Successful management of perforation during cystogastrostomy with an esophageal fully covered metallic stent placement

Abstract

A 49-year-old woman presented for endoscopic treatment of symptomatic pseudocyst refractory to conservative management for the past year. EUS showed a thickwalled 49 39-mm pseudocyst in the pancreatic tail in close opposition to the gastric fundus. The cyst was punctured by using a 19-gauge FNA needle (Fig. 1) followed by guidewire placement and dilation of the fistula with a needle-knife cautery and a 6-mm balloon. Attempted placement of a 10F, 4-cm long double-pigtail stent resulted in dislodgment of the guidewire from the pseudocyst because of extreme angulation of the endoscope required to obtain a satisfactory endoscopic view. The guidewire was re-placed into what appeared to be the pseudocyst cavity under endoscopic control, and balloon dilation was repeated using a 12-mm balloon. Fluoroscopic examination showed possible free air at this point, and thus, the echoendoscope was exchanged for a gastroscope to examine the cystogastrostomy tract. Endoscopy showed a clear perforation next to the true lumen of the cystogastrostomy tract (Fig. 2). We then placed an 18 70-mm esophageal fully covered self-expandable metallic stent (FCMS) (ALIMAXX-ES; Merit Medical Endotek, South Jordan, Utah) by using a stiff guidewire (Savary-Gilliard Wire Guides; Cook Medical Inc, Bloomington, Ind) into the pseudocyst cavity to drain it and to seal the perforation (Fig. 2). Broad-spectrum antibiotics were initiated during the procedure. Abdominal CT after the procedure showed free air and the stent to be in good position (Fig. 3). No pain or other signs of peritonitis developed in the patient, and she was discharged after 48 hours of observation on oral antibiotics. The stent was removed uneventfully 1 month later after repeat CT scan confirmed resolution of the pseudocyst.