Use of a planned dual-gateway technique for endoscopic ultrasound-guided management of a large symptomatic pancreatic pseudocyst associated with complete pancreatic duct disruption in chronic pancreatitis

Endoscopic ultrasound (EUS)-guided drainage is the preferred treatment for symptomatic pancreatic pseudocysts.In patients with complete pancreatic duct disruption, prolonged transmural drainage may be needed to prevent recurrence after removal of lumen-apposing metal stents (LAMS).However, collapse of the pseudocyst cavity after LAMS removal may can prevent subsequent placement of long-term transmural plastic stents.We describe a planned dual-gateway technique for managing a large symptomatic pancreatic pseudocyst associated with complete pancreatic duct disruption in a patient with chronic pancreatitis.A 49-year-old man underwent EUS-guided cystogastrostomy after transpapillary bridging during endoscopic retrograde cholangiopancreatography was unsuccessful.The procedure was deliberately planned to include simultaneous placement of a parallel transmural double-pigtail plastic stent and a LAMS containing a coaxial plastic stent.EUS performed 20 days later confirmed complete resolution of the collection, allowing removal of the LAMS and coaxial plastic stent.As anticipated, the cavity collapsed immediately after LAMS removal, preventing placement of an additional transmural plastic stent; however, the previously placed parallel plastic stent remained in situ to provide long-term drainage.Follow-up computed tomography at 3 months demonstrated complete pseudocyst resolution without recurrence, and the patient remained free of pseudocyst-related symptoms during 6 months of follow-up.This planned dual-gateway technique may be considered by experienced interventional endoscopists in carefully selected patients who require prolonged transmural drainage after EUS-guided pseudocyst drainage.