C. Roberto Simons-Linares

EUS-Guided Drainage of Post-operative Subphrenic Fluid Collection Through Gastric Pouch with a Lumen-Apposing Metal Stent in a Patient with Roux-en-Y Gastric Bypass

Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedure in the USA. Anastomosis leak has been well described and it can present acutely or become chronic. It can lead to acute or chronic fluid collection formation, development of an abscess, peritonitis, sepsis, and death. Endoscopic drainage of these symptomatic fluid collections can be challenging, especially in patients with modified anatomy such as RYGB [1, 2]. We hereby report the first case of successful drainage of symptomatic, post-operative subphrenic fluid collection from an anastomotic leak using a lumen-apposing metal stent (LAMS) through the gastric pouch of a patient with a recent RYGB surgery. A 67-year-old woman with history of RYGB complicated by gastrojejunal anastomosis leak that was managed endoscopically with over the scope endoscopic clip (Ovesco Endoscopy GmbH, Tuebingen) presented to us with nausea, vomiting, and abdominal pain 2 months after gastric bypass. On clinical exam, she was afebrile and had epigastric tenderness. Laboratory analysis was unremarkable. Abdominal CT scan revealed a new subphrenic fluid collection (10 × 5.1 cm) compressing the gastric pouch and causing outlet obstruction (Figs. 1, 2). She underwent endoscopic ultrasound (EUS) evaluation, cystgastrostomy creation, and drainage of the post-operative fluid collection with hot Axios sys tem (Xlumena Inc. , Mounta in View, California) and placement of a 15-mm × 10-mm lumenapposing metal stent (LAMS) (Figs. 3, 4, 5, 6, 7, 8 and 9). Procedure was uneventful and the patient reported resolution of her symptoms within 24 h of LAMS placement and was discharged home. Follow-up imaging 2 months after the drainage revealed complete resolution of fluid collection. The LAMS was removed uneventfully on follow-up endoscopy at 8 weeks. There were no immediate or late post-procedure complications. The patient continues to do well and is asymptomatic at 6month follow-up. The use of LAMS for the management of post-surgical abdominal fluid collections through a Roux-en-Y gastric pouch has not been reported. LAMS are fully covered metal stents with a unique lumen-apposing capacity over its two anchoring ends. The wide proximal and distal anchoring ends limits migration of the stent. Even though LAMS have been well studied in the endoscopic drainage of pancreatic fluid collections, the use of LAMS for the drainage of other abdominal fluid collections, that are endosonographically accessible, has not been widely reported and merit further studies. LAMS usage to drain post-operative fluid collections after RYGB surgery can be performed safely and successfully in expert hands. Larger studies on endoscopic management of abdominal fluid collections related to bariatric surgery are needed. * Prabhleen Chahal chahalp@ccf.org