Transgastric Endoscopic Cystogastrostomy in a Patient With Gastric Sleeve Anatomy

Abstract

The endoscopic cystogastrostomy has become the standard for management of walled-off pancreatic fluid collections (PFC). However, altered gastric anatomy, such as the gastric sleeve, can present a challenge to endoscopists. As a result, patients with altered gastric anatomy may be referred for surgery, rather than endoscopic intervention. However, surgery is associated with increased costs and length of stay. Here, we report a successful transgastric necrosectomy/ PFC drainage. A 70 year old man with a history of sleeve gastrectomy in 2009 for obesity presented with necrotizing gallstone pancreatitis and subsequent peri- pancreatic fluid collection. After conservative management, the patient was discharged to home, only to present six weeks later with recurrent pancreatitis and poor oral intake. A CT of the abdomen showed an 8 cm pancreatic pseudocyst compressing the gastric sleeve. On upper endoscopy, gastric sleeve anatomy was noted without obstruction. Endoscopic ultrasound (EUS) showed a large 8 cm x 7 cm walled off necrosis adjacent to the stomach with approximately 50% necrosis. Using electrocautery, the hot Axios system (Boston Scientific) was used to access the necrotic collection from the antrum, approximately 3 cm proximal to the pylorus. This site was chosen to avoid intervening vessels seen more proximally and in surrounding areas. Cystogastrostomy was successfully performed with balloon dilation of the stent and placement of pigtail stents. Repeat EGD/EUS one month after Axios placement showed intact gastric anatomy and complete collapse of the prior necrotic fluid collection cavity. To our knowledge, no case reports have been published to date describing a transgastric approach to cystogastrostomy in patients with gastric sleeve anatomy. Endoscopists may shy away from this patient population due to concerns for decreased working space, increased intraluminal pressure and possible disruption of the suture line. One case report notes pseudocyst drainage via the duodenum in a gastric sleeve patient due to the above mentioned concerns. While concerns exist about the feasibility of necrosectomy in post gastric sleeve anatomy, this case shows that transgastric cystogastrostomy can be successfully and safely performed in patients with altered gastric anatomy, such as sleeve gastrectomy. Given the decreased maneuverability, more distal sites, such as the gastric antrum, may be most amenable to the procedure.1408_A.tif Figure 1: Axios stent in the distal gastric wall in post- sleeve gastrectomy anatomy.1408_B.tif Figure 2: 8 cm x 7 cm walled off necrosis adjacent to the stomach.