EUS-Guided Pancreaticoduodenostomy: A New Technique for Main Pancreatic Duct Drainage in Acute and Chronic Pancreatitis

Abstract

Background: Endoscopic drainage of the main pancreatic duct (MPD) in chronic pancreatitis (CP) can lead to a decrease in ductal hypertension, resulting in pain relief. Moreover, MPD drainage can be helpful in acute pancreatitis (AP) complicated with pancreatic duct disruption (PDD), in order to decrease the leakage of pancreatic juice from the disconnected pancreatic segment. However, in case of complete MPD obstruction (CP) or complete PDD (AP), transpapillary access to the proximal MPD segment cannot be obtained and conventional endoscopic ductal drainage is not possible. In these cases, a new technique, EUS-guided pancreaticoduodenostomy (PD), can be useful. Patients and Methods: We report five patients with CP (n = 4) or AP (n = 1) who underwent EUS-guided PD in order to achieve MPD drainage. In all patients, cannulation of the proximal segment of the MPD was not possible by means of a transpapillary approach. Results: Four patients with painful CP presented severe ductal dilation above a tight distal stricture. The remaining patient had presented severe AP, complicated with complete PDD and a pancreaticocutaneous fistula secondary to a previous percutaneous collection drainage. The proximal segment of the MPD was dilated in all patients. PD was performed as follows: Under EUS-guidance, a 19 gauge needle was inserted transduodenally into the proximal, dilated MPD, after its visualization with the tip of the echo-endoscope positioned in the duodenal bulb. Contrast medium was injected, confirming correct location of the needle in the duct. The needle was then exchanged over a guidewire for a 6.5 F diathermic sheath, introduced in the pancreaticoduodenal channel using cutting current. This channel was further enlarged by balloon dilation in two patients. Finally, a pancreaticoduodenal plastic straight stent was placed. In both patients who had previous balloon dilation of the PD, a 10 F stent was placed, whereas smaller diameter stents (6 F or 7 F) were initially used in the remaining patients. These stents were replaced by 10F stents during a second procedure. No complications were recorded. All patients had initial symptom resolution (pain relief and fistula closure) and remained well during a mean follow-up of 10 months (range: 3-30) with the stent in place. Conclusions: EUS guided PD is a new method of ductal decompression in patients with CP or AP, in cases when conventional ERCP fails to obtain access to the proximal MPD. Background: Endoscopic drainage of the main pancreatic duct (MPD) in chronic pancreatitis (CP) can lead to a decrease in ductal hypertension, resulting in pain relief. Moreover, MPD drainage can be helpful in acute pancreatitis (AP) complicated with pancreatic duct disruption (PDD), in order to decrease the leakage of pancreatic juice from the disconnected pancreatic segment. However, in case of complete MPD obstruction (CP) or complete PDD (AP), transpapillary access to the proximal MPD segment cannot be obtained and conventional endoscopic ductal drainage is not possible. In these cases, a new technique, EUS-guided pancreaticoduodenostomy (PD), can be useful. Patients and Methods: We report five patients with CP (n = 4) or AP (n = 1) who underwent EUS-guided PD in order to achieve MPD drainage. In all patients, cannulation of the proximal segment of the MPD was not possible by means of a transpapillary approach. Results: Four patients with painful CP presented severe ductal dilation above a tight distal stricture. The remaining patient had presented severe AP, complicated with complete PDD and a pancreaticocutaneous fistula secondary to a previous percutaneous collection drainage. The proximal segment of the MPD was dilated in all patients. PD was performed as follows: Under EUS-guidance, a 19 gauge needle was inserted transduodenally into the proximal, dilated MPD, after its visualization with the tip of the echo-endoscope positioned in the duodenal bulb. Contrast medium was injected, confirming correct location of the needle in the duct. The needle was then exchanged over a guidewire for a 6.5 F diathermic sheath, introduced in the pancreaticoduodenal channel using cutting current. This channel was further enlarged by balloon dilation in two patients. Finally, a pancreaticoduodenal plastic straight stent was placed. In both patients who had previous balloon dilation of the PD, a 10 F stent was placed, whereas smaller diameter stents (6 F or 7 F) were initially used in the remaining patients. These stents were replaced by 10F stents during a second procedure. No complications were recorded. All patients had initial symptom resolution (pain relief and fistula closure) and remained well during a mean follow-up of 10 months (range: 3-30) with the stent in place. Conclusions: EUS guided PD is a new method of ductal decompression in patients with CP or AP, in cases when conventional ERCP fails to obtain access to the proximal MPD.