S5318 Transgastric Cyst-Cystostomy for Management of a Remote Pelvic Fluid Collection: First Report of a Novel Endoscopic Approach

Introduction: Endoscopic ultrasound guided transluminal drainage has become the standard of care for managing pancreatic fluid collections and walled-off necrosis. However, drainage of distant, complex, or multiloculated collections remains technically challenging and has traditionally required surgical intervention or percutaneous drainage. We present a novel case of sequential lumen-apposing metal stent (LAMS) placement to access a distant pancreatic fluid collection. To our knowledge, this layered approach has not been previously described. Case Description: A 57-year-old man with a history of sleeve gastrectomy and recent alcohol-induced necrotizing pancreatitis was admitted to our facility with symptomatic and enlarging peri-pancreatic fluid collections. Cross-sectional imaging revealed a large 6 by 6.5 by 7.4 cm walled off necrotic collection with mass effect on the gastric body and an adjacent 5.8 by 6.4 by 14.9 cm separate, well-formed pelvic fluid collection. Endoscopic ultrasound-guided cyst gastrostomy was performed using a 20 mm × 10 mm LAMS to drain the peri-gastric pancreatic collection. After one week, an echoendoscope was passed into the peri-gastric collection and a cyst-cystostomy using 15 mm × 15 mm LAMS was performed to drain the pelvic fluid collection. The patient underwent a few endoscopic necrosectomies and was noted to have significant clinical and radiological improvement. He was ultimately discharged to a rehabilitation facility in stable clinical condition. Discussion: This case highlights an innovative endoscopic strategy for managing complex, multiloculated pancreatic and pelvic fluid collections. By utilizing sequential LAMS—first establishing a cyst gastrostomy from the stomach to a pancreatic collection, then creating a cyst-cystostomy to a remote pelvic abscess—this approach provided minimally invasive access to otherwise surgically challenging locations. The successful use of this novel technique suggests a potential role for layered endoscopic drainage in the management of refractory fluid collections and highlights the expanding capabilities of interventional endoscopy in the treatment of complicated necrotizing pancreatitis.