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

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 (Figure 1, 1a). EUS-CG was performed using 15mm LAMS + 7 fr double pigtail plastic stent (DPPS) (Figure 1, 1b). No intra-procedural bleeding. Two 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 (Figure 1, 1c). Embolization performed, bleeding controlled (Figure 1, 1d). LAMS was removed, DPPS left in place (Figure 1, 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 (Figure 1, 2a). EUS-CG using 15mm LAMS +7 Fr DPPS done, patient went home next day. Five 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 (Figure 1, 2b). Repeat CTA done, actively bleeding pseudoaneurysm (Figure 1, 2c). Successful embolization done (Figure 1, 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 (Figure 1, 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.Figure 1.: Endoscopic and fluoroscopic images demonstrating interventions performed in both cases. 1,1a: CT revealing 10 cm pancreatic pseudocyst. 1,1b: Endoscopic view of cystgastrostomy with LAMS and DPPS. 1,1c: IR angiogram revealing 7 mm pseudoaneurysm in close proximity to the LAMS. 1,1d: IR coil embolization of the SMA jejunal branch pseudoaneurysm. 1,1e: LAMS removed and DPPS left in place across the cystgastrostomy. 1, 2a: CT scan showing recurrent 8 x 8 x 7cm pancreatic pseudocyst Image 2b: Oozing of fresh blood through and around the LAMS. 1, 2c: IR angiogram revealing actively bleeding GDA pseudoaneurys. 1, 2d: IR coil embolization of the GDA pseudoaneurysm. 1, 2e: PuraStat gel used to achieve hemostasis within the pseudocyst cavity.