Rendezvous in WONderland: combined percutaneous and transluminal approach for an undrained area of massive walled-off necrosis

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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.

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Publication History

Article published online:
18 November 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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