Abstract
BackgroundAfter an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases. Drainage of the cavity is recommended when specific indications are met. Endoscopic drainage has been adopted as the main intervention for symptomatic walled-off PFC. Altered gastric anatomy in these patients poses an interesting challenge. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN).Case presentationForty year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 was found to have symptomatic gallstone disease complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging significant for 10.8 × 7.6 cm fluid collection with necrotic debris in the body and tail of the pancreas and endoscopic necrosectomy was attempted. EGD showed tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. Patient underwent successful TDN in two sessions. Patient had symptomatic improvement at follow-up with resolution of WOPN.ConclusionTo our knowledge, this is the first reported case of EUS-guided endoscopic necrosectomy in a patient with sleeve gastrectomy. The duodenal approach was used in our patient due to history of sleeve gastrectomy.
Highlights
After an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases
The duodenal approach was used in our patient due to history of sleeve gastrectomy
Endoscopic treatment outcomes are directly related to the type of pancreatic fluid collection (PFC) being treated; while the treatment success for pancreatic pseudocysts is greater than 90 %, it is 50 to 65 % for walled off pancreatic necrosis (WOPN) [9, 10]
Summary
This is the first reported case of a patient with sleeve gastrectomy undergoing successful. Manipulation nearby the staple line may lead to an anastomotic leak and disruption of the staple line and should be avoided Another potential location of drainage of PFCs in this patient population is the preserved portion of the antrum. The surgical approach is an adequate intervention for these patients, randomized trials have validated similar outcomes between endoscopic and surgical pancreatic pseudocyst drainage, with endoscopic treatment linked with reduced hospital stays, improved physical and mental health of patients, and decreased cost [6, 23] This case illustrates the feasibility of endoscopic drainage and necrosectomy for WOPN in patients with altered gastric anatomy through EUS-guided TDN [24].
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