Endoscopic Treatment of Complex Walled-Off Necrosis in Necrotizing Pancreatitis With Two Simultaneous Lumen-Apposing Metal Stents: A Case Report.

Organized pancreatic and peripancreatic collections are complications of pancreatitis and should be treated when symptomatic or complicated. When feasible, the endoscopic ultrasound approach presents high efficacy and low morbidity and mortality, making it the first likely option. Among the available accessories for endoscopic drainage, the lumen-apposing metal stent can be a better option, with a low migration rate; furthermore, it allows endoscopic necrosectomy. Here, we present the case of complex walled-off necrosis treated with two lumen-apposing metal stents in the same procedure. A 41-year-old male patient with walled-off necrosis presented with delayed gastric emptying and obstruction of the main biliary duct. Magnetic resonance imaging and endoscopic ultrasound revealed two non-communicating collections. We opted for endoscopic ultrasound-guided drainage with the deployment of two simultaneous lumen-apposing metal stents: one transduodenal and the other transgastric, with clinical improvement. After three weeks, endoscopic retrograde cholangiopancreatography showed a biliary fistula communicating with the periduodenal collection, which was treated with a biliary plastic stent. An endoscopic necrosectomy was performed, and the metal stents were removed. Control magnetic resonance imaging demonstrated improvement. The patient was asymptomatic at the six-month follow-up. The treatment of symptomatic complex walled-off necrosis remains a challenge and may require multiple endoscopic approaches; moreover, surgical treatment may be necessary in case of failure. In the present report, we demonstrate that the deployment of two lumen-apposing metal stents in the same procedure is feasible when necessary as it was associated with technical success and short-term clinical success.