Secondary Logo

Journal Logo

IMAGE: COLON

Retained Cystogastrostomy Stents Eroding Into the Left Colon After Endopancreatic Intervention Without Any Symptoms

Vanek, Petr MD1,2; de Groen, Piet MD1

Author Information
doi: 10.14309/crj.0000000000000509
  • Open

CASE REPORT

A 68-year-old woman with a history of necrotizing pancreatitis (NP) with disconnected pancreatic duct syndrome managed in 2014 with 2 long-term cystogastrostomy stents underwent surveillance colonoscopy 5½ years later. During water exchange endoscope insertion, 2 double-pigtail stents (DPS) were found protruding into the splenic flexure (Figure 1). At previous gas-based colonoscopies in 2016 and 2018, no stents were seen. A tattoo was placed in case repeat exploration was indicated, and she was dismissed with return to usual regimen. She has had no symptoms attributable to stents connecting stomach with colon during the past 5 years, and physical examination was unremarkable. A review of computed tomography scans performed as follow-up on sequelae of NP from 2015 to 2018 showed that the stents had already eroded into the colon early in 2015 (Figures 2 and 3). Secretin-enhanced magnetic resonance cholangiopancreatography was performed with no appreciable response in the disconnected pancreatic remnant; no contrast was noted in the stomach or colon. A multidisciplinary majority decision was to leave the stents in situ as the patient was asymptomatic, stents had likely been in the current position for over 4 years, and removal could result in the formation of an actual fistula.

Figure 1.
Figure 1.:
Endoscopy image from 2019 showing 2 double-pigtail stents in the splenic flexure with a drainage hole in the top stent.
Figure 2.
Figure 2.:
(A) Transverse and (B) sagittal view of computed tomography from 2015 showing 2 double-pigtail stents with distal ends in the colonic lumen (circled).
Figure 3.
Figure 3.:
Computed tomography image from 2018 showing 2 double-pigtail stents with distal ends in the colonic lumen (circled); transverse view.

Common consequences of disconnected pancreatic duct syndrome in NP are recurrent fluid collections after successful drainage of necrotic collections. The most widely used approach to prevent these is to keep cystenterostomy prostheses indefinitely to redirect pancreatic secretions back into the gastrointestinal lumen.1 DPS were demonstrated effective in that manner with safety confirmed in long-term studies.2,3 However, indwelling stents-related adverse events have been reported. Most of the literature highlights stent occlusion and dislocation. A case of small bowel obstruction due to stent migration was described.4 In addition, stents may erode into adjacent organs.

Our case presents an incidental finding of a potential gastro-cysto-colonic fistula. Abdominal pain, diarrhea, halitosis, nausea, and (feculent) vomiting would be expected if symptoms were pronounced with additional risk of intra-abdominal infection from gut flora. The asymptomatic nature could be explained by gradual atrophy of the remnant confirmed on magnetic resonance cholangiopancreatography and stent occlusion leaving no true connection between the organs involved. Although not without risk, careful follow-up without stent removal may be reasonable in asymptomatic patients with eroding DPS. Finally, the stents were missed on 2 previous colonoscopies. Missing lesions in the colon is common; up to 28% of polyps are likely missed.5 The location close to the splenic flexure and retraction from the fistula tract resulted in the stents being buried deep between haustrae. Water exchange decompresses the colon and thereby brings lateral lesions into view.

DISCLOSURES

Author contributions: P. Vanek wrote the manuscript. P. de Groen edited the manuscript, revised the manuscript for intellectual content, and is the article guarantor.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

REFERENCES

1. Trikudanathan G, Wolbrink DRJ, van Santvoort HC, et al. Current concepts in severe acute and necrotizing pancreatitis: An evidence-based approach. Gastroenterology. 2019;156(7):1994–2007.e3.
2. Rana SS, Bhasin DK, Sharma R, et al. Factors determining recurrence of fluid collections following migration of intended long term transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome. Endosc Ultrasound. 2015;4(3):208–12.
3. Téllez-Aviña FI, Casasola-Sánchez LE, Ramírez-Luna MA, et al. Permanent indwelling transmural stents for endoscopic treatment of patients with disconnected pancreatic duct syndrome: Long-term results. J Clin Gastroenterol. 2018;52(1):85–90.
4. Lorenzi B, Pesenti C, Bories E, et al. Small-bowel obstruction due to a migrated cystogastric endoprosthesis: Report of a case. Endoscopy. 2007;39(Suppl 1):E307.
5. Zhao S, Wang S, Pan P, et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: A systematic review and meta-analysis. Gastroenterology. 2019;156(6):1661–74.e11.
© 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.