Dr. Isis Araujo

Cystogastrostomy outside the operating room

Case A 47-year-old male, regular smoker and mild alcohol consumption suffered and abdominal blunt trauma 8 years ago. After recurrent abdominal pain a CT Scan was performed showing a pancreatic pseudocyst that measured 11 cm. A cystogastrostomy by laparoscopy was performed, the recovery was uneventful and the patient was discharged. The alcohol intake continued, after 10 months of follow up the abdominal pain came back and a CT Scan revealed a relapse with compression of the stomach. Additional investigation with a gastroscopy showed that the cystogastrostomy was closed. A transgastric ultrasound was carried out with the intention to perform endoscopic treatment. It revealed a pancreatic pseudocyst that measured 62x52mm with thin walls, a doppler confirmed that there was no vascularization. Treatment Patient was advised to avoid alcohol. Endoscopic treatment was performed after confirmation of abstinence. A therapeutic linear echoendoscope (UCT140 Olympus Optical; Hamburg, Germany) and a 15 mm lumen diameter ¨Hot axios¨ stent (AXIOS™; Xlumena, MountainView, CA) were used. As it is seen in the video, the ¨Hot axios¨catheter is passed into the working channel of the echoendoscope, and, under ecographic guidance, the catheter is placed in contact to the pseudocyst wall. Then the pure cut/autocut setting of the electrosurgery generator is activated and the control hub is advanced until the catheter is fully visible inside the pseudocyst by EUS. In the next step, the stent is deployed inside, and the endoscope is pulled back to assure the correct position. After this, the second flange is deployed into the gastric cavity under endoscopic vision. Immediately after the placement of the second flange, the pus drains from the gastro-cystic fistula to the gastric cavity. Outcome The next day after the procedure, a gastroscopy confirmed that the prosthesis was in its correct place without necrotic tissue inside the pseudocyst. The patient started oral intake with good tolerance and was discharged the next day and completed 5 days of prophylactic antibiotics.