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Retrieval of a self-expanding metal stent after migration and incorporation in the omental bursa, using a gastroscopic-transgastric laparoscopic rendezvous technique.

Patrzyk M, Dierzek P, Glitsch A, Paul H, Heidecke CD - J Minim Access Surg (2015 Jul-Sep)

Bottom Line: Drainage-related complications may be related directly to the procedure or may occur later as stents migrate or erode into adjacent structures.Migration of a self-expanding metal stent into peritoneal cavity and incorporation in the omental bursa is rare.When endoscopic retrieval fails a combined laparoscopic-endoscopic (rendezvous technique) approach offers an alternative to open surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Clinic of General, Visceral, Thoracic and Vascular Surgery, Ernst-Moritz-Arndt-University Hospital, Greifswald, Germany.

ABSTRACT
Endoscopic drainage is a widely used treatment for pancreatic pseudocysts. Drainage-related complications may be related directly to the procedure or may occur later as stents migrate or erode into adjacent structures. Migration of a self-expanding metal stent into peritoneal cavity and incorporation in the omental bursa is rare. When endoscopic retrieval fails a combined laparoscopic-endoscopic (rendezvous technique) approach offers an alternative to open surgery. We report a case of successful gastroscopic-transgastric laparoscopic removal of a stent that was dislocated into the omental bursa after a ½ year observation period.

No MeSH data available.


Related in: MedlinePlus

Blunt dissection near the omental bursa after incision and retrieval of the stent (a). Removal of the stent with the aid of an endoscope (b)
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Figure 2: Blunt dissection near the omental bursa after incision and retrieval of the stent (a). Removal of the stent with the aid of an endoscope (b)

Mentions: In 2013, a 49-year-old male smoker with a history of diabetes mellitus and arterial hypertension developed severe necrotizing pancreatitis. The cause was eventually determined to be choledocholithiasis. Due to persistent inflammation suggestive of cholangitis antibiotic treatment with meropenem was initiated. Imaging revealed paralytic ileus along with an expanding cystic formation near the liver hilus and pancreatic head with compression of the duodenum. A pseudocyst near the left abdominal wall with enormous but stable proportions was also found to be compressing the left colon transversum (14 cm). Due to the extreme thinness of the wall only transcutaneous drainage was possible. After accidental removal of the drain, the cyst again filled with fluid. Areas of necrosis in the corpus area developed, necessitating transgastral cystotomy and placement of a wall stent (Niti-S™ Nagi™ Stent-Taewoong-Medical Co, Seoul, South Korea, 14 mm wide, 22 mm long). Twenty-four hours later, however, the stent became dislodged and migrated into the omental bursa. An attempt at endoscopic removal the following day was unsuccessful, making the insertion of a second stent (Nagi™ fully covered Taewoong,16 mm wide, 22 mm long) necessary. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed, along with papilotomy and insertion of an 8.5 Fr. 10 stent. Two weeks later, after significant clinical improvement and drainage of necrotic tissue, the second transgastric stent was removed with no complications. For technical reasons, retrieval of the migrated stent was not possible. At follow-up gastroscopy 4 weeks later the gastric wall had completely closed and hence that endoscopic localization of the stent was no longer possible. In November 2013, an ERCP was performed, during which the 8.5 Fr. pancreas stent was replaced. The pseudocysts had regressed significantly, and a computed tomography of the abdomen showed the migrated stent in the omental bursa with no direct contact to the gastric wall. In February 2014, we decided to attempt a laparoscopic-endoscopic retrieval of the displaced wall stent. In the first step, a laparoscopic cholecystectomy was performed in a typical manner. Intraoperative endoscopy demonstrated normal gastric mucosa so that a purely macroscopic localization of the stent was not possible [Figure 1]. After localization of the stent via image converter we made a targeted 3 cm incision into the posterior gastric antrum using an Endo Knife (ERBE, Germany). Due to the location of the stent deep within the omental bursa neither optical nor palpatory contact could be made, and consequently, endoscopic retrieval was not an option. In the next step, three transgastral trocars were placed. First, electrocoagulation was used to make three incisions in the anterior wall of the greater gastric curvature (two in antrum, one in fundus). Then, 3 (Applied Medical KII®, USA) 5 mm trocars were inserted [Figure 1]. The 5 mm optics permitted a good view of the posterior gastric wall. Dissection within the omental bursa was performed using two dissectors, inserted through an incision that had been made endoscopically. An image transformer also provided assistance. After localization of the stent and some blunt dissection it was possible to carefully dislodge the stent into the gastric lumen [Figure 2]. The omental bursa was then rinsed with saline solution and suctioned. No complications occurred [Figure 2]. After further inspection, the transgastral trocars were removed, and the gastric wall incisions were closed with Lahodny stitches (Ethicon, USA). Finally, we performed an endoscopic test for leaks. The postoperative clinical course was without complications, and the patient was discharged on the 6th postoperative day. At follow-up 4 weeks later, no complications were found.


Retrieval of a self-expanding metal stent after migration and incorporation in the omental bursa, using a gastroscopic-transgastric laparoscopic rendezvous technique.

Patrzyk M, Dierzek P, Glitsch A, Paul H, Heidecke CD - J Minim Access Surg (2015 Jul-Sep)

Blunt dissection near the omental bursa after incision and retrieval of the stent (a). Removal of the stent with the aid of an endoscope (b)
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4499929&req=5

Figure 2: Blunt dissection near the omental bursa after incision and retrieval of the stent (a). Removal of the stent with the aid of an endoscope (b)
Mentions: In 2013, a 49-year-old male smoker with a history of diabetes mellitus and arterial hypertension developed severe necrotizing pancreatitis. The cause was eventually determined to be choledocholithiasis. Due to persistent inflammation suggestive of cholangitis antibiotic treatment with meropenem was initiated. Imaging revealed paralytic ileus along with an expanding cystic formation near the liver hilus and pancreatic head with compression of the duodenum. A pseudocyst near the left abdominal wall with enormous but stable proportions was also found to be compressing the left colon transversum (14 cm). Due to the extreme thinness of the wall only transcutaneous drainage was possible. After accidental removal of the drain, the cyst again filled with fluid. Areas of necrosis in the corpus area developed, necessitating transgastral cystotomy and placement of a wall stent (Niti-S™ Nagi™ Stent-Taewoong-Medical Co, Seoul, South Korea, 14 mm wide, 22 mm long). Twenty-four hours later, however, the stent became dislodged and migrated into the omental bursa. An attempt at endoscopic removal the following day was unsuccessful, making the insertion of a second stent (Nagi™ fully covered Taewoong,16 mm wide, 22 mm long) necessary. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed, along with papilotomy and insertion of an 8.5 Fr. 10 stent. Two weeks later, after significant clinical improvement and drainage of necrotic tissue, the second transgastric stent was removed with no complications. For technical reasons, retrieval of the migrated stent was not possible. At follow-up gastroscopy 4 weeks later the gastric wall had completely closed and hence that endoscopic localization of the stent was no longer possible. In November 2013, an ERCP was performed, during which the 8.5 Fr. pancreas stent was replaced. The pseudocysts had regressed significantly, and a computed tomography of the abdomen showed the migrated stent in the omental bursa with no direct contact to the gastric wall. In February 2014, we decided to attempt a laparoscopic-endoscopic retrieval of the displaced wall stent. In the first step, a laparoscopic cholecystectomy was performed in a typical manner. Intraoperative endoscopy demonstrated normal gastric mucosa so that a purely macroscopic localization of the stent was not possible [Figure 1]. After localization of the stent via image converter we made a targeted 3 cm incision into the posterior gastric antrum using an Endo Knife (ERBE, Germany). Due to the location of the stent deep within the omental bursa neither optical nor palpatory contact could be made, and consequently, endoscopic retrieval was not an option. In the next step, three transgastral trocars were placed. First, electrocoagulation was used to make three incisions in the anterior wall of the greater gastric curvature (two in antrum, one in fundus). Then, 3 (Applied Medical KII®, USA) 5 mm trocars were inserted [Figure 1]. The 5 mm optics permitted a good view of the posterior gastric wall. Dissection within the omental bursa was performed using two dissectors, inserted through an incision that had been made endoscopically. An image transformer also provided assistance. After localization of the stent and some blunt dissection it was possible to carefully dislodge the stent into the gastric lumen [Figure 2]. The omental bursa was then rinsed with saline solution and suctioned. No complications occurred [Figure 2]. After further inspection, the transgastral trocars were removed, and the gastric wall incisions were closed with Lahodny stitches (Ethicon, USA). Finally, we performed an endoscopic test for leaks. The postoperative clinical course was without complications, and the patient was discharged on the 6th postoperative day. At follow-up 4 weeks later, no complications were found.

Bottom Line: Drainage-related complications may be related directly to the procedure or may occur later as stents migrate or erode into adjacent structures.Migration of a self-expanding metal stent into peritoneal cavity and incorporation in the omental bursa is rare.When endoscopic retrieval fails a combined laparoscopic-endoscopic (rendezvous technique) approach offers an alternative to open surgery.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery, Clinic of General, Visceral, Thoracic and Vascular Surgery, Ernst-Moritz-Arndt-University Hospital, Greifswald, Germany.

ABSTRACT
Endoscopic drainage is a widely used treatment for pancreatic pseudocysts. Drainage-related complications may be related directly to the procedure or may occur later as stents migrate or erode into adjacent structures. Migration of a self-expanding metal stent into peritoneal cavity and incorporation in the omental bursa is rare. When endoscopic retrieval fails a combined laparoscopic-endoscopic (rendezvous technique) approach offers an alternative to open surgery. We report a case of successful gastroscopic-transgastric laparoscopic removal of a stent that was dislocated into the omental bursa after a ½ year observation period.

No MeSH data available.


Related in: MedlinePlus