Novel Purastat Gel Application as Part of Multimodal Treatment of Severe Cystgastrostomy Bleeding: First Reported Case

Introduction: Pseudoaneurysm (PA) related bleeding after placement of lumen apposing metal stent (LAMS) for management of pancreatic fluid collections (PFC) is a known complication of EUS-guided cystgastrostomy (CG) using LAMS, with potential for high morbidity/mortality. We report the first case of endoscopic application of the novel Purastat gel within the PFC cavity, as part of a multimodal approach to achieve complete hemostasis in a patient who presented with severe, persistent bleeding post-CG. Case Description/Methods: A 66-year-old man with a history of severe biliary pancreatitis complicated by PFC managed at outside hospital with percutaneous drainage by IR. Course complicated by pancreatic duct injury resulting in re-accumulation of PFC managed by laparoscopic converted to open transgastric pancreatic cystgastrostomy (CG). Four months later patient presented with recurrence of abdominal pain, nausea, poor oral intake, weight loss; CT with 8.5 cm recurrent pseudocyst with extrinsic gastric compression. Patient referred to our center for management. Uneventful EUS-CG performed with 15mm LAMS + 7 Fr x 4 cms double pigtail plastic stent (DPPS). Five days later patient presented with hematemesis and drop in Hb from 11.5 to 8. CT angiogram revealed large amount of blood within stomach, but no active bleeding. Endoscopy revealed oozing of fresh blood from the LAMS not amenable to endoscopic therapy. Angiography of gastroduodenal artery (GDA) demonstrated actively bleeding PA, successful embolization performed. Patient continued to have melena with persistent transfusion requirement. Repeat EGD revealed fresh bleeding from the LAMS. This was treated successfully with Purastat Gel application within the PFC and removal of LAMS. DPPS replaced. Patient discharged 48 hours later with stable Hb and tolerating PO diet. CT 6 weeks later revealed complete resolution of PFC, patient doing well. Discussion: Severe bleeding after EUS-CG with LAMS is well known, IR embolization is effective in most cases. Endoscopic intracystic application of the novel Purastat Gel was used for effective control of persistent bleeding post-embolization in our patient. To our knowledge, this is the first report of successful management of persistent bleeding from a pseudocyst using the novel Purastat Gel. Our experience with this approach in our patient has significant clinical practice implications for managing this problem; endoscopists should consider this as part of the treatment algorithm for pseudocyst. Watch the video at https://tinyurl.com/S2647ACG2023.