Endoscopic treatment of walled-off necrosis with fistulas to the small intestine and colon using a lumen-apposing metal stent

Abstract

Figures

Computed tomographic images showing walled-off necrosis adjacent to the stomach. Axial ( a ) and coronal ( b ) images.

Computed tomographic images demonstrating fistulous communication between the walled-off necrosis and the small intestine ( a ), and between the walled-off necrosis and the colon ( b ).

A radiographic image showing lumen-apposing metal stent placement ( a ) and the corresponding endoscopic image after stent deployment ( b ).

A radiographic image showing contrast injection into the walled-off necrosis through the lumen-apposing metal stent, demonstrating communication with both the small intestine and the colon.

A radiographic image showing reduction of the walled-off necrosis and resolution of fistulas to the small intestine and the colon after lumen-apposing metal stent placement.

Full text

Walled-off necrosis (WON) is a recognized complication after acute pancreatitis 1 , and the usefulness of endoscopic treatment with lumen-apposing metal stent (LAMS) placement using interventional endoscopic ultrasound (IV-EUS) has been reported 2 . WON has also been reported to occasionally form fistulas with the adjacent gastrointestinal tract 3 . We report the first case of WON with fistulas to both the small intestine and the colon successfully treated by LAMS placement using IV-EUS ( Video 1 ).

Endoscopic treatment of walled-off necrosis with fistulous communication to both the small intestine and the colon, successfully performed by lumen-apposing metal stent placement using interventional endoscopic ultrasound.Video 1

An 82-year-old man developed alcohol-induced acute pancreatitis and subsequently formed WON. He was admitted with abdominal pain and elevated inflammatory markers, suggesting infected WON. Computed tomography demonstrated WON adjacent to the stomach ( Fig. 1 ), with suspected fistulous communication to both the small intestine and the colon ( Fig. 2 ). After discussion with surgeons, endoscopic treatment was selected as the initial therapeutic approach. A LAMS (Hot AXIOS, 15 mm, 1 cm; Boston Scientific, Marlborough, MA, USA) was placed transgastrically into the WON using IV-EUS. After stent deployment, a catheter was inserted into the WON through the LAMS ( Fig. 3 ), and contrast injection demonstrated opacification of both the small intestine and the colon via the fistulas ( Fig. 4 ). After LAMS placement, the patient’s abdominal symptoms and inflammatory markers improved, and no procedure-related adverse events were observed. Six weeks after LAMS placement, the WON had decreased in size, and a decision was made to remove the LAMS. A catheter was reinserted through the LAMS and contrast injection was performed, which demonstrated no contrast leakage and no fistulous communication with either the small intestine or the colon ( Fig. 5 ). The LAMS was subsequently removed. During a 6-month follow-up period after stent removal, no recurrence of WON or fistula formation with the gastrointestinal tract was observed.

Computed tomographic images showing walled-off necrosis adjacent to the stomach. Axial ( a ) and coronal ( b ) images.

Computed tomographic images demonstrating fistulous communication between the walled-off necrosis and the small intestine ( a ), and between the walled-off necrosis and the colon ( b ).

A radiographic image showing lumen-apposing metal stent placement ( a ) and the corresponding endoscopic image after stent deployment ( b ).

A radiographic image showing contrast injection into the walled-off necrosis through the lumen-apposing metal stent, demonstrating communication with both the small intestine and the colon.

A radiographic image showing reduction of the walled-off necrosis and resolution of fistulas to the small intestine and the colon after lumen-apposing metal stent placement.

This is the first reported case of WON with fistulas to both the small intestine and the colon successfully treated by LAMS placement using IV-EUS, avoiding surgical intervention.

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