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Management of walled‐off necrosis using the multiple transluminal gateway technique with the Hot AXIOS System

A 67year-old woman with acute pancreatitis presented for treatment of septated walled-off necrosis (WON) measuring 14×10cm on computed tomography (CT) (Fig. 1). At endoscopic ultrasonography (EUS), WON contained 35% solid debris and had two compartments: one adjacent to the duodenum and another adjacent to the stomach. Decision was made to drain both compartments adopting the multiple transluminal gateway technique (MTGT) using 15-mm diameter dual-flanged lumen-apposing metal stents with an electrocautery-enhanced delivery system (Hot AXIOS System; Xlumena Inc., Sunnyvale, CA, USA). WON adjacent to the duodenum was first accessed using electrocautery. After positioning the catheter within the WON, stent deployment hub was released to deploy the distal flange of the stent. Echoendoscope was retracted to visualize the catheter shaft in the duodenum and catheter deployment hub was then completely released to deploy the proximal flange within the duodenal lumen. Echoendoscope was subsequently withdrawn into the stomach and the perigastric compartment of WON was drained using the same technique (Video S1). Necrotic material (1.3L) drained within 10min. A follow-up CT scan at 72h revealed that both compartments of the WON were <3 cm with >90% decrease in total volume (Fig. 2), with associated clinical improvement. This is the first report of successful use of the Hot AXIOS System in MTGT. We have previously demonstrated that the treatment success rate for WON with MTGT using plastic stents was superior to the standard technique (92 vs 52%, P=0.017). However, the median procedural duration for MTGTwas significantly longer (37 vs 22min) as a result of placement of multiple stents. However, unlike plastic stents, the recently approved Hot AXIOS System allows single-step creation of transmural tracts and therefore enables more rapid creation of multiple gateways, ultimately making the endoscopic management of WON safer and less laborious.