P0656 - Paraesophageal Pseudocyst Treated With Tandem Lumen-Apposing Metal Stent and Wallstent

Trupti Akella, MD¹, Shashank Vemala, MD², Kairavee Dave, MD¹, Rulz Cantave, MD¹, Franklin Kasmin, MD^1
1Aventura Hospital and Medical Center, Aventura, FL; ²HCA Aventura Hospital, Aventura, FL

Introduction: Symptomatic pancreatic fluid collections (PFCs) commonly require surgical, percutaneous, endoscopic, or combination therapies for drainage. Endoscopic transluminal drainage is becoming an increasingly favorable first-line therapy at available centers. One of the challenges to endoscopic management of PFCs is the transluminal accessibility of the collection. We present a challenging case of a EUS-guided tandem transluminal stenting to achieve drainage of a large, lobulated pseudocyst extending into the mediastinum causing dysphagia.

Case Description/Methods: A 75 year old male with metastatic pancreatic adenocarcinoma presented with progressive dysphagia. He was found to have an obstructing mid-body pancreatic mass with a leak identified at the tail end of the pancreas on ERCP. A resultant, large, multi-lobulated pseudocyst had formed tracking from the perigastric region into the mediastinum compressing the distal esophagus. EUS identified a large pseudocyst divided into two cavities by a septum; the only site of access was the distal esophagus. A 10Fr x 10cm hot lumen apposing metal stent (LAMS) was deployed with good drainage of the proximal cavity. Upon re-examination, the space entered by the LAMS was collapsed with healthy granulation tissue. The echoendoscope tip was passed through the LAMS with good sonographic visualization of the adjacent fluid cavity. Under EUS-guidance a needle was passed into this well-defined cystic space and a tract was created. A 10mm x 60mm fully covered wallstent was placed in tandem through the existing LAMS into the cystic cavity. The wallstent was clipped to the LAMS to prevent migration. After two weeks, imaging and fluoroscopy confirmed reduced cavity sizes and the combined LAMS-Wallstent were removed. Patient’s dysphagia improved and he was able to tolerate oral intake.

Discussion: Dysphagia secondary to a mediastinal pancreatic pseudocyst is very uncommon. Endoscopic management of difficult to access collections can be very challenging. This serves as an example of combining the utility of a Wallstent with that of a larger diameter, wider lumen conduit (LAMS) to gain access to a challenging paraesophageal pancreatic fluid collection.



Disclosures:


Trupti Akella, MD¹, Shashank Vemala, MD², Kairavee Dave, MD¹, Rulz Cantave, MD¹, Franklin Kasmin, MD¹. P0656 - Paraesophageal Pseudocyst Treated With Tandem Lumen-Apposing Metal Stent and Wallstent, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.