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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.
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).
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).
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.
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.
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.
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.