EUS-guided Endoscopic Transduodenal Necrosectomy in a Patient With Sleeve Gastrectomy

Abstract

Walled-off pancreatic fluid collections (PFC) occur after an acute attack of pancreatitis in approximately 10 percent of cases. Decompression of the collection is advocated when specific indications are met, such as pain, gastric outlet or biliary obstruction, fluid leakage, fistulization, weight loss and infection. Endoscopic drainage has been widely adopted as the primary approach for symptomatic walled-off PFC. Difficulty can arise in cases of altered gastric anatomy, as the procedure requires an adequate amount of space to maneuver. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN). 40 year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 with intermittent post-prandial RUQ abdominal pain was found to have symptomatic gallstone disease. Patient's course was complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging at 8 weeks revealed 10.8 x 7.6 cm fluid collection with portions of solid components seen in the body and tail of the pancreas. The decision was made to attempt endoscopic necrosectomy. EGD revealed a 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. The patient underwent successful TDN with placement of three 10Fr pigtail stents. Patient had symptomatic improvement and was discharged to outpatient follow-up. Although the transgastric approach is preferred for walled-off PFC, usually due to more favorable location, as well as the comfort level of endoscopists, there is no definite evidence that transgastric drainage is superior to transduodenal drainage. The duodenal approach was used in our patient as sleeve gastrectomy involves removal of the stomach body and a large portion of the antrum producing a high pressure system inside the stomach which may lead to inadequate drainage. Additionally, intervention adjacent to the staple line may predispose to anastomotic leak and break down of the staple line. One prior case has been reported of a patient with sleeve gastrectomy undergoing laparoscopic cyst-gastrostomy after aborted endoscopic cyst-gastrostomy due to limited working space and the inability to visualize the posterior aspect of the stomach. Although laparoscopic cyst-gastrostomy is an acceptable approach for these patients, randomized trials have demonstrated equal efficacy between endoscopic and surgical luminal pancreatic pseudocyst drainage, with endoscopic treatment associated with shorter hospital stays and lower cost. This case illustrates the feasibility of endoscopic necrosectomy in patients with altered gastric anatomy.Figure 1Figure 2Figure 3