Trans-gastric pancreatic necrosectomy via fully covered esophageal stent placed by a novel rendezvous technique: A never before described technique

Patients with acute pancreatitis can develop necrosis and the removal of dead tissue is critical. Typically this debridement is done surgically but it can also be accomplished by EUS-guided endoscopic trans-gastric-necrosectomy (EUS-ETGN). A 53-year-old male developed acute pancreatitis secondary to alcohol consumption. A repeat CT scan at 6 weeks revealed persistent pancreatic necrosis and he continued to have bacteremia. The patient was referred for endoscopic debridement. A linear-echo-endoscope revealed a large hypoechoic collection with mixed echogenicity. The collection was accessed using a 19-gauge needle. A 0.035 guidewire was advanced into the cavity under fluoroscopic guidance and the wire coiled inside what appeared to be a mature cavity. Contrast was injected into the cavity further confirming correct placement of the wire in the cavity of necrosis. The fistula tract was dilated from 6 mm to 12 mm using a through-the-scope balloon and a large release of purulent material confirmed placement. However due to the acute angulation of the gastro-peritoneal fistula, endoscopic access to the necrotic area was not possible. At this time two 10 fr × 5 cm double pig-tail stents were placed. Then during a second procedure a? novel access approach was employed. A guidewire was introduced into the fistula tract and advanced into the necrotic cavity. A mini-snare was then advanced through the external drain into the cavity of necrosis. Then using a tandem cannulation catheter the wire was advanced into the snare. This rendezvous technique was then successfully used to carry the wire out through the external drain, and with traction on the wire, we were successfully able to deploy an 18 mm × 6 cm fully covered stent through the cystgastrostomy tract under direct endoscopic and fluoroscopic guidance. This facilitated access to the cavity allowing for subsequent debridement of necrosis. After complete debridement of the cavity, the covered stent was removed and again two pigtail stents were left in its place. EUS-ETGN of in? fected necrosis in acute pancreatitis appears to be safe treatment option. This novel technique describes how access to the retroperitoneum can be accomplished in the face of difficulty angulation and orientation.