P1506 - Does Prior Surgical Cystgastrostomy Increase Risk of Bleeding Post EUS-Guided Cystgastrostomy Using Lumen Apposing Metal Stents? A Case Series

Shivangi Kothari, MD¹, Nicholas Bartell, MD², Elliot Graziano, MD², Truptesh Kothari, MD¹, Sarah Enslin, PA-C², Asad Ullah, MD², Ahmed Dirweesh, MBBS², Mary Vetter, ANPC², Christopher Walker, MD², Amulya Penmetsa, MD², Peter Fields, MD², Vivek Kaul, MD, FACG^1
1University of Rochester, Rochester, NY; ²University of Rochester Medical Center, Rochester, NY

Introduction: Bleeding is a known complication of EUS-guided cystgastrostomy (CG). We report 2 patients with prior surgical CG who underwent EUS-CG for recurrent pseudocyst (PC) complicated by severe gastrointestinal (GI) bleeding from a pseudoaneurysm requiring additional interventions.

Case Description/Methods: Patient 1:

70-yr M with necrotizing pancreatitis s/p surgical CG. Referred to our center with symptomatic recurrent pseudocyst (Image 1a). EUS-CG was performed using 15mm LAMS + 7 fr double pigtail plastic stent (DPPS) (Image 1b). No intra-procedural bleeding. 2 days later patient had hematochezia and Hb dropped by 3 gms/dL. CT angiogram (CTA) no bleed, PFC smaller, stents in place. Patient remained stable, sent home, but returned 2 days later with recurrent hematochezia. CTA with actively bleeding pseudoaneurysm from SMA branch close to LAMS (Image 1c). Embolization performed, bleeding controlled (Image 1d). LAMS was removed, DPPS left in place (Image 1e). CT 2 months later without residual cyst, patient doing well.

Patient 2:

65-yr M with severe necrotizing pancreatitis s/p surgical CG 1 yr ago. Referred to our center with symptomatic recurrent pseudocyst (Image 2a). EUS-CG using 15mm LAMS +7 Fr DPPS done, patient went home next day. 5 days later, readmitted with hematemesis, anemia, hypotension. CT no bleed, stents in place. EGD revealed LAMS+DPPS in place, active bleeding noted from cyst cavity (Image 2b). Repeat CTA done, actively bleeding pseudoaneurysm (Image 2c). Successful embolization done (Image 2d), but patient continued with intermittent bleeding requiring transfusions. Repeat EGD, active oozing from within cyst cavity. 15cc of novel PuraStat gel used to fill pseudocyst cavity with complete hemostasis (Image 2e). LAMS removed, a 7-Fr x 4cm DPPS placed into cyst cavity. Patient stabilized, discharged home after 2 days. CT scan 6 weeks later, no residual pseudocyst, patient doing well.

Discussion: Surgical CG is rarely performed in the era of EUS-CG with LAMS. Our patients needed EUS-CG for recurrent PC post-surgery. Severe bleeding within 1 week post EUS-CG is unusual. Both patients had nearly identical presentation, bleeding etiology, imaging findings and clinical course. Our experience suggests that patients who undergo LAMS based EUS-CG after initial surgical CG may be at higher risk for bleeding. Initial CTAs may be negative. IR embolization is effective. Endoscopists should keep these caveats in mind when managing such patients.



Disclosures:


Shivangi Kothari, MD¹, Nicholas Bartell, MD², Elliot Graziano, MD², Truptesh Kothari, MD¹, Sarah Enslin, PA-C², Asad Ullah, MD², Ahmed Dirweesh, MBBS², Mary Vetter, ANPC², Christopher Walker, MD², Amulya Penmetsa, MD², Peter Fields, MD², Vivek Kaul, MD, FACG¹. P1506 - Does Prior Surgical Cystgastrostomy Increase Risk of Bleeding Post EUS-Guided Cystgastrostomy Using Lumen Apposing Metal Stents? A Case Series, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.