If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Patients with surgically altered anatomy present unique challenges to traditional endoscopic management of foregut pathology, such as drainage of peripancreatic fluid collections. Recent advances in endoscopic techniques have enabled less-invasive access with EUS-directed transgastric intervention or gastric access temporary for endoscopy.
Here we present a case of same session EUS-guided transgastric intervention to facilitate cystgastrostomy (Video 1, available online at www.giejournal.org).
A 58-year-old woman with a history of Roux-en-Y gastric bypass in 2003 as well as recurrent alcohol-related pancreatitis complicated by peripancreatic fluid collections presented with abdominal pain, nausea, early satiety, and 20-pound weight loss. A CT scan was notable for a 10- × 8-cm unilocular cystic lesion at the head of the pancreas, abutting the gastric remnant (Fig. 1). The decision was made to attempt endoscopic drainage.
A linear array echoendoscope was advanced into the gastric pouch, and a large anechoic lesion was identified. Attempts were made to find a safe window for pseudocyst drainage; however, there was pancreatic tissue and multiple blood vessels precluding safe access into the cavity (Fig. 2).
Figure 2Endosonographic image showing blood vessels precluding safe access into the peripancreatic fluid collection from gastric pouch.
The decision was made to obtain gastric access into the remnant stomach. The excluded stomach was identified under EUS, and after confirming the absence of interposed vessels via Doppler imaging, the remnant was punctured with a 19-gauge needle. A mixture of contrast and sterile water was then injected to expand the remnant stomach (Fig. 3A) to allow for placement of a lumen-apposing metal stent (LAMS) (AXIOS, Boston Scientific, Marlborough, Mass, USA). Using freehand technique, we deployed a 20- × 10-mm electrocautery-enhanced LAMS with the flanges in close approximation to the walls of the gastric remnant and gastric pouch (Fig. 3B). The LAMS was then dilated to a maximum diameter of 18 mm using a hydrostatic balloon (Fig. 3C).
Figure 3EUS-guided transgastric stent placement. A, Injecting fluid and contrast into the gastric remnant. B, Deployment of LAMS under endosonographic guidance. C, Dilation of the LAMS. D, Plastic double-pigtail stent placed through the gastro-gastric LAMS, which was placed after the completion of the cystgastrostomy. LAMS, Lumen-apposing metal stent.
Given the severity of the patient’s symptoms, the decision was made to proceed with same-session cystgastrostomy. The echoendoscope was advanced through the dilated LAMS with caution to ensure that there was no migration. The peripancreatic fluid collection was now visualized from the gastric remnant and a safe window was identified. Using freehand technique, a 15- × 10-mm electrocautery-enhanced LAMS was deployed with the flanges in close approximation to the walls of the pseudocyst and gastric remnant (Fig. 4). This LAMS was dilated to a maximum of 12 mm using a hydrostatic balloon and anchored in place with plastic double pigtail stent (Fig. 5). Subsequently, a second plastic double-pigtail stent was placed through the gastro-gastric LAMS (Fig. 3D).
Figure 4EUS-guided cystgastrostomy. Deployment of lumen-apposing metal stent between pseudocyst and gastric remnant under endosonographic (A) and endoscopic (B) guidance.
At the planned follow-up 1 month later, the patient reported resolution of her symptoms. Both LAMSs were removed and the gastro-gastric fistula was closed with endoscopic suturing (Fig. 6). The patient had no further symptoms and no recrudescence of the fluid collection at 18 months of follow-up.
Figure 6Closure of gastro-gastric fistula with endoscopic suturing.
Same-session EUS-guided gastrogastrostomy with placement of LAMSs can be used to access the excluded stomach and facilitate endoscopic drainage of pancreatic fluid collections that would be otherwise unreachable endoscopically in patients with surgically altered anatomy.
These procedures are commonly performed in stages, given the concern for transgastric stent dislodgement.
Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible.
If performed in a single session, we would recommend using the largest commercially available LAMS, which is 20 mm in diameter and appears to be protective against LAMS migration.
We also recommend careful evaluation of the gastric pouch under Doppler EUS because a window may exist for standard cystgastrostomy precluding the need for gastrogastrostomy. Caution should be taken when removing the distal AXIOS stent through the proximal AXIOS stent to prevent dislodgement. Timing of transgastric LAMS removal is critical. Multidisciplinary discussion and patient trajectory, including response to treatment, is important because ERCP may be required in cases of refractory cyst drainage.
Disclosure
Dr Schulman is a consultant at Apollo Endosurgery, Boston Scientific, MicroTech, and Olympus and receives research/grant support from GI Dynamics. All other authors disclosed no financial relationships.
Single-session EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) and EUS-guided gallbladder drainage is safe and feasible.
00209-0&id=gr1.jpg){kind=link}
00209-0&id=gr2.jpg){kind=link}
00209-0&id=gr3.jpg){kind=link}
00209-0&id=gr4.jpg){kind=link}
00209-0&id=gr5.jpg){kind=link}
00209-0&id=gr6.jpg){kind=link}