S7 Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A 10-Year Single-Center Experience

Abstract

Introduction: EUS-guided pancreatic duct drainage (EUS-PDD) has been recognized as an alternative to surgery for those in whom transpapillary drainage is unfeasible. Previous studies have outlined hurdles that may be encountered with performance of this challenging procedure. These can include lack of stability of the echoendoscope, difficulty with moving a guidewire through the needle for creation of a fistulous tract, or dilation of the fistulous tract. Methods: We performed a retrospective chart review of cases performed in a tertiary academic center of those in whom EUS-PDD was attempted from January 2010 to November 2021. Documentation and imaging were reviewed up to 12 months after the incident event. Figure demonstrates an example of the performance of the procedure. Results: 27 patients were identified for whom baseline characteristics are listed in Table: The pancreatic duct was accessed through the stomach in 26 of 27 cases. Technical success was achieved in 22 of these. Access through the duodenum was attempted in a single case but was unsuccessful due to a discontinuous duct. Clinical success was defined in terms of improvement of upstream dilation of the pancreatic duct on imaging and of symptoms, and was achieved in all 22 patients. However, 5 patients had persistent albeit improved abdominal pain after the procedure. One had bleeding that resulted in a self-limited hematoma, which developed an infection with Escherichia coli that resolved after conservative management with antibiotics. Another patient developed a pancreatic duct leak that was managed with cystgastrostomy with eventual resolution. Stent migration occurred in two of which one was monitored conservatively without laboratory or imaging findings of recurrence of pancreatic duct obstruction. In the second case, the patient had recurrence of pain and was found to have migration of the distal end of the stent on endoscopic evaluation. The stent was nonetheless left in place to allow the fistulous tract to remain patent, with eventual removal 16 months later with resolution of stricture (Figure 1). Conclusion: EUS-PDD is a technically challenging procedure that may nonetheless be the only nonsurgical option in patients in whom endoscopic retrograde pancreatography is infeasible. Technical and clinical success in this cohort is comparable with previous studies. By describing our experience with EUS-PDD, we hope to inform endoscopists of potential hurdles and adverse events that may occur with performance of the procedure (Table 1).Figure 1.: Sample images from one of the cases in this review. 1A shows the fluoroscopic image of the stent placed during EUS-PDD. 1B demonstrates cannulation of the PD through the stomach under ultrasound guidance. Table 1. - Baseline characteristics of patient cohort and post-procedural follow-up Characteristic n (%) Age, mean (SD) 54.6 (12.8) Gender Male Female 12 (44.4)15 (55.6) Indication for EUS-PDD Stricture Stone Mixed (stone + stricture) Pancreas divisum Discontinuous duct 9 (33.3)8 (29.6)2 (7.4)5 (18.5)3 (11.1) Approach Antegrade Retrograde 22 (81.5)5 (18.5) Technical success 22 (81.5) Type of stent Straight Pigtail 12 (54.5)10 (45.5) Adverse events Pancreatitis Stent migration Bleeding Pancreatic duct leak 3 (11.1)2 (7.4)1 (3.7)1 (3.7) Clinical success 22 (100) Number of readmissions, mean (SD) 1.7 (SD 2.2) Re-intervention required 2 (9.1)