5 centimeter double pigtail plastic stents were placed. Here is the fluoroscopic view with esophageal stem and old double pigtail plastic stents in place. And then here's the final fluoroscopic view with the two new double pigtail plastic stents. Since then the patient is clinically doing very well and has not needed further therapy. With introduction of LANs, endoscopists have alternative methods of draining large fluid collections and bypassing blockages and strictures. At the same time potential adverse events must be anticipated especially for medically complex patients. We demonstrate a case where a LANs was maldeployed twice and salvaged by switching to a fully covered metal esophageal stem into the wall of necrosis with subsequent therapy via multiple direct endoscopic necrosectomies.

case study

56-year-old female patient

pancreatic leak

distal pancreatectomy

recurrent acute pancreatitis