Episode 4
October 2024
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Presenter:
Idrees Suliman, MD
Advanced Endoscopy Fellow
Harbor UCLA Medical Center, Torrance, CA, US
A 41-year-old male presented to an outside hospital with acute pancreatitis complicated by the development of walled-off necrosis. He presented one month later with abdominal pain and post prandial nausea vomiting, and difficulties with oral tolerance. Laboratory evaluation did not suggest acute infection. CT scan showed a 13.6 x 20 x 11.5cm collection centered at the boy of the pancreas. Upon review of the images there appeared to be a large vessel within the walled off necrosis. Esophagogastroduodenoscopy (EGD) confirmed extrinsic compression of the stomach and duodenum to match the patient’s oral intolerance.
After multidisciplinary discussion with surgery, a Lumen Apposing Metal Stent (LAMS) measuring 15mm x 10mm was placed in a trans gastric fashion to achieve drainage. In light of ongoing fever and symptoms EGD was undertaken two days after the index procedure with placement of a double pig-tail plastic stent through the LAMS. He remained admitted to the hospital due to ongoing abdominal pain and fevers.
Approximately one week after LAMS procedure it was noted that the hemoglobin had gradually trended downward to 6.5g/dL from 11.8g/dL on admission. There was no overt evidence of GI bleeding and CTA showed no active hemorrhage. Repeat EGD at this time showed obstructed LAMS from hemorrhage into the cyst lumen. After multidisciplinary discussion, repeat EGD with clot clearance and necrosectomy was performed with technical success. LAMS was subsequently removed successfully two months after initial placement.
Post operatively, chylous ascites and pleural effusion have developed. This has been refractory to medium chain fatty acid diet, TPN with octreotide, and repeat paracentesis. Lymphangiogram did not identify any targets for intervention.
Discussion Questions:
Can endoscopic drainage of WON be undertaken when they contain blood vessels? Are there any changes in approach?
In the setting of hemorrhage post-LAMS placement, what is the approach?
What is the treatment of chylous ascites?
Expert Comments:
In WON that contain a blood vessels IR embolization should be considered only if a pseudoaneurysm is present. Placement of plastic pigtail stents with these collections could theoretically act as a barrier to protect the blood vessel from the LAMS.
Hemorrhage is a known post LAMS complication and can be present in the absence of overt GI hemorrhage. Treatment should include input from surgery, interventional radiology and gastroenterology. IR embolization is helpful if there is suggestion of an arterial component of hemorrhage.
Chylous ascites is treated with a diet high in medium chain fatty acids. Should this not be effective, a trial of octreotide with NPO/TPN can be undertaken. Lymphangiogram may be helpful in identifying targets for intervention. Experts felt that the above interventions are likely to succeed eventually, but symptom improvement might require watchful waiting.
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Presenter:
Nuttapat Tungtrongchitr, MD
Advanced Endoscopy Fellow
Siriraj Hospital, Bangkok, Thailand
A 71-year-old man with multiple medical problems. He presented with gastric outlet obstruction due to a non-healing peptic ulcer at the pre-pyloric area, causing pyloric stricture and a 10 kg weight loss in three months. Biopsies of the stricture were negative for malignancy or other infectious etiologies. CT scan did not show any evidence of malignancy. He was treated with endoscopic balloon dilation without good response and was placed on NJ tube feeding for 3 months as he refused to undergo surgery. Based on the clinical presentation and the imaging, the preoperative diagnosis was benign gastric outlet obstruction with failed endoscopic therapy. After discussing the treatment options with the patient, an EUS-guided gastrojejunostomy (EUS-GJ) was planned.
This case demonstrated a DIY single balloon catheter, adapted from a 30-mm aortic balloon with a 10 French nasogastric (NG) tube attached. The procedure began with examining the stomach with a gastroscope, followed by inserting a 0.035-inch jag wire into the jejunum. The DIY balloon was advanced over the wire and placed into the jejunum. The balloon was inflated, and the water was administered through the NG tube to distend the small bowel. Once an appropriate position was identified, the small bowel was punctured using a hot AXOIS preloaded with a 0.035 jag wire under the EUS guidance. The wire was advanced into the punctured small bowel loop, and the first flange was deployed. The stent was mildly pulled back to bring it closer to the wall. The visualization was transiently obscured while manipulating the stent. The second flange was then deployed. The endoscopic view showed evidence of mesenteric fat, suggesting stent misdeployment. Then, we decided to remove the stent using rat tooth forceps, and a hemoclip was applied at the gastric puncture site to close the gastric wall. The patient was managed conservatively with NPO, NG tube placement, intravenous fluid, and antibiotics for 2 days. He remained stable and was discharged after 2-day of admission. He was discharged on oral antibiotics for 5 days.
The patient returned for a successful EUS-GJ six weeks later without using a guidewire.
Discussion Questions:
What is the key to the success of EUS-GJ?
Is a guidewire recommended in EUS-GJ?
How to manage Lumen-apposing metallic stent (LAMS) misdeployment?
Expert Comments:
Experts suggest that maintaining a clear visualization of the endoscopic ultrasound view is essential to minimize complications during therapeutic EUS. Guidewire-assisted EUS-GJ is not recommended because the wire can displace the target small bowel from the scope during the stent insertion, leading to misdeployment. If stent misdeploymet occurs, it should be managed according to the specific type of misdeployment. Using a single balloon catheter with an NG tube may be an option for performing EUS-GJ.
