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A 32-year-old man with no relevant medical history initially presented to the emergency
department with 24 hours of severe abdominal pain and received a diagnosis of acute
interstitial pancreatitis. He was given supportive treatment and discharged home;
however, 6 weeks after discharge he returned with abdominal pain, fever, and gram-negative
rod bacteremia. Repeated imaging at that time demonstrated walled-off necrosis (WON)
involving the pancreas and extrapancreatic tissues and a possible cystduodenal fistula.
Upper endoscopy with an adult endoscope revealed a spontaneous cystduodenal fistula,
which was used for necrosectomy. He underwent complete necrosectomy in only one session
by use of a snare and tripod, and his fever resolved within 24 hours (Fig. 1; Video 1, available online at www.giejournal.org). Six weeks after discharge, at his follow-up appointment, he underwent repeated
imaging, which showed resolution of the WON. Spontaneous cystduodenal or gastric fistulas
are rare adverse events of WON or pseudocysts. The solid or adherent debris within
WON is unlikely to drain spontaneously through these fistulas; however, endoscopic
transmural necrosectomy through a well-formed fistulous tract is safe and efficacious
in obtaining control of the source.
Figure 1Endoscopic transmural necrosectomy through spontaneous cystduodenal fistula. A, Endoscopic view of necrotic material during debridement. B, Cavity marked by healthy granulation tissue after debridement.
