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.
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.
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.
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