Post-EUS Cystogastrostomy and Necrosectomy Management
After EUS-guided cystogastrostomy with necrosectomy, patients should be admitted for observation, receive intravenous fluids, be kept nothing by mouth, receive broad-spectrum antibiotics, have nasogastric tube placement, and undergo surgical consultation to minimize morbidity and mortality. 1
Immediate Post-Procedure Care
Medical Management
- Keep patient NPO (nothing by mouth)
- Administer broad-spectrum antibiotics to cover Gram-negative and anaerobic organisms 1
- Continue antibiotics post-procedurally 1
- Provide intravenous fluid resuscitation
- Place nasogastric tube (with some exceptions based on clinical scenario) 1
Monitoring and Surveillance
- Admit for observation to monitor for complications 1
- Monitor vital signs closely for signs of bleeding, infection, or perforation
- Watch for symptoms of perforation including abdominal pain, distension, fever
- Assess for signs of bleeding (hematemesis, melena, dropping hemoglobin)
- Monitor for signs of infection (fever, increasing white blood cell count)
Imaging Follow-up
- Obtain water-soluble contrast study before initiating clear liquid diet to confirm absence of leakage at the cystogastrostomy site 1
- Consider follow-up cross-sectional imaging (CT or MRI) to assess:
- Resolution of the collection
- Position of stents
- Potential complications
Potential Complications to Monitor
Bleeding
- High-risk complication, especially in cases with hidden vessels within walled-off necrosis 2
- May require angiographic embolization if severe 3
- Observe for hematemesis, melena, tachycardia, or dropping hemoglobin
Perforation
- Keep the area of potential perforation clean
- Minimize carbon dioxide insufflation to avoid compartment syndrome 1
- Use carbon dioxide (rather than air) for all endoscopic procedures with increased risk of perforation 1
Infection
- Continue prophylactic antibiotics post-procedure 1
- Monitor for fever, increasing white blood cell count, or worsening abdominal pain
Multidisciplinary Approach
- Urgent surgical consultation should be considered in all cases with perforation, even when endoscopic repair is technically successful 1
- Maintain multidisciplinary support including interventional radiologists, surgeons, and anesthesiologists 1
- This collaborative approach between radiologists, endoscopists, and surgeons improves outcomes in necrotizing pancreatitis 4
Stent Management
- For pseudocysts, one or two plastic double pigtail stents are typically sufficient for maintaining cystogastrostomy patency 1, 5
- For walled-off necrosis, lumen-apposing metal stents may be used, but require careful follow-up 6, 4
- Stent removal timing should be based on resolution of the collection and clinical improvement
Special Considerations for Walled-off Necrosis (WON)
- WON may require more aggressive management than simple pseudocysts 5
- Approximately 9% of WON cases may show little or no clinical improvement after initial drainage 5
- Some patients may require additional interventions such as CT-guided drainage 5
- Exercise caution when performing necrosectomy in WON with multiple hidden vessels to prevent bleeding 2
Follow-up Schedule
- Regular clinical assessment during hospitalization
- Outpatient follow-up within 2-4 weeks after discharge
- Consider repeat imaging to confirm resolution before stent removal
- Monitor for recurrence for up to 12 months after stent removal 5