External pancreatic fistula treated by endoscopic ultrasound-guided drainage with a novel lumen-apposing metal stent mounted on a cautery-tipped delivery system

One of the most common causes of external pancreatic fistula is the iatrogenic manipulation of a complex pancreatic fluid collection concomitantly associated with a disconnected pancreatic duct [1] [2]. This situation can lead to the development of a high output (up to 400 mL/d) external pancreatic fistula that is difficult to manage and sometimes requires surgery [3].\r\n\r\nIn 2012, a 40-year-old woman underwent laparoscopic cholecystectomy with a hepaticojejunal Roux-en-Y anastomosis for a congenital Todani’s type IV common bile duct cyst. Postoperative pancreatitis resulted in the development of a complex pancreatic fluid collection in the pancreatic head, which was drained percutaneously. Subsequently, an external pancreatic fistula formed with an output of 200 mL/d.\r\n\r\nIn 2014, the patient was referred to us for further evaluation. Endoscopic retrograde cholangiopancreatography (ERCP) showed a normal main pancreatic duct that lacked a clear communication with the collection ([Fig. 1]). The injection of contrast through the percutaneous catheter showed the presence of a 4-cm fluid collection ([Fig. 2]). Endoscopic ultrasound (EUS)-guided drainage with the placement of plastic stents was planned.