Gastric Colonic Fistula Formation After Fully Covered Self-Expanding Stent Utilized for Cyst-Gastrostomy of a Pancreatic Pseudocyst

Abstract

Introduction: Endoscopic cyst-gastrostomy demonstrates equality to surgical drainage of pancreatic pseudocyst but is not without complications, infection and bleeding. We present a case of 34 year old male who developed a gastric colonic fistula secondary to erosion of fully covered self-expanding metal stent (FCSEMS) into the splenic flexure. Case: Mr. L is a 34 year old male with multiple episodes of acute pancreatitis who presented with abdominal pain, diarrhea and bright red blood per rectum. Six years prior he developed pancreatitis secondary to choledocholithiasis and was treated via ERCP and cholecystectomy. One month after cholecystectomy he developed nausea, vomiting, and epigastric pain. Computer Tomography (CT) abdomen/pelvis with contrast demonstrated an 8 cm pseudocyst in the pancreatic body. Medical management was determined to be the best course of action secondary to resolution of symptoms. His symptoms returned after two months and CT imaging demonstrated enlarging pseudocyst to 23 cm with impingement on the stomach (Figure 1). Pseudocyst drainage via endoscopic approach was the best approach because of overlying bowel making a percutaneous approach difficult. Endoscopic ultrasound (EUS) demonstrated a clear window for transmural cyst-gastrostomy and an insertion of a 10 x 40 mm FCSEMS produced copious amounts of “dishwater” type fluid into the stomach. He continued to have epigastric pain with no resolution of the pseudocyst per CT imaging and open gastrocystostomy was performed. His symptoms resolved shortly after surgery. Over the next 5 years he did well with only intermittent epigastric pain associated with eating fatty foods.Figure 1Current presentation demonstrated vitals within normal limits, abdomen was non distended, soft, nontender, and no palpable mass. Two melenic stools were noted. CBC and CMP were unremarkable. EGD and colonoscopy performed didn't identify a bleeding source. A FCSEMS was noted in the gastric antrum and colonoscopy demonstrated FCSEMS protruding into the splenic flexure (Figures 2 & 3). Attempts were made to remove the FCSEMS but were not successful due to tissue ingrowth. He is currently awaiting further treatment with argon plasma coagulation to remove ingrown tissue and attempt to remove the stent.Figure 2Figure 3Discussion: Cyst-gastrostomy are not without complications and without close follow up can cause complications, as demonstrated by our patient developing a gastrocolonic fistula secondary to long term placement of a FCSEMS.