Same-session placement of multiple lumen-apposing metal stents to provide effective drainage of extensive walled-off pancreatic necrosis.

A 78-year-old man initially presented with gallstone pancreatitis. Three months later he presented with abdominal pain, early satiety, and weight loss. Blood test results showed severe leukocytosis. CT imaging of the abdomen showed an extensive, complex, multilocular, rim-enhancing fluid collection with significant necrosis that surrounded the entire pancreas and extended into the mesentery (Fig. 1A). On the basis of the radiologic findings, it was highly unlikely that the walled-off pancreatic necrosis (WOPN) could be successfully treated by the placement of 1 lumen-apposing metal stent (LAMS). Thus, we opted to place 2 LAMSs at different locations in the stomach to allow for better drainage and more effective necrosectomy (Video 1, available online at www.VideoGIE.org). At the initial procedure, EUS was performed with the placement of 2 LAMSs: 1 in the distal stomach at the antrum, and the other in the proximal body of the stomach (Figs. 1B and C). Large amounts of purulent drainage from both stents were seen. No further intervention was performed at the initial procedure. Over the next few weeks, the patient was brought back for a total of 3 necrosectomies, with the use of a combination of diluted hydrogen peroxide (0.3%), grasping forceps, and snare to clear the necrotic tissue within the cavity (Figs. 1D and E). By the third necrosectomy, the cavity was essentially surrounded with pink granulation tissue and very minimal necrotic tissue. The upper endoscope could be easily passed through the LAMS in the proximal stomach, through the course of the entire cavity, and to the level of the distal LAMS near the antrum of the stomach (Fig. 1F). Both LAMSs were removed 4 weeks after the final necrosectomy. In the setting of extensive WOPN, the placement of 2 LAMSs in separate locations may be more effective for the complete resolution of WOPN, and it may potentially reduce the number of necrosectomies needed. Dr Sejpal is a consultant for Boston Scientific. All other authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MjVkMDYyZWFmMjZmYjBiODk4ZmI0MTg2MzNhMTA5OCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NjQ5MTEwfQ.H7-DdX7ekqntRAM3KcTv5RhjVlOxLn9P34GgqjMtbPXJM5wPFv0_pjwNRI-gyNXKGqNHSlc-q7UigQq_uE1psQmE6NSEuVp96NfcbWdl74c41019AnVOR0flbYp6efaL-xyA3PB1LRzuabGkFiTFfCl2jMYJUQZb6bvMDWW-aur89Y8CyDNRPGz2g3j7bz8YuKJRWSgsl2_gOO_tjuDLqI3OcguUfw7uaGS5SWc6kPIJdEL3scEJtG_c_DI8R8raETQ3HldiISrfcpfkDIrY5fK0ZY6SjxTHgUmrJ9QreeFPntvYz6Aexgne-2YvATF5nISroxFZMtRphhFL9oAAdQ Download .mp4 (81.1 MB) Help with .mp4 files Video 1Same-session placement of 2 lumen-apposing metal stents with subsequent endoscopic necrosectomies for treatment of extensive walled-off pancreatic necrosis. Download .docx (.01 MB) Help with docx files Video Script