Post written by Rintaro Fukuda, MD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan, Yousuke Nakai, MD, PhD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, and the Department of Endoscopy and Endoscopic Surgery, The University of Tokyo Hospital, Tokyo, Tomotaka Saito, MD, PhD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, and Tsuyoshi Hamada, MD, MPH, PhD, from the Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, and the Department of Hepato-Biliary-Pancreatic Medicine, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo. 

Although EUS-guided transmural drainage is increasingly used to manage walled-off necrosis (WON), some challenging cases still remain. In this video report, we demonstrate successful EUS-guided drainage of WON behind the pancreas from the third portion of the duodenum in a 92-year-old woman.

Initially, WON was unamenable to drainage from the stomach or proximal duodenum because of the intervening pancreas on EUS, but we eventually found the puncture route from the third portion of the duodenum, and a lumen-apposing metal stent was placed in an upward direction via the transduodenal route. The resolution of WON was confirmed on follow-up CT, and the patient was discharged without adverse events. 

The EUS-guided approach from the third portion of the duodenum can be a treatment option for WON in the dorsal area of the pancreas, potentially expanding the indications of EUS-guided drainage. 

Careful preprocedure evaluation of a CT scan is important to obtain EUS-guided access in the difficult location.

Less-invasive EUS-guided drainage of WON by upward lumen-apposing metal stent placement helped with early recovery in this very elderly patient. We need to think upside down in a difficult situation.

WON treated via EUS-guided placement of a LAMS from the third portion of the duodenum. The echoendoscope can be seen at a deflected position at the time of EUS-guided placement of a LAMS. WON, walled-off necrosis.

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