EUS-guided wirsung-gastrostomy: Outcomes and long-term management

Abstract

Introduction: Technical success for endoscopic wirsung-gastrostomy (EWG) is about 40% with a complication rate >20%. Long-term results are scarce. Case: A 46 year old patient with alcoholic liver and pancreatic chronic disease with active consumption referred recurrent pancreatic like type pain requiring intensive analgesic therapy. CT scan showed pancreatic duct dilation proximal to the head of the pancreas with distal pancreatic duct stenosis and severe perigastric collateral vessels related to portal hypertension. The patient was considered as high surgical risk so in October 2011 pancreatic stent placement was attempted but failed because of impossibility of pancreatic duct cannulation. EUS-guided transgastric pancreatic duct access was performed. Wirsungraphy was accomplished through the transgastric EUS guided needle showing a severe pancreatic duct stenosis in the pancreatic isthmus hindering guidewirenavigation and the EWGwas completed by insertion of a 5F pancreatic stent connecting the pancreatic duct and the gastric lumen. The patient had a favourable outcome and could stop taking analgesics. In may 2012 a second transgastric 7F stent placement was scheduled uneventfully to ensure pancreatic drainage. The patient remained asymptomatic thereafter despite keeping toxic habits, until august 2013 when he was admitted for a septic clinical picture with abdominal pain. A CT scan showed two abdominal collections with transgastric pancreatic stents correctly placed. The patient was diagnosed of acute relapse over chronic pancreatitis and percutaneous drainage of both collections was performed. In order to rule out origin of those collections from the EWG, the transgastric fistula was cannulated showing no leakage and improvement of the pancreatic head stenosis. Three plastic pancreatic stents were placed through the gastric wall into the pancreatic duct. The patient remains asymptomatic 40 months after initial EWG. Conclusion: In our experience, the EWG offers good clinical long-term outcomes in patients with high surgical risk.