Geisinger Medical Center Danville, PA, United States
Monica Dzwonkowski, DO1, Ruchit Shah, DO1, Pranav Patel, MD1, Dan Dometita, DO2, Harshit Khara, MD, FACG1 1Geisinger Medical Center, Danville, PA; 2Geisinger Health System, Danville, PA
Introduction: Acute pancreatitis (AP) secondary to primary hyperparathyroidism (PHPT) is a rare cause of pancreatitis. Recurrent pancreatitis can lead to complications such as walled-off necrosis (WON). Few studies have discussed a multi-transluminal gateway technique to treating loculated WON. We present an unusual case of recurrent AP secondary to PHPT with large, single-compartment pancreatic WON. The patient was treated utilizing EUS-guided cystogastrostomy and a unique Dual Transluminal Gateway Technique (DTGT) with two lumen apposing metal stents (LAMS).
Case Description/Methods: A 57-year-old male with a history of a previous episode of idiopathic pancreatitis presented with symptomatic, recurrent AP. A CT scan of the abdomen revealed a large 28 cm WON (Fig 1.1). An abdominal ultrasound ruled out cholelithiasis. The patient’s initial parathyroid hormone was 492 pg/mL (ref: 15-65 pg/mL), calcium 14.3 mg/dL (ref: 8.4-10.2 mg/dL), and lipase 2,251 U/L (ref: 13-60 U/L). His liver chemistries, IgG4 level, triglyceride level, renal function, and 24-hour urine calcium were normal. A neck ultrasound revealed a 1.7 cm parathyroid mass. He had a successful parathyroid resection.
He underwent EUS-guided cystogastrostomy with placement of 20mm LAMS in the gastric body with same-session direct endoscopic necrosectomy (DEN) and aspiration of 5 liters of purulent, necrotic fluid (Fig 1.2). He was brought back one week later for repeat DEN with removal of large pieces of necrosum (Fig 1.3). He developed symptomatic stent occlusion several days later, which was cleared with repeat DEN through the LAMS. One week after, he had stent re-occlusion thus a second cystogastrostomy was created with placement of a second LAMS in the gastric antrum to utilize the DTGT (Fig 1.4). Two more sessions of DEN were performed, and the patient achieved complete resolution of the WON cavity per endoscopic evaluation and CT imaging using this unique approach (Fig 1.5, 1.6).
Discussion: DTGT with LAMS is an effective method to assist with drainage of necrosum in patients with large, symptomatic WON. This method allows for increased access to the WON cavity and helps facilitate DEN. PHPT-induced AP is an uncommon association. Patients presenting with AP in the setting of hypercalcemia should raise suspicion for PHPT as prompt treatment can resolve pancreatitis attacks and can also prevent complications from AP, including WON. If complications develop, endoscopic techniques such as the DTGT are a safer alternative to surgical interventions.
Figure: Fig 1.1 CT abdomen showing large WON measuring 28cm
Fig 1.2 Purulent, necrotic fluid draining from WON cavity through LAMS
Fig 1.3 Large piece of necrotic tissue removed during DEN
Fig 1.4 Endoscopic images showing dual LAMS in place for Dual Transluminal Gateway Technique
Fig 1.5 Granulation tissue in healed WON cavity viewed through LAMS
Fig 1.6 Resolution of WON seen on CT abdomen with the two LAMS in place
Monica Dzwonkowski indicated no relevant financial relationships.
Ruchit Shah indicated no relevant financial relationships.
Pranav Patel indicated no relevant financial relationships.
Dan Dometita indicated no relevant financial relationships.
Harshit Khara indicated no relevant financial relationships.
Monica Dzwonkowski, DO1, Ruchit Shah, DO1, Pranav Patel, MD1, Dan Dometita, DO2, Harshit Khara, MD, FACG1. P2178 - Transluminal Gateway Technique with Lumen Apposing Metal Stents for EUS-Guided Cystogastrostomy of Unusual Primary Hyperparathyroidism-Induced Giant Walled-Off Necrosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.