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A 56-year-old man was admitted to our hospital with severe acute necrotizing gallstone pancreatitis. Computed tomography showed a 15-cm infected walled-off pancreatic necrosis (WOPN) extending to the anterior pararenal space with free air bubbles inside. After multidisciplinary evaluation and according to septic status, endoscopic ultrasound-guided drainage was planned. Using a linear echoendoscope (GFUC140P; Olympus Europa, Hamburg, Germany), the collection was accessed from the antrum by placing a 20×10-mm electrocautery-enhanced lumen-apposing metal stent (LAMS; Hot AXIOS; Boston Scientific, Marlborough, Massachusetts, USA). Balloon dilation up to 20mm and direct endoscopic necrosectomy (DEN) using a basket catheter and instillation of saline solution diluted with hydrogen peroxide were successfully performed using a standard gastroscope. A second DEN procedure was performed after 48 hours and a modest amount of yellowish fluid was observed inside the cavity without a clear source. Owing to suspicion of a biliary fistula, magnetic resonance cholangiopancreatography was performed and showed a regular biliary profile. During the next DEN procedure in a dedicated X-ray room, and after having completely cleansed the WOPN walls, a small orifice was detected, through which we inserted a bending cannula (SwingTip; Olympus Medical Systems, Tokyo, Japan) (▶Fig. 1). Contrast medium injection revealed clear communication with the descending duodenum without fluid passage into the biliary system (▶Video 1). A guidewire was then passed through the cannula, confirming WOPN fistulization E-Videos

Cystoduodenal fistula: unusual complication after acute necrotizing pancreatitis with collection