The advent of lumen-apposing metal stents (LAMSs) has expanded opportunities for the
endoscopic management of symptomatic walled-off necrosis (WON) through increasing
drainage efficiency and facilitation of subsequent endoscopic necrosectomy [1]
[2]. Peripheral areas of massive WON may however not be endoscopically accessible, potentially
hampering treatment success [3].
A 38-year-old woman was admitted for endoscopic management of infectious WON. Endoscopic
ultrasound (EUS)-guided drainage was undertaken using a 15-mm LAMS (Hot AXIOS; Boston
Scientific Japan, Tokyo, Japan). Resolution of the WON was achieved with four sessions
of necrosectomy, and the LAMS was replaced with plastic stents. On follow-up computed
tomography performed 2 months later, recurrence of the collection was documented in
the right paracolic gutter, extending to the erector spinae muscles, with deterioration
of inflammatory markers also noted ([Fig. 1]).
Fig. 1 Computed tomography image delineating a residual cavity of walled-off necrosis in
the right paracolic gutter.
Endoscopic drainage of the recurrent collection was attempted through the transgastric
fistula. Despite the use of various types of guidewire, along with a bendable cannula,
passage of the guidewire to the peripheral paracolic collection failed. A decision
was therefore made to perform percutaneous puncture of the collection and conduct
a rendezvous maneuver ([Fig. 2]). Following ultrasonography-guided percutaneous puncture of the collection, a guidewire
was passed to the stomach. We reinserted a therapeutic duodenoscope and grasped the
remaining guidewire using a snare. Finally, endoscopic access to the paracolic collection
was achieved over the rendezvous guidewire, and a 7-Fr double-pigtail stent and a
7-Fr pigtail nasobiliary catheter were successfully deployed. When resolution of the
collection had been achieved, the nasocystic and percutaneous catheters were removed,
with the plastic stent kept in situ.
Fig. 2 Fluoroscopic images of the rendezvous technique based on combined percutaneous and
transluminal approaches showing: a ultrasonography-guided percutaneous puncture of the walled-off necrosis (WON) cavity
in the right paracolic gutter; b the guidewire that was successfully passed into the stomach through the percutaneous
puncture route; c a nasocystic catheter and plastic stent in the WON cavity in the right paracolic
gutter.
Although the percutaneous approach can help in the drainage of peripheral areas of
large-sized WON [4]
[5], patient discomfort and pancreaticocutaneous fistulas are potential disadvantages.
The percutaneous–transluminal rendezvous technique ([Video 1]) enables not only extensive drainage of the WON, but also conversion to internal
drainage.
Video 1 The rendezvous technique based on combined percutaneous and transluminal approaches
is used for an undrained area of walled-off necrosis.
Endoscopy_UCTN_Code_TTT_1AR_2AI
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