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Tip of delivery system of a lumen‐apposing metal stent getting stuck in a patient undergoing endoscopic ultrasound‐guided drainage of walled‐off pancreatic necrosis

TRANSMURAL ENDOSCOPIC DRAINAGE with the use of lumen-apposing metal stent (LAMS) has been an appropriate first-line, nonsurgical approach to walled-off pancreatic necrosis (WON). LAMS allows direct endoscopic necrosectomy and can shorten the time to resolution of WON and the length of hospital stay. Especially, single-step delivery systems of LAMS can significantly reduce the risk of adverse events and procedure time. However, we are first to report a patient undergoing endoscopic ultrasound (EUS)guided drainage of WON and the tip of delivery system of LAMS getting stuck in the saddle part of stent (Video S1). This 50-year-old man with alcoholism came to our hospital due to coffee ground vomitous and abdominal pain. A computed tomography scan showed a 6.8 cm pancreatic cystic lesion suggestive of WON (Fig. 1A) and a thick wall surrounded this cystic lesion, as noted by EUS (Fig. 1B). EUS-guided drainage of WON with 15-mm LAMS (hot AXIOS stent; Boston Scientific, Marlborough, MA, USA) was performed 2 weeks after upper gastrointestinal bleeding was under control. During the LAMS deployment, the tip of the delivery system of hot AXIOS stent was stuck in the under-expanded saddle part of stent due to thickening wall of WON and the delivery system could not be withdrawn (Fig. 2A). Therefore, we inserted another gastroscope (GIFHQ290; Olympus Medical Systems, Tokyo, Japan) along with ultrasonic endoscope (EG-580UT; Fujifilm Corporation, Tokyo, Japan) at the same time without any resistance. It is safe to use a forward-viewing gastroscope to pass the upper esophageal sphincter under direct visualization. After using a catheter to place a 0.025-inch guidewire into the cavity of WON (Fig. 2B), 6 mm balloon dilatation catheter (Hurricane RX Biliary Balloon Dilatation Catheter; Boston Scientific)