Abstract
Introduction: Endoscopic ultrasound (EUS) - guided pancreaticogastrostomy (PG) has been used as an alternative to surgery and/or conventional endoscopic techniques to drain the pancreatic duct in cases of pancreatic duct strictures, stenotic pancreaticodigestive tract anastomosis (PD) and/or disconnected pancreatic duct syndrome (DPDS). Previous techniques employ use of needle-knife cautery, bougie dilation or a stent extraction screw to allow stent passage across the muscular gastric wall and pancreatic parenchyma. This can result in complications such as bleeding, perforation or acute pancreatitis. Moreover, passing standard balloon through pancreatic parenchyma into a small duct has a substantial risk of duct leak if the procedure fails. INTERVENTION:We present a novel technique employing EUS guided puncture and opacification of the PD with a 19-gauge (n=2) or a 22-gauge (n=3) needle, passage of 0.018 guidewire, creation of a trans-gastric fistula using a small shaft diameter (4 Fr) angioplasty balloon and subsequent ductal decompression with a plastic endoprosthesis (reverse insertion of a 3 Fr plastic pigtail stent over 0.018 wire with pigtail beginning to form in the duct to keep the stent in place). Methods: This is a retrospective study conducted at a single tertiary care center in Minneapolis, MN. An EUS-guided PG was offered to patients when conventional ERCP and/or EUS-guided rendezvous access to drain the pancreatic duct failed. A total of 5 patients were included in the study. Main outcomes that we report include technical success of the procedure and procedure related complications. Results: Indications for the duct drainage were DPDS (n=3) and stenotic PD anastomosis after Whipple procedure (n=2). Mean PD diameter was 4.3 mm (n=5). Technical success was achieved in 100% of the cases (5/5) and the angioplasty balloon passed easily over the guidewire without noticeable resistance in all cases. There were no immediate or late procedure related complications in our cohort of patients. Conclusion: EUS-guided PD decompression via creation of a transgastric fistula using a small shaft diameter angioplasty balloon and maintained via reverse placement of a small diameter pigtail plastic endoprothesis is a safe and technically simple alternative when conventional endoscopic techniques for PD access fail. Use of a small caliber angioplasty balloon provides easy access across the muscular gastric wall without the need for cautery, bougie or screw dilation.817_A Figure 1. Demographics, diagnostic findings and therapeutic first interventions in pancreatic duct drainage817_B Figure 2. Procedure related outcomes
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