Endoscopic rescue after lumen-apposing metal stent deployment failure during endoscopic ultrasound-guided drainage of a giant pancreatic pseudocyst

A 32-year-old man with a 1-year history of acute pancreatitis presented with obstructive jaundice caused by a large pancreatic body–tail pseudocyst (14.5 × 6.6 × 10.0 cm) compressing the bile duct ([ Fig. 1 ]). Fig. 1 A pseudocyst located in the body–tail region of the pancreas. During endoscopic ultrasound-guided HOT-AXIOS lumen-apposing metal stent (LAMS) drainage, proximal flange deployment failed and the stent migrated into the pseudocyst ([ Fig. 2 ] a, b ). As the original tract was not identifiable, the pseudocyst was punctured via the gastric wall with a 19-G needle, a guidewire was advanced, and the tract dilated to 12 mm. Due to an unfavorable angle, endoscopic entry failed, so two 7 F × 7cm double-pigtail stents were placed for temporary drainage ([ Fig. 2 ] c ). Fig. 2 a Failed deployment of the proximal flange of the LAMS. b Migration of the LAMS into the pseudocyst cavity. c Placement of double-pigtail stents. LAMS, lumen-apposing metal stent. The next day, a salvage procedure was performed. Despite right lateral positioning, direct access remained difficult. The tract was dilated with an 18-mm balloon and further enlarged with an insulation-tipped (IT) knife ([ Fig. 3 ] a, b ). After removing the pigtail stents, the endoscope entered the pseudocyst, the migrated LAMS was retrieved with forceps ([ Fig. 4 ] a, b ), and a nasocystic tube was placed for drainage ([ Video 1 ]). Fig. 3 a Endoscopic 18-mm balloon dilation. b Endoscopic incision and enlargement using an IT knife. IT, insulation-tipped. Fig. 4 a LAMS within the pseudocyst. b The LAMS was retrieved from the pseudocyst cavity using grasping forceps. LAMS, lumen-apposing metal stent. Download Video Endoscopic tract dilation with an 18-mm balloon and IT-knife incision was performed to retrieve the migrated LAMS. IT, insulation-tipped; LAMS, lumen-apposing metal stent.Video 1 Two weeks later, endoscopy showed a narrowed tract with persistent drainage, and computed tomography confirmed significant pseudocyst reduction ([ Fig. 5 ]). Fig. 5 Marked reduction of the pseudocyst 2 weeks after the procedure. Stent deployment failure is a challenging complication in endoscopic drainage of pancreatic pseudocysts [ 1 ]. Endoscopic salvage provides a feasible treatment option [ 2 ], and combined IT-knife incision with balloon dilation allows safe, controlled pseudocyst access, offering a key technical approach for managing LAMS deployment failure. Endoscopy_UCTN_Code_CPL_1AL_2AD Publication History Article published online: 28 January 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany