Endoscopic ultrasound-guided drainage of pancreatic pseudocyst after gastrogastric anastomosis in patient with Roux-en-Y gastric bypass: The dream becomes reality!

A 33‐year‐old female with a previous bariatric surgery according to the Roux‐en‐Y gastric bypass (RYGB) was admitted to our hospital because of persistent abdominal pain. The presence of a cyst in 7 cm diameter in the pancreatic body was detected at computed tomography (CT). The endoscopic ultrasound (EUS) evaluation was performed to characterize the cystic lesion. From gastric stump, the cyst was observed, but the excluded gastric pouch was interposed. A fine‐needle aspiration of the cyst with a 19 gauge needle (ECHO‐19, Cook‐Medical Inc., Bloomington, Indiana, USA) was performed from the gastric stump through the excluded pouch. The cytological analysis showed the absence of malignant cells while biochemical analyses documented elevated amylase (6785 U/mL) and carcinoembryonic antigen <5 ng/mL. Then, a therapeutic endoscopic approach was proposed. Initially, an EUS‐guided puncture from the gastric stump with a 19 gauge needle was performed, and an access to excluded gastric lumen was obtained. Following contrast injection, a 0.035‐guidewire was placed into the gastric pouch, and a gastrogastric fistula was created by pushing a 10 Fr cystotome (CST10, Cook‐Medical, Bloomington, Indiana, USA) on the guidewire. Finally, a 2 cm/16 mm self‐expandable metallic stent (SEMS) (Nagi‐stent; Taewoong‐Medical; Seoul, Korea) was left in place [Figure 1a and b]. However, 2 weeks later, it was impossible to pass through the gastrogastric anastomosis with a therapeutic echoendoscope (Pentax; Tokyo, Japan), so that the SEMS was substituted by a 6 cm/20 mm enteral fully covered SEMS (Niti‐S; Taewoong‐Medical, Seoul, Korea). One week later, it was possible to reach the excluded gastric pouch with a therapeutic echoendoscope (Pentax; Tokyo, Japan) passing through the enteral stent that was removed. EUS‐guided puncture from the gastric pouch with a 19-gauge needle was performed and a 0.035-guidewire was placed into the cyst, so that a gastrocystic fistula was created by pushing a 10 Fr cystotome on the guidewire. Finally, a 2 cm/16 mm SEMS (Nagi‐stent; Taewoong‐Medical; Seoul, Korea) was positioned. Passage of air in the peritoneal cavity occurred, which was successfully evacuated using percutaneously a 19 G needle under CT guidance. The patient was asymptomatic, and she was discharged 72 h later. Two months later, the CT showed complete cyst drainage.