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Start of a new TREnD: TransRemnant Endoscopic Drainage for management of walled-off necrosis in a patient with Roux-en-Y gastric bypass

Open AccessPublished:June 17, 2020DOI:https://doi.org/10.1016/j.vgie.2020.04.027

      Abbreviations:

      LAMS (lumen-apposing metal stent), RYGB (Roux-en-Y gastric bypass), WON (walled-off necrosis)
      A 64-year-old woman with a history of Roux-en-Y gastric bypass (RYGB) was admitted to an outside hospital with severe necrotizing pancreatitis. Three weeks after her initial presentation, the patient was transferred to our hospital because of persistent abdominal pain and nausea, along with fever and worsening leukocytosis.
      Upon admission, a CT scan demonstrated the presence of areas of large, walled-off necrosis (WON) filling both the left and right pericolic gutters (Fig. 1). Imaging also demonstrated that the collection in the left pericolic gutter was adjacent to the excluded stomach, and the collection in the right pericolic gutter was adjacent to the duodenum. Given the concomitant signs of worsening sepsis, it was determined that drainage of the collections was required. To achieve successful internal drainage, the decision was made to perform a transremnant endoscopic drainage procedure by endoscopically creating a conduit between the gastric pouch and the excluded stomach.
      Figure thumbnail gr1
      Figure 1CT scan at initial presentation demonstrating the presence of bilateral regions of walled-off necrosis (WON) in a patient with Roux-en-Y gastric bypass anatomy. Internal drainage of the WON in the left pericolic gutter (white arrow) required access to the excluded stomach.

      Procedure

      Before accessing the excluded stomach, the different possible access vectors were carefully assessed. Given the location of the WON along the greater curvature of the excluded stomach, the decision was made to access the excluded stomach from the blind limb of the gastrojejunostomy. The vector created by this approach was thought to make future attempts at endoscopic necrosectomy technically easier to accomplish (Fig. 2).
      Figure thumbnail gr2
      Figure 2Fluoroscopic (A) and endoscopic (B) images of positioning of the endosonoscope at the blind limb of the gastrojejunostomy. The fluoroscopic image demonstrates that positioning at the blind limb of the gastrojejunostomy provides an optimal vector (white arrow) to access the walled-off necrosis at the left pericolic gutter (red circle).
      First, a 15- × 10-mm lumen-apposing metal stent (LAMS) was deployed across the blind limb of the gastrojejunostomy, sutured in place, and dilated to accommodate a therapeutic echoendoscope (Fig. 3). Once access to the excluded stomach was secure, the therapeutic echoendoscope was advanced to the excluded stomach, and the area of the WON was visualized. A second 15- × 10-mm LAMS was then deployed from the excluded stomach to the WON in the left pericolic gutter (Fig. 4). After initial drainage of debris and pus, additional necrosectomy was performed through the LAMS (Fig. 5).
      Figure thumbnail gr3
      Figure 3Fluoroscopic (A) and endoscopic (B) images of dilation of the transremnant lumen-apposing metal stent.
      Figure thumbnail gr4
      Figure 4Sonographic (A) and endoscopic (B) images after initial placement of a lumen-apposing metal stent into the walled-off necrosis.
      Figure thumbnail gr5
      Figure 5Direct endoscopic visualization of walled-off necrosis with necrosectomy.
      Several weeks later, the patient returned to our endoscopy suite for management of the area of the WON in the right pericolic gutter. Using the same transgastric conduit created originally, we deployed a LAMS into the left pericolic gutter across the duodenum. All interventions were possible given the presence of the transremnant LAMS conduit (Video 1, available online at www.VideoGIE.org).

      Outcome and discussion

      After the completion of our interventions, the patient returned for further imaging to assess the areas of persistent necrosis. After 3 months of interventions, CT scan demonstrated resolution of the areas of WON in the bilateral pericolic gutters (Fig. 6). At 3 months after the patient’s initial presentation, all of the LAMSs had been removed.
      Figure thumbnail gr6
      Figure 6Comparison of initial (A) and postintervention (B) CT scans of our patient. Images demonstrate the efficacy of our interventions in resolving the complex areas of walled-off necrosis in the bilateral pericolic gutters.
      Over the past decade, the increasing adoption of LAMSs into clinical practice has changed the way endoscopists can address challenging pancreaticobiliary pathology in patients with RYGB anatomy. The development of the EUS-directed transgastric ERCP simplified the management of biliary pathology in patients with RYGB anatomy.
      • Kedia P.
      • Sharaiha R.Z.
      • Kumta N.A.
      • et al.
      Internal EUS-directed transgastric ERCP (EDGE): game over.
      ,
      • Kedia P.
      • Kumta N.A.
      • Widmer J.
      • et al.
      Endoscopic ultrasound-directed transgastric ERCP (EDGE) for Roux-en-Y anatomy: a novel technique.
      Similarly, a recent case series by Krafft et al
      • Krafft M.R.
      • Hsueh W.
      • James T.W.
      • et al.
      The EDGI new take on EDGE: EUS-directed transgastric intervention (EDGI), other than ERCP, for Roux-en-Y gastric bypass anatomy: a multicenter study.
      reported on the outcomes of 14 cases of interventions (luminal and extraluminal) that were performed from the region of the excluded stomach and duodenum after a LAMS was used to connect the gastric pouch and the remnant. As our case, their series included 2 cases of successful drainage of pancreatic fluid collections into the excluded stomach. This case is demonstrative of how technological and procedural advancements now provide endoscopists with the ability to manage complex fluid collections in patients with altered anatomy, specifically those patients who have undergone RYGB.

      Disclosure

      Dr Maarya is consultant for AnX Robotica. Dr Chandrasekhara is a consultant for Interspace Diagnostics and a shareholder in Nevakar Corporation. Dr Peterson is a consultant for Olympus America, Boston Scientific, Advanced Sterilization Products, and GIE Medical and is an investor in Exact Sciences, AbbVie, and Johnson & Johnson. Dr Storm is a consultant for Olympus America, Boston Scientific, and Edno-TAGGS. All other authors disclosed no financial relationships.

      Supplementary data

      References

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