title: Case report of EUS-guided endoscopic transduodenal necrosectomy in a patient with sleeve gastrectomy.
abstract: BACKGROUND
  After an acute attack of pancreatitis, walled-off pancreatic fluid collections (PFC) occur in approximately 10 % of cases. Drainage of the cavity is recommended when specific indications are met. Endoscopic drainage has been adopted as the main intervention for symptomatic walled-off PFC. Altered gastric anatomy in these patients poses an interesting challenge. We present the first case of a patient with sleeve gastrectomy who underwent successful endoscopic transduodenal necrosectomy (TDN).
  
  
  METHODS
  Forty year old woman with history of morbid obesity status post sleeve gastrectomy in 2009 was found to have symptomatic gallstone disease complicated by severe necrotizing gallstone pancreatitis and further complicated by symptomatic walled off pancreatic necrosis (WOPN). Imaging significant for 10.8 × 7.6 cm fluid collection with necrotic debris in the body and tail of the pancreas and endoscopic necrosectomy was attempted. EGD showed tubular gastric body and antrum, with extrinsic compression in the antrum and duodenal bulb from the pancreatic cyst. Duodenal bulb was selected as the preferred fistula site due to sleeve gastrectomy. Patient underwent successful TDN in two sessions. Patient had symptomatic improvement at follow-up with resolution of WOPN.
  
  
  CONCLUSIONS
  To our knowledge, this is the first reported case of EUS-guided endoscopic necrosectomy in a patient with sleeve gastrectomy. The duodenal approach was used in our patient due to history of sleeve gastrectomy.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 478, New Brunswick, NJ 08901 USA.
authors.forename: Avik
authors.initials: A
authors.lastname: Sarkar
authors.affiliation: Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ USA.
authors.forename: Ragui
authors.initials: R
authors.lastname: Sadek
authors.affiliation: Department of Surgery, Rutgers - Robert Wood Johnson Medical School, New Brunswick, NJ USA.
authors.forename: Matthew
authors.initials: M
authors.lastname: Lissauer
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Rutgers - Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, Medical Education Building Room 478, New Brunswick, NJ 08901 USA.
authors.forename: Swati
authors.initials: S
authors.lastname: Pawa
keywords: Altered gastric anatomy endoscopic necrosectomy; Sleeve gastrectomy endoscopic necrosectomy