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IMAGES AND VIDEOS
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 309-310

Safe removal of lumen-apposing metal stent using argon plasma coagulation after EUS-guided cyst gastrostomy (with video)


1 Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
2 Gastroenterology Division, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan

Date of Submission29-Sep-2020
Date of Acceptance17-Nov-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Dr. Haruo Miwa
Gastroenterological Center, Yokohama City University Medical Center, 4-57 Urafune-Cho, Minami-Ku, Yokohama, Kanagawa 232- 0024
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/EUS-D-20-00211

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How to cite this article:
Miwa H, Sugimori K, Tsuchiya H, Nishimura M, Tozuka Y, Kaneko T, Maeda S. Safe removal of lumen-apposing metal stent using argon plasma coagulation after EUS-guided cyst gastrostomy (with video). Endosc Ultrasound 2021;10:309-10

How to cite this URL:
Miwa H, Sugimori K, Tsuchiya H, Nishimura M, Tozuka Y, Kaneko T, Maeda S. Safe removal of lumen-apposing metal stent using argon plasma coagulation after EUS-guided cyst gastrostomy (with video). Endosc Ultrasound [serial online] 2021 [cited 2021 Sep 20];10:309-10. Available from: http://www.eusjournal.com/text.asp?2021/10/4/309/308930

A 25-year-old woman was referred to our hospital owing to the development of walled-off necrosis after severe acute pancreatitis [Figure 1]. We performed EUS-guided cyst gastrostomy using a 10 mm × 15 mm lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific, Marlborough, MA, US), and direct endoscopic necrosectomy was performed through the LAMS. After 3 weeks, we planned to remove the LAMS; however, the proximal flange was fixed to the gastric wall due to circumferential tissue ingrowth [Figure 2]a. First, we caught the middle portion of the LAMS using a snare; however, removal of the LAMS failed because the proximal flange did not come off the gastric wall. Moreover, the ingrowing tissue began to bleed after snaring. Thereafter, we used argon plasma coagulation (APC) to burn down the ingrowing tissue. The electrical setting of APC was adjusted to 30 W (1.0 L/min of flow) which is lower than that normally used for gastric mucosa. By using such a lower electrical setting, it was possible to easily break only the tissue inside the LAMS while preventing thermal damage of the wire. Circumferential cauterization was achieved in 7 min [Figure 2]b. Subsequently, the LAMS was again caught using a snare and easily removed by pulling the endoscope [Additional file 1]. The LAMS was retrieved through the scope, and there was no evidence of bleeding or perforation at the cyst gastrostomy anastomosis [Figure 2]c. The silicon cover of the LAMS was broken at the distal flange [Figure 2]d. The patient was discharged without any complications 2 days after the procedure. LAMS has been widely used for various types of intra-abdominal drainage, including peripancreatic fluid collection;[1],[2] however, few cases have reported about difficulty in removal of LAMS.[3],[4],[5] To the best of our knowledge, this is first report about removal of LAMS with tissue ingrowth using APC. Lower electrical setting is favorable to break only the tissues inside the LAMS.
Figure 1: Contrast-enhanced computed tomography showing large walled-off necrosis on the dorsal side of the stomach

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Figure 2: (a) Lumen-apposing metal stent with tissue ingrowth. (b) After argon plasma coagulation, tissue ingrowth completely disappears. (c) After removal of the stent, the fistula does not have any bleeding or perforation. (d) Silicon cover of the lumen-apposing metal stent is broken; however, the wire does not show any thermal change

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Itoi T, Binmoeller KF, Shah J, et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012;75:870-6.  Back to cited text no. 1
    
2.
DeSimone ML, Asombang AW, Berzin TM. Lumen apposing metal stents for pancreatic fluid collections: Recognition and management of complications. World J Gastrointest Endosc 2017;9:456-63.  Back to cited text no. 2
    
3.
Parekh PJ, Shakhatreh MH, Yeaton P. A tale of two LAMS: A report of benign tissue ingrowth resulting in recurrent gastric outlet obstruction. Endosc Int Open 2018;6:E1390-4.  Back to cited text no. 3
    
4.
Saumoy M, Madanat L, Carr-Locke DL, et al. Tissue ingrowth within lumen-apposing metal stents. How long is long term? Endoscopy 2018;50:E284-5.  Back to cited text no. 4
    
5.
Fugazza A, Sethi A, Trindade AJ, et al. International multicenter comprehensive analysis of adverse events associated with lumen-apposing metal stent placement for pancreatic fluid collection drainage. Gastrointest Endosc 2020;91:574-83.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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