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Several multicenter observational studies and a small randomized controlled trial
have demonstrated that endoscopic treatment of walled-off necrosis (WON) is safe and
effective. Although we and others have observed that WON can be treated by transmural
drainage alone with the use of aggressive stenting strategies, most available data
suggest that active debridement of the necrotic debris increases the likelihood of
cyst collapse and resolution. Debridement may be accomplished by aggressive irrigation
through a nasocystic or percutaneous catheter, but the most efficient and popular
approach has become direct endoscopic removal of necrotic content. Lumen-apposing
metallic stents (LAMSs) represent an important innovation in the drainage of pancreatic
fluid collections, providing a larger stent diameter that may allow spontaneous egress
of necrotic content from the cyst cavity. Thus, it is tempting to use LAMS monotherapy
for transmural drainage of WON without concurrent mechanical debridement. However,
we present 3 cases of cystgastrostomy tract obstruction despite LAMS placement; in
2 cases the LAMS became occluded by necrotic debris and the cyst wall, respectively,
and in the third case the prosthesis migrated into the lumen of the stomach (Fig. 1; Video 1, available online at www.giejournal.org). These cases demonstrate that large-caliber stenting alone may be insufficient for
WON drainage, and they underscore the importance of concurrent mechanical debridement.
Figure 1Endoscopic image of an externally migrated lumen-apposing metal stent that is occluded
by necrotic debris.
