Lumen apposing metal stents for pancreatic fluid collections: Recognition and management of complications

Abstract

For patients recovering from acute pancreatitis, the development of a pancreatic fluid collection (PFC) predicts a more complex course of recovery, and introduces difficult management decisions with regard to when, whether, and how the collection should be drained. Most PFCs resolve spontaneously and drainage is indicated only in pseudocysts and walled-off pancreatic necrosis when the collections are causing symptoms and/or local complications such as biliary obstruction. Historical approaches to PFC drainage have included surgical (open or laparoscopic cystgastrostomy or pancreatic debridement), and the placement of percutaneous drains. Endoscopic drainage techniques have emerged in the last several years as the preferred approach for most patients, when local expertise is available. Lumen-apposing metal stents (LAMS) have recently been developed as a tool to facilitate potentially safer and easier endoscopic drainage of pancreatic fluid collections, and less commonly, for other indications, such as gallbladder drainage. Physicians considering LAMS placement must be aware of the complications most commonly associated with LAMS including bleeding, migration, buried stent, stent occlusion, and perforation. Because of the patient complexity associated with severe pancreatitis, management of pancreatic fluid collections can be a complex and multidisciplinary endeavor. Successful and safe use of LAMS for patients with pancreatic fluid collections requires that the endoscopist have a full understanding of the potential complications of LAMS techniques, including how to recognize and manage expected complications.

Keywords: Pancreatic fluid collection; Lumen apposing metal stent; Endoscopic necrosectomy; Cystgastrostomy

Core tip: Pancreatic fluid collections (PFC) are a recognized complication of pancreatitis, trauma or surgical injury to the pancreas. Over the years, management has included surgical, radiologic or endoscopic intervention. Endoscopic interventions are now at the forefront for management of PFCs, and development of lumen apposing metal stents (LAMS) have made endoscopic drainage more accessible and easy. It is important for practitioners to understand the risks of LAMS including bleeding, stent migration, buried stent, stent occlusion, and perforation, as well as proper management approaches to these complications.