Creation of multiple transluminal gateway during endoscopic ultrasound-guided drainage of pancreatic necrosis by enlarging tract of impending rupture in duodenum

Necrotic pancreatic collections are difficult to treat endoscopically due to a concern for inadequate drainage of the necrotic debris. Multiple techniques including the use of metallic stents, endoscopic necrosectomy and use of hybrid approaches utilizing endoscopic and percutaneous approaches have been described for the management of pancreatic necrotic collections. Furthermore, multiple transluminal gateway technique has been used to create endosonography guided multiple tracts to drain a perigastric or periduodenal collection. We hereby report about a patient with walled off necrosis resulting as a complication of alcohol related acute pancreatitis that was drained using endoscopic ultrasound-guided approach. However, a spontaneous cystoduodenal fistula was used to create another tract and place transmural stents resulting in a quick resolution of symptoms.