A 67-year-old man with pancreatic head cancer developed acute pancreatitis due to obstruction of the main pancreatic duct. He subsequently developed an infected walled-off necrosis (WON) ( Fig. 1 ). Endoscopic ultrasound-guided transluminal drainage (EUS-TD) was performed using a 6-Fr endoscopic nasobiliary drainage catheter (SilkyPass; Boston Scientific, Tokyo, Japan) as an external drainage tube and a 7-Fr/7-cm double-pigtail plastic stent (DPS) (Zimmon biliary stent; Cook Medical, Tokyo, Japan) as an internal drainage tube ( Fig. 2 ). Subsequently, the patient’s condition improved, and the external drainage tube was removed. Computed tomography (CT) performed 4 months after EUS-TD revealed that the WON had disappeared. The DPS was in place until pancreaticoduodenectomy after neoadjuvant chemotherapy and was removed endoscopically 8 months after EUS-TD because of the risk that the DPS could cause infection during adjuvant chemotherapy. At the time the stent was removed, massive arterial bleeding occurred from the fistula ( Video 1 ). Since endoscopic hemostasis was difficult, urgent interventional radiology was performed, and a splenic artery pseudoaneurysm causing massive bleeding was detected ( Fig. 3 ). Hemostasis was achieved using coil embolization ( Fig. 4 ).
Fig. 1.
An abdominal computed tomography image shows walled-off necrosis (arrows). The diameter of the lesion is approximately 8 cm.
Fig. 2.
Endoscopic ultrasound-guided transluminal drainage was performed using a 6-Fr endoscopic nasobiliary drainage catheter (white arrowheads) as an external drainage tube and a 7-Fr/7-cm double-pigtail plastic stent (yellow arrowheads) as an internal drainage tube.
Fig. 3.
Interventional radiology detected a splenic artery pseudoaneurysm. a Selective angiogram of the celiac artery showed pooling of contrast medium (arrow), indicating the presence of a splenic artery pseudoaneurysm. b A computed tomography image detected the splenic artery pseudoaneurysm (arrowhead).
Fig. 4.
Angiogram after coil embolization for hemostasis shows no pooling of the contrast medium (arrow).
Video 1 Massive bleeding caused by the removal of a double-pigtail plastic stent after its prolonged placement for internal drainage of a walled-off necrosis.
WON is a late complication of acute necrotizing pancreatitis. Currently, EUS-TD is the best therapeutic option for WON 1 . Although lumen-apposing covered self-expanding metal stents have been introduced, EUS-TD with DPS remains the main endoscopic therapy for WON. DPS is associated with lower rates of procedure-related bleeding, such as serious pseudoaneurysm bleeding 2 3 . Nevertheless, in this case, massive bleeding due to a pseudoaneurysm occurred after stent removal. The pseudoaneurysm may have been formed by the long period of stent placement and contact, causing arteritis. When removing a plastic stent after a long period of placement, it is crucial to consider that serious complications can occur, and contrast-enhanced CT should be performed to check for the presence of a pseudoaneurysm before stent removal.
Endoscopy_UCTN_Code_TTT_1AO_2AD
Footnotes
Competing interests The authors declare that they have no conflict of interest.
Endoscopy E-Videos : https://eref.thieme.de/e-videos .
Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply (currently EUR 375), discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
References
- 1.Ang T L, Teoh A YB. Endoscopic ultrasonography-guided drainage of pancreatic fluid collections. Dig Endosc. 2017;29:463–471. doi: 10.1111/den.12797. [DOI] [PubMed] [Google Scholar]
- 2.Brimhall B, Han S, Tatman P D et al. Increased incidence of pseudoaneurysm bleeding with lumen-apposing metal stents compared to double-pigtail plastic stents in patients with peripancreatic fluid collections. Clin Gastroenterol Hepatol. 2018;16:1521–1528. doi: 10.1016/j.cgh.2018.02.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lang G D, Fritz C, Bhat T et al. EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates. Gastrointest Endosc. 2018;87:150–157. doi: 10.1016/j.gie.2017.06.029. [DOI] [PubMed] [Google Scholar]