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A 67-year-old man with infected pancreatic necrosis underwent serial endoscopic necrosectomies through a spontaneously formed massive duodenal fistula (●" Fig.1). He also required percutaneous drainage of a communicating paracolic gutter collection. Despite resolution of necrosis, the fistula remained open with high-volume output through the percutaneous drain. The patient’s severe coronary disease precluded surgical repair. Transoral placement of a fully covered esophageal self-expandable metal stent (SEMS) was attempted but faileddue to loopingof thedelivery system within the stomach. To overcome this obstacle, a fluoroscopically guided percutaneous gastrostomy puncture was performed by an interventional radiologist; the tract was balloon dilated to 10mm, and a 26-Fr Amplatz Renal Introducer Sheath (Cook Urological Inc., Spencer, Indiana, USA) was inserted into the gastric lumen. Through the sheath, a guide wire was positioned into the distal duodenum, and a 12-cm long, 23-mm diameter, partially covered esophageal SEMS (Ultraflex; Boston Scientific, Natick, Massachusetts, USA)wasdeployed across the fistula under fluoroscopy. Contrast injection showed continued leakage through the fistula (●" Fig.2). Therefore, a 7-cm long, 18-mm diameter, fully covered esophageal SEMS (Alimaxx; Merit Medical Endotek, South Jordan, Utah, USA) was passed through the gastrostomy sheath and fluoroscopically deployed within the first stent in an overlapping fashion. Contrast injection confirmed luminal patency without further leakage (●" Fig.3). After 2 months, an upper gastrointestinal series revealed persistent absence of contrast extravasation. Fistula closurewas endoscopically confirmed, and stent removal was performed by forceps extraction. The patient remains well 2 years later. Gastroduodenal SEMS are typically utilized for palliation of malignant obstruction, but have also been used to close fistulas after gastric surgery [1–4] as well as to close iatrogenic duodenal perforations [5]. However, their use in the small intestine is limited by difficult placement due to imperfect delivery systems. Our case illustrates an innovative approach for SEMS deployment through a gastrostomy site to treat a massive pancreatitisinduced duodenal fistula.

Novel technique for placement of overlapping self-expandable metal stents to close a massive pancreatitis-induced duodenal fistula