VideoGIE| Volume 84, ISSUE 6, P1059-1060, December 2016

Mechanical debridement of walled-off pancreatic necrosis remains necessary despite lumen-apposing metal stent use

      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 These cases demonstrate that large-caliber stenting alone may be insufficient for WON drainage, and they underscore the importance of concurrent mechanical debridement.
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      Figure 1Endoscopic image of an externally migrated lumen-apposing metal stent that is occluded by necrotic debris.
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