Single-Session EOS-Guided Transgastric Stent Placement to Facilitate Cis-Gastrostomy in Roux-en-Y Gastric Bypass. We present the case of a 58-year-old woman with a history of a Roux-en-Y gastric bypass in 2003. She has been having alcohol-related pancreatitis episodes since 2018, which have been complicated by peripancreatic fluid collections. She was referred for worsening abdominal pain, nausea, early satiety, and a 20-pound weight loss. CT showed evidence of gastric bypass anatomy and a large 10-by-8-centimeter unilocular cystic structure arising from the pancreatic head and causing dilation of the pancreatic duct. The coronal section shows the close approximation of the cyst and the excluded stomach. On upper endoscopy, there was evidence of a Roux-en-Y gastrogynostomy with a mildly stenotic but patent gastrogynol anastomosis and a prominent recess laterally. A linear array echoendoscope was then advanced into the gastric pouch and a large anechoic lesion was identified in the region of the pancreatic head suggestive of a pseudocyst. The lesion measured 9-by-7 centimeters in cross-sectional diameter. Attempts were made to find a safe window for pseudocyst drainage. However, there was pancreatic tissue and multiple blood vessels precluding safe access into the cavity. The decision was made to access the gastric remnant. The excluded stomach was identified, and after interrogation with doppler imaging, the remnant was punctured with a 19-gauge FNA needle. A 1-liter mixture of contrast and sterile water was then injected to fill the gastric remnant. A 20-by-10-millimeter electrocautery-enhanced lumen-opposing metal stent was then deployed with the phalanges in close approximation to the walls of the remnant stomach and the gastric pouch. Given the degree of the patient's symptoms, the decision was made to dilate the stent with the intention of passing the echoendoscope through for a single-session cyst gastrostomy. A long guide wire was advanced into the gastric remnant, and the stent was dilated with a balloon dilator to a maximum of 18 millimeters. The wall of the gastric remnant could be nicely visualized through the stent. The EUS scope was then very carefully advanced through the lambs, with caution not to dislodge the stent. This was watched closely on fluoroscopy. The anechoic fluid collection was then re-identified. Similar imaging was used, and this time confirmed that there were no interposing vessels. With the safe window identified, a 15-by-10-millimeter electrocautery-enhanced lumen-opposing metal stent was placed between the pseudocyst and the gastric remnant. Copious amounts of fluid could be seen emanating from the cyst cavity. A long guide wire was advanced into the cyst cavity, and the lambs was dilated with a through-the-scope balloon to a maximum of 12 millimeters. A 10-french-by-3-centimeter plastic double-pigtail stent was then advanced through the lambs to anchor it across the cyst gastrostomy. The scope was withdrawn through the lambs across the gastro-gastrostomy, and in similar fashion, a 10-french-by-4-centimeter plastic double-pigtail stent was advanced through the lambs to anchor it. The final fluoroscopic image shows the two lambs with coaxial double-pigtail stents. There were no periprocedural adverse events, and the patient was discharged home on the same day. She returned one month later for planned stent removal. The lambs across the gastro-gastrostomy was intact, and the scope was passed through the stent, where the lambs across the cyst gastrostomy was visualized. The plastic pigtail stent was first removed using a snare. Evaluation of the cavity showed that the collection had drained entirely, without evidence of retained necrosis, and the lambs across the cyst gastrostomy was removed. Similarly, the lambs across the gastro-gastrostomy was removed. The decision was made to pursue closure of the gastro-gastric communication. First, argon plasma coagulation was used circumferentially around and within the site to deepothelialize the tract. The upper endoscope was exchanged for a dual-chamber therapeutic endoscope, and it was fitted with the overstitched endoscopic suturing device. Starting at the 9 o'clock position, a running suture was placed around the margin of the fistula. A total of four stitches were placed in a running pattern. The anchor was dropped, and the suture was cinched in position. Reinforcement sutures were not placed given the proximity to the gastro-jejunostomy. Additional inspection of the fistula site confirmed a successful endoscopic closure with maintained patency of the gastro-jejunostomy. There were no periprocedural adverse events, and the patient was discharged home the same day. Three months later, the patient continued to feel great. She was symptom-free and able to return to work without limitation. In conclusion, same-session EUS-guided transgastric stent placement to facilitate cis-gastrostomy is feasible and safe in patients with Roux-en-Y anatomy. Furthermore, should there be a need for repeated necrosectomy sessions, the gastro-gastric stent can serve as a conduit.

Roux-en-Y gastric bypass

alcohol-related pancreatitis

pancreatic duct dilation

cyst gastrostomy

EUS-guided transgastric stent placement