pancreatic abscess ( pa ) is a common complication of acute pancreatitis or pancreatic pseudocyst infection that is associated with a high mortality . pa is defined as a circumscribed intra - abdominal collection of pus that is typically in proximity to the pancreas and contains little or no pancreatic necrosis . treatment for pa is complicated.1 surgery , while recommended , carries a significant morbidity ( 13%-53% ) and mortality ( 6.2%25%).2345 endoscopic ultrasound ( eus)-guided puncture and drainage is a widely accepted non - surgical intervention for pancreatic pseudocyst67891011 that also can be used in pa treatment . endoscopic interventions include endoscopic cystogastrostomy , balloon dilation of the fistula , endoscopic necrosectomy , and placement of double - pigtail stents for drainage.1 here , we report a case of large pa that was not resolved by an initial trial involving the placement of multiple double - pigtail stents , the placement of a nasogastric decompression tube for lavage , or repeated debridement . it ultimately was resolved by debridement and placement of a fully covered metal stent for drainage . a 59-year - old woman with severe epigastric pain and fever lasting 3 days was referred to our hospital . at admission , she complained of abdominal pain and fever . computed tomography ( ct ) indicated pancreatic necrosis and a large pseudocyst involving the head , body , and tail of the pancreas . the presence of fever suggested that the pseudocyst was infected . the cyst location and clinical symptoms supported eus - guided pseudocyst drainage . a longitudinal echoendoscope ( pentax eg-3830-ut , pentax corporation , japan ) with a working channel of 3.8 mm was introduced to scan for the pseudocyst and mark the puncture point . the contact zone ( i.e. , the closest approximation of the region between the gastric wall and the cyst wall ) was identified . color doppler then was applied to identify interposing vessels and thus avoid them during puncture . an echotip ultra endoscopic needle ( 19-g , willson - cook medical inc , usa ) was then introduced via the working channel of the echoendoscope , and the cyst was punctured under eus guidance . a sample of the cyst was aspirated for biochemical , cytological , and tumor marker analysis . the needle path was then dilated by the cystotome ( 10-fr , wilson cook medic ) and a balloon dilator ( 10 mm , changzhou jiuhong medical instrument co. , ltd , china ) to form a fistula . a double pigtail stent then was introduced for the drainage of pus . following this procedure , 1 ) . a : endoscopic ultrasound ( eus ) showed a large cyst involving the head , body , and tail of the pancreas , and was punctured under eus guidance ; b : the needle path was dilated by the cystotome and a balloon dilator to form a fistula ; c : computed tomography scan showed no reduction of the cyst1 week later . the majority of the necrotic and purulent material was evacuated , and a double pigtail stent and depressing tube were introduced for drainage . a large diameter stent was placed to facilitate adequate drainage during a third endoscopic intervention . following this necrosectomy , a guide wire ( tracer metro direct wire guide , 0.035 inch /480 mm , wilson cook medical inc , usa ) was kept in the abscess to guide the placement of a covered metal stent ( 14 mm/40 mm , micro - tech / nan jing co. , ltd . ) . a double pigtail stent ( pe double - pigtail 10 fr/7 cm , endo - flex gmbh , germany ) was introduced through the metal stent for auxiliary drainage ( fig . ct scan showed a more than 70% reduction of the abscess 1 week later ( fig . the double pigtail stent was removed during a follow - up eus examination . a : the third time necrosectomy . the majority of the necrotic and purulent material was evacuated ; b : the placement of a covered metal stent ; c : a guide wire was kept in the metal stent to guide the placement of a double pigtail stent for auxiliary drainage . computed tomography scan showed a more than 70% reduction of the abscess 1 week after the metal stent placement . management approaches for pa include endoscopic , radiologic ( percutaneous ) , and surgical procedures ( e.g. , open or laparoscopic drainage ) . pancreatic pseudocyst traditionally is treated surgically , but this approach is accompanied by a high morbidity ( 13%53% ) and mortality ( 6.2%25%).2345 an alternative nonsurgical treatment involves percutaneous drainage with a long catheter ; however , the effectiveness of this approach is inconsistent even for the drainage of a non - contagious pancreatic pseudocyst.1213 during the past decade , endoscopic treatment emerged as a preferred approach in the management of pancreatic pseudocyst and abscess . long - term placement of a stent in the pancreatic duct is likely to induce morphological changes in the duct and the surrounding tissues . therefore , eus - guided pancreatic pseudocyst drainage via cystoenterostomy is considered an effective therapy.1415 when pas are complicated by infected necrosis , plastic stents and daily lavage are inadequate . prior to this report , no data was available regarding the optimal frequency of necrosectomy , but it was recommended that necrosectomy be performed daily until the necrotic material had been completely removed.1 fever is one of the most sensitive indicators in patients with pa . if the hemorrhage is not self - limited , it can be difficult to manage endoscopically . thus , following initial debridement , a large lumen stent to facilitate adequate drainage should be considered . to provide adequate drainage while avoiding the need for repeated evacuation , we placed a covered metal stent after the third necrosectomy . transluminal drainage via metal stents has been performed in numerous cases since 2008.1617 covered metal stents are retrievable , which is essential for benign lesions . in theory , the covered metal stent can easily be removed within 1 month . in our case , when the patient returned for 1-month follow - up , ct scan indicated an almost complete collapse of the abscess cavity with the metal stent expelled . these results support the safety of stent placement , but also highlight the limitation of early stent migration . novel metal stent designs involving large lumens for the collection of extra - intestinal fluid are warranted . to our knowledge , this report describes the first case of eus - guided metal sent placement to treat pa after repeated endoscopic necrosectomy failed . additional studies are needed to validate this method , determine the optimal timing of metal stent intervention , and prevent premature stent expulsion .
for the management of pancreatic abscess , endoscopic ultrasound ( eus)-guided puncture and drainage has become recognized as a safer and more effective alternative to surgery . 
 typically , a double - pigtail plastic stent is placed for drainage . 
 when an abscess is complicated by infected necrosis , endoscopic evacuation is essential . 
 however , endoscopic evacuation carries a high risk of hemorrhage and needs to be performed daily to be effective . 
 we describe eus - guided endoscopic evacuation and placement of a fully covered metal stent following two failed evacuations . 
 patient recovery time was excellent , and no complications occurred .