EUS-guided insertion of self-expandable metal stent and direct endoscopic necrosectomy in the management of infected walled-off pancreatic necrosis

Fully covered self-expandable metal stents (FCSEMSs) have larger diameters than plastic stents and can provide more effective drainage for pancreatic collections. Enteral or biliary FCSEMSs are suboptimal for drainage of pancreatic collections because of the higher risk of migration, excessive length, and lack of lumen apposition. FCSEMSs customized for drainage are characterized by short lengths and biflanged designs that allow apposition and prevent migration. Examples include the NAGI stent (Taewoong, Seoul, Korea) and the Axios stent (Boston Scientific, Natick, Mass). The NAGI stent comes in lengths of 10, 20, and 30 mm with lumen diameters of 10, 14, 12, and 16 mm, and flared ends of 20 mm. In comparison with the NAGI stent, the Axios stent is 10 mm long with lumen diameters of 10 mm (flange, 21 mm) or 15 mm (flange, 24 mm). The delivery catheter of the NAGI stent is 9F (10-mm and 12-mm stents) or 10F (14-mm and 16-mm stents), whereas that of the Axios stent is 10.8F. Radiopaque markers to guide placement are present for both stents. The NAGI stent is deployed by simple retraction of the catheter sheath, whereas deployment of the Axios stent is characterized by a Luer lock mechanism that allows independent deployment of the distal and proximal stent anchors. The estimated cost of the Axios stent is 3-fold to 4-fold that of the NAGI stent.

This case illustrates the use of a NAGI stent in the management of infected walled-off necrosis (WON).

A 68-year-old man with recent severe gallstone pancreatitis presented with fever and abdominal pain. CT revealed WON measuring 15.5 cm by 10.3 cm. He was treated with intravenous antibiotics, and EUS-guided transmural drainage was performed. The collection was punctured with a 19G needle, and a 0.035-inch guidewire was inserted. Sequential dilation of the puncture tract was performed with use of a 6F biliary dilator and a 10-mm balloon dilator. A 16-mm × 20-mm NAGI stent was then successfully deployed (Fig. 1A). The patient’s symptoms resolved promptly; interval CT at 7 days demonstrated a reduction in size of the WON, and he was discharged from the hospital. He experienced fever and abdominal pain 24 days later. Intravenous antibiotics were restarted. Repeated CT showed an increase in the size of the WON despite the presence of the FCSEMS (Fig. 1B). Endoscopy revealed solid debris blocking the opening of the FCSEMS. Direct endoscopic necrosectomy was performed with the patient under sedation (Video 1), and 4 sessions were required (Fig. 1C). All necrotic debris was removed. Follow-up CT revealed resolution of the WON. The FCSEMS was removed.

Figure 1.

A, Endoscopic view after deployment of a fully covered self-expandable metal stent (FCSEMS). B, CT image of persistent collection despite placement of FCSEMS. C, Endoscopic debridement with removal of large solid debris.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

EUS-guided insertion of self-expandable metal stent and direct endoscopic necrosectomy.