Endoscopic Retrograde Pancreatography Research Articles

A suspected case of serum IgG4-negative type 1 autoimmune pancreatitis detected due to localized pancreatic duct narrowing: a case report.

A 50-year-old woman was referred to our hospital with elevated serum amylase levels. Physical examination revealed no jaundice or abdominal tenderness. Serum IgG4 was negative. Computed tomography revealed a localized pancreatic duct narrowing in the pancreatic head, with caudal pancreatic duct dilation and an intraductal papillary mucinous neoplasm. Pancreatic enlargement was not observed. Endoscopic ultrasonography (EUS) showed a small hypoechoic mass. Although EUS-guided, fine-needle aspiration was performed, no diagnosis was established. Endoscopic retrograde pancreatography showed a localized narrowing in the main pancreatic duct of the pancreatic head. A biopsy of the narrowing was performed through the minor papilla because of difficult access from the major papilla. The specimen showed the infiltration of numerous IgG4-positive plasma cells, suggesting type 1 autoimmune pancreatitis (AIP). Six months later, magnetic resonance cholangiopancreatography revealed improvement in the narrowing without specific treatment. The patient presented with localized narrowing of the pancreatic duct and caudal duct dilation, which was distinct from pancreatic cancer. Diagnostic difficulties arose from negative serum IgG4 results, the lack of typical imaging characteristics of AIP, and failure to meet the AIP criteria according to the relevant Japanese and international guidelines. However, AIP was suspected and surgery was successfully avoided through a biopsy.

Extracorporeal Shock-Wave Lithotripsy and Endoscopy for the Treatment of Pain in Chronic Pancreatitis : A Sham-Controlled, Randomized Trial.

No randomized controlled trials have substantiated endoscopic decompression of the pancreatic duct in patients with painful chronic pancreatitis. To investigate the pain-relieving effect of pancreatic duct decompression in patients with chronic pancreatitis and intraductal stones. 24-week, parallel-group, randomized controlled trial (ClinicalTrials.gov: NCT03966781). Asian Institute of Gastroenterology in India from February 2021 to July 2022. 106 patients with chronic pancreatitis. Combined extracorporeal shock-wave lithotripsy (ESWL) and endoscopic retrograde pancreatography (ERP) compared with sham procedures. The primary end point was pain relief on a 0- to 10-point visual analog scale (VAS) at 12 weeks. Secondary outcomes were assessed after 12 and 24 weeks and included 30% pain relief, opioid use, pain-free days, questionaries, and complications to interventions. 52 patients in the ESWL/ERP group and 54 in the sham group were included. At 12 weeks, the ESWL/ERP group showed better pain relief compared with the sham group (mean difference in change, -0.7 [95% CI, -1.3 to 0] on the VAS; P = 0.039). The difference between groups was not sustained at the 24-week follow-up, and no differences were seen for 30% pain relief at 12- or 24-week follow-up. The number of pain-free days was increased (median difference, 16.2 days [CI, 3.9 to 28.5 days]), and the number of days using opioids was reduced (median difference, -5.4 days [CI, -9.9 to -0.9 days]) in the ESWL/ERP group compared with the sham group at 12-week follow-up. Safety outcomes were similar between groups. Single-center study and limited duration of follow-up. In patients with chronic pancreatitis and intraductal stones, ESWL with ERP provided modest short-term pain relief. Asian Institute of Gastroenterology and Aalborg University Hospital.

Feasibility and safety of a novel plastic stent designed specifically for endoscopic ultrasound-guided pancreatic duct drainage.

Background and study aims Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) is emerging as an effective alternative treatment for obstructive pancreatitis after unsuccessful endoscopic retrograde pancreatography (ERP). However, the high incidence of adverse events associated with EUS-PD (approximately 20%) remains an issue. Recently, we developed a novel plastic stent for EUS-PD, with a radiopaque marker positioned at approximately one-third of the length from the distal end of the stent and side holes positioned exclusively distal to the marker. This study aimed to evaluate the feasibility and safety of using this stent in EUS-PD. Patients and methods We retrospectively reviewed data from 10 patients who underwent EUS-PD with the novel plastic stent at the National Cancer Center Hospital between March 2021 and October 2023. Technical and clinical success, procedure times, adverse events (AEs), recurrent pancreatic duct obstruction (RPO), and time to RPO were assessed. Results Of the 10 patients, five had postoperative benign pancreaticojejunal anastomotic strictures and five had malignant pancreatic duct obstruction. The technical and clinical success rates were both 100% (10/10). An AE (self-limited abdominal pain) occurred in one patient (10.0%). Two patients (20.0%) died of their primary disease during the follow-up period (median, 44 days; range, 25-272 days). The incidence of RPO was 10.0% (1/10), and the 3-month non-RPO rate was 83.3%. Conclusions The novel plastic stent shows potential as a useful and safe tool in EUS-PD.

Rendezvous-assisted endoscopic retrograde pancreatography in groove pancreatitis with a nondilated pancreatic duct.

Rendezvous-assisted endoscopic retrograde pancreatography in groove pancreatitis with a nondilated pancreatic duct.

Outcomes of asymptomatic common bile duct stones detected at intraoperative cholangiography.

The aim of this study was to investigate the outcome of common bile duct stones (CBDS) in asymptomatic patients at laparoscopic cholecystectomy (LC) and intra-operative cholangiogram (IOC). All patients undergoing LC and IOC at Te Whatu Ora - Health New Zealand Waikato between January 2017 and January 2022 were retrospectively reviewed. Electronic records were screened for asymptomatic CBDS. Exclusion criteria were hyperbilirubinaemia, gallstone pancreatitis, cholangitis and imaging-detected CBDS. IOC reports were reviewed to determine presence of CBDS. A second blinded review was undertaken by a radiologist. Outcomes were use of endoscopic retrograde pancreatography (ERCP), complications and readmission with retained CBDS. Included were 1,297 patients undergoing LC and IOC. Of these, 150 (24.1%) patients had a positive IOC, of which 58 (38.7%) were asymptomatic. Attempted flushing of CBDS was employed in 49 cases, 10 successfully. Common duct exploration was successful in a further six out of seven cases. Of the remaining 42 patients, 18 were offered ERCP. Seven had no stone at endoscopy. Sixteen had imaging, revealing clear ducts in 14. The remaining two then had ERCP confirming choledocholithiasis. Eight patients were managed expectantly, of whom none required readmission with retained stones. Rates of retained asymptomatic stones after positive IOC were low. Acknowledging risks associated with intervention and low rates of readmission with retained CBDS, an expectant approach could be more readily considered.

A case of young male with recurrent acute pancreatitis caused by an intrapancreatic gastric duplication cyst.

Gastric duplication cyst (GDC) is a rare gastrointestinal malformation that frequently occurs in the greater curvature of the gastric antrum or corpus. Herein, we reported a case of intrapancreatic GDC found as a result of recurring pancreatitis. A 15-year-old man experienced repeated episodes of acute pancreatitis and was found to have a cystic lesion in the pancreatic tail. Contrast-enhanced computed tomography revealed a 20-mm cystic lesion with an enhanced thick wall. Endoscopic ultrasonography revealed an anechoic cyst with a three-layered wall. Magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography (ERP) revealed a connection between the cyst and the main pancreatic duct (MPD), and the duplication of the MPD. ERP showed the pancreatic duct stenosis downstream of the cyst. Although preoperative diagnosis was difficult, distal pancreatectomy was performed to prevent recurrence of pancreatitis. Pathological examination revealed that the cystic lesion was circumferentially surrounded by the pancreatic parenchyma. The epithelial lining of the cyst was crypt epithelium containing the fundic or pyloric glands and surrounded by a smooth muscle layer. The final diagnosis was intrapancreatic GDC.

Pancreatic Trauma; Surgical Management, 4 Cases Reported

Pancreatic traumas are rare, but particularly serious. Its management involves diagnostic and therapeutic difficulties. The mechanism of injury generally corresponds to crush injuries or direct trauma during public road accidents. They most often occur during polytrauma and the associated lesions then determine the prognosis and treatment methods. In stable patients, an imaging assessment using CT, magnetic resonance imaging, or even endoscopic retrograde pancreatography determines the type and topography of pancreatic lesions and specifies the damage of the main pancreatic duct, which accounts for the seriousness of the pancreatic trauma. The treatment of pancreatic trauma essentially depends on the integrity or not of the Wirsung duct. Treatment can be solely medical, but above all surgical and endoscopic when canal is damaged. There is report of 4 patient observations who were treated in the surgical emergency department at Annaba Algeria University Hospital during the year 2023 for isolated trauma of the pancreas. There are diagnostic circumstances and description of therapeutic conduct and the surgical consequences.

Retained stone retrieval basket causing chronic pancreatitis: a case report.

Endoscopic retrograde cholangiopancreatography is a common procedure performed for choledocholithiasis and gallstone pancreatitis. Although a relatively low risk procedure, it is not without its complications. Cases of impacted Dormia baskets during stone retrieval have been reported, but these are usually retrieved surgically during the same setting. A 40-year-old man presented to our hospital with an episode of epigastric pain and discomfort. He has a prior background of recurrent episodes of pancreatitis of which he underwent prior endoscopic therapy in his home country. Initial investigations revealed a metallic object seen on abdominal x-ray, computer tomographic scan of the abdomen and pelvis, and magnetic resonance imaging of the pancreas. Further evaluation was done with endoscopy, which revealed a retained stone extraction basket from a previous endoscopic retrograde pancreatography, resulting in recurrent episodes of acute chronic pancreatitis. Although the retained foreign body was removed, he subsequently developed further complications of portal vein thrombosis as a result of recurrent acute chronic pancreatitis, which required anticoagulation. This case highlights the importance of retrieving any foreign body from the pancreas, especially on the head, to prevent the development of further complications.

Rendezvous-assisted endoscopic retrograde pancreatography in a patient with annular pancreas and coexisting pancreas divisum.

An 18-year-old female was hospitalized for chronic pancreatitis of unknown origin. No history of alcohol abuse and hereditary diseases were found. Enhanced computed tomography (CT) and magnetic resonance cholangiography revealed dilated pancreatic duct system and abnormal pancreatic tissue incompletely wrapping around the second portion of the duodenum ([Fig. 1], [Fig. 2]). Endoscopic retrograde pancreatography (ERP) with intended minor papilla cannulation was attempted and yet failed due to the polypoid nodular papilla ([Fig. 3]).

Long-term outcomes of pancreatoscopy-guided electrohydraulic lithotripsy for the treatment of obstructive pancreatic duct stones.

Background and study aims Pancreatoscopy-guided electrohydraulic lithotripsy (EHL) has proven to be an effective first-line therapy in symptomatic chronic pancreatitis (CP) patients with obstructing pancreatic duct (PD) stones 1 . However, long-term outcomes of endoscopic EHL remain unknown. The aim of the present study was to evaluate the long-term treatment effects of EHL as first-line therapy and to compare with those obtained in a historical cohort of patients who underwent extracorporeal shockwave lithotripsy (ESWL) as primary treatment. Patients and methods An observational retrospective single-center long-term follow-up study was performed including 19 consecutive patients who previously underwent endoscopic EHL compared to 18 patients who underwent ESWL followed by endoscopic retrograde pancreatography (ERP). The primary endpoint was long-term treatment success after EHL or ESWL defined as no recurrence of symptomatic intraductal stones confirmed on imaging. Secondary endpoints for the EHL-population included long-term clinical success (i. e., a similar or lower Izbicki Pain Score or reduction in opiate usage as compared to 6-month follow-up), quality of life (QoL), pancreatic function and hospital re-admission rate. Results In the EHL group, 37 % of the patients developed recurrent symptomatic PD stones versus 61 % in the ESWL group after a median follow-up of 35.0 and 76.5 months. Of the patients with recurrence, 71 % versus 100 % underwent a reintervention. Median time to recurrence was 12.0 versus 13.0 months. Clinical success sustained in 58 % of the EHL patients. QoL was not significantly different compared with 6-month follow-up and baseline. Conclusions Also at long-term follow-up, endoscopic EHL as first-line treatment is moderately effective for symptomatic CP patients with treatment success rates that seems at least equally effective as ESWL.

Techniques and Outcomes of Endoscopic Ultrasound Guided—Pancreatic Duct Drainage (EUS- PDD)

Endoscopic ultrasound guided-pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed.

Evaluation of the Paraoxonase-1 Level in Patients with Acute Pancreatitis.

This study, aimed to evaluate the role of paraoxonase-1 (PON-1), in the pathogenesis of acute pancreatitis (AP). PON-1 plays a significant role in antioxidant, anti-inflammatory and antiatherogenic responses and may help predict the severity of AP. A total of 50 patients with AP and 45 healthy volunteers were included in the study. AP was diagnosed when serum amylase and/or lipase values increased threefold and/or more than the upper limit of normal, together with a complaint of abdominal pain. Modified Atlanta and Ranson scoring were used for AP severity. AP causes were biliary for 35 (70%) patients and idiopathic for 8 (16%) patients, AP developed in 6 (12%) patients after endoscopic retrograde pancreatography, and AP in 1 (2%) patient was a consequence hypertriglyceridemia. No difference in PON-1 level was found between the groups (PON-1=197.06±164.6 and 192.1±111.78, respectively, p=0.86). On the other hand, patients were stratified according to the modified Atlanta (177.5±166.8 for mild to moderate vs. 268.5±64.2 for severe, p<0.018) or Ranson (163.2±133.06 for mild vs. 208.8±158.0 for severe, p<0.016). PON-1 level was significantly higher in patients with severe AP compared to patients with mild and/or moderate disease. Although PON-1 level did not differ in patients with and without AP, PON-1 level increased significantly in parallel with the severity of AP. Thus, PON-1 can be a potential marker for the severity of the disease and can predict prognosis.

Role of Preoperative MRCP in the Management of Biliary Pancreatitis: A Retrospective Study from Saudi Arabia

Background: Gallstones are the leading cause of acute pancreatitis worldwide. Acute biliary pancreatitis occurs when distal common bile duct stones obstruct the ampulla. This can result in severe consequences for some patients, including significant fluid loss, metabolic imbalances, hypotension, and sepsis. Definitive management strategies for choledocholithiasis include laparoscopic cholecystectomy and/or endoscopic retrograde pancreatography. Magnetic resonance cholangiopancreatography (MRCP) has been increasingly used to evaluate bile duct pathology, leading to more frequent pre-operative biliary duct evaluations for patients with acute gallstone pancreatitis. Despite its widespread use, there have been conflicting reports in the literature regarding its effectiveness and impact on hospital stay duration and healthcare-associated costs. Aim: The aim of this study was to compare the impact of performing MRCP in biliary pancreatitis and its utility, measure its cost-effectiveness, and assess the sensitivity and specificity of different laboratory and radiological investigations in diagnosing impacted biliary stones. Methods: This study followed a retrospective design and analyzed, the records of all patients diagnosed with acute biliary pancreatitis during the study period (2015-2019). Data regarding the following variables were obtained and analyzed from patients’ records: age, comorbidities, and previous medications of the patients; BISAP pancreatitis severity score; serum amylase, at the time of admission; serial recordings for biomarkers and liver function test results (for Day, 1, 3, and 6); ultrasonography results; computed tomography results; MRCP and ERCP results; postoperative complications; length of hospital stay in days; and the time waiting for surgery in days. Results: 133 participants were found in the hospital admission registry and included in this analysis, with an average age of 51.73 years. At the time of admission, the average serum amylase level was 1310 units/liter. Regarding the length of hospital stay, 8.9 days was the average among the patients, with a maximum length of stay of 48 days. Our analysis revealed that MRCP has a sensitivity of 77% and a specificity of 64% for detecting CBD stones. Patients who had MRCP stayed longer at the hospital with an average of 9.21 days, although the difference was not statistically significant (p-value: 0.570), compared with International Journal of Surgery &amp; Surgical Techniques 2 Shaher A, et al. Role of Preoperative MRCP in the Management of Biliary Pancreatitis: A Retrospective Study from Saudi Arabia. Int J Surg Surgical Tech 2023, 7(2): 000196. Copyright© Shaher A, et al. an average of 6.15 among patients who did not have MRCP. As for the days to surgery, the average time until surgery was 3.79 (standard deviation 3.73), with a maximum of 16 days until surgery. Patients who had MRCP had to wait for a longer period of time until surgery than their counterparts who waited for less than a day for their surgery (p-value: &lt; 0.001). Conclusion: Our results revealed that patients who underwent MRCP preoperatively had a longer hospital stay and significantly waited longer for surgery than their counterparts. However, more multi-centered, large studies are needed to further support our findings.

Outcomes of endoscopic papillary large balloon dilatation in comparison to mechanical lithotripsy for large common bile duct stone

Background: The management of common bile duct stone (CBDS) has changed drastically over the past two decades, as open surgery has been supplanted by per-oral endoscopic procedures. Currently, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) is the standard worldwide. After performing an endoscopic biliary sphincterotomy (EBST), endoscopic therapy entails CBDS extraction using conventional procedures. Lithotripsy is an endoscopic procedure used to remove CBDS that are too large to be extracted using conventional techniques.Aim: The aim of the present work is to compare the results of endoscopic large balloon dilatation and mechanical lithotripsy for large CBDS.Subjects and Methods: This prospective cohort study was conducted on 60 cases undergoing endoscopic retrograde cholangial pancreatography for large CBDS who were referred to out-case's clinic and in-case's wards of Gastroenterology, Hepatology and Endoscopy unit of Internal Medicine Department at Tanta University Hospitals December 2019 to February 2021. Cases were divided into two equal groups. Group I included cases undergoing endoscopic papillary large balloon dilatation (EPLBD) and Group II included cases undergoing mechanical lithotripsy (ML).Results: Success of CBDS extraction, Hb, PLT, TLC, albumin, PA, ALT, AST, creatinine and urea and CBDS parameters (diameter, CBDS size, CBDS number) after ERCP were insignificantly different between both groups. Total serum bilirubin, direct serum bilirubin and, Alkaline phosphatase after ERCP were significantly lower in EPLBD. However, Amylase and lipase were significantly higher in EPLBD.Conclusion: Despite that the endoscopic large balloon dilatation caused significantly higher pancreatitis, it showed lower TSB, DSB and ALP. However, both techniques showed no difference regarding the success of CBDS extraction and laboratory investigations.

Potential factors affecting success rate and long term outcome in single balloon enteroscopy-assisted therapeutic endoscopic retrograde cholangiopancreatography in patients with pancreaticojejunal anastomotic stenosis: a retrospective study

Pancreaticojejunal anastomotic stenosis (PJS) after pancreaticoduodenectomy (PD) is difficult to treat. Single-balloon enteroscope-assisted endoscopic retrograde pancreatography (SBE-assisted ERP) is a safe way to treat PJS with the strength of minimally invasion and repeatability, but since its technical difficulty and few patient number, data on long-term outcomes remain limited. The optimal treatment is still unknown. We aim to study the safety, effectiveness, and long-term outcome of single balloon enteroscopy-assisted (SBE-assisted) therapeutic ERP in patients with PJS in this study. The clinical information of patients undergoing SBE-assisted therapeutic ERP from March 2016 to March 2021 were retrospectively analyzed. All patients were diagnosed as PJS and without any contraindication for therapeutic endoscopy. Treatment details, postoperative complications, factors influencing technical success rate were evaluated. Long-term outcomes results were obtained by clinical or telephone follow-up. Sixteen patients with median age of 51 years were included in this study, surgical reconstruction methods including PD with Whipple reconstruction, PD with Child reconstruction, pylorus-preserving pancreaticoduodenectomy (PpPD) with Whipple reconstruction. Eight patients were successfully treated. No serious complications happened. Risk factors for the failure of pancreaticojejunal anastomotic site identification include the digestive tract reconstruction sequence, pancreaticojejunostomy method, pancreatic duct tube implantation, pancreatic duct width before surgery, and pancreatic fistula during perioperative period. The median follow-up time was 77.2 months, the mean indwelling time of the stent was 62.3 months [interquartile range (IQR), 6.8-153.7 months]. Two of eight patients developed recurrent PJS. The variation in body mass index (BMI) was +2.46 in the non-recurrence group compared to -1.09 in the recurrence group and -2.12 in the endoscopic retrograde cholangiopancreatography (ERCP) treatment failure group. ERP intervention should be carried out early once PJS occurs in order to increase success rate. BMI is a crucial indicator which can reflex PJS rehabilitation degree during follow-up. In order to reduce PJS recurrence rate, a wider pancreatic stent and a longer stent indwelling time are recommended.

Surprise finding at endoscopic retrograde pancreatography in a patient with pancreatic duct disruption

Surprise finding at endoscopic retrograde pancreatography in a patient with pancreatic duct disruption

Per-oral pancreatoscopy-guided lithotripsy vs. extracorporeal shock wave lithotripsy for treating refractory main pancreatic duct stones in chronic pancreatitis: Protocol for an open-label multi-center randomized clinical trial

Backgrounds/ObjectivesPatients with chronic pancreatitis may develop pancreatic duct stones that can obstruct outflow leading to ductal hypertension and pain. Both endoscopic retrograde pancreatography (ERP) with per-oral pancreatoscopy (POP) and intraductal lithotripsy and extracorporeal shock wave lithotripsy (ESWL) are feasible options to attempt ductal stone clearance. This study aims to compare POP-guided lithotripsy with ESWL in the management of refractory symptomatic main pancreatic duct stones. MethodsThis is an open-label, multi-center, parallel, randomized clinical trial. Patients with chronic pancreatitis and main pancreatic duct stones ≥5 mm who fail standard ERP methods for stone removal will be eligible for this study. In total, 150 subjects will be randomized 1:1 to either ESWL or POP. A maximum of 4 sessions of either ESWL or POP will be allowed in each arm, with crossover permitted thereafter. The primary outcome is complete stone clearance and secondary outcomes include quality of life, pain scores, number of interventions, and daily opiate requirements. ConclusionsThis study aims to answer the question of which lithotripsy method is superior in removing refractory pancreatic duct stones while addressing the effects of lithotripsy on quality of life and pain in patients with chronic calcific pancreatitis (ClinicalTrials.gov NCT04115826).

Carcinoembryonic antigen levels in pancreatic juice are associated with histological subtypes of intraductal papillary mucinous neoplasm of the pancreas.

BackgroundThe present study aimed to examine the correlation between preoperative carcinoembryonic antigen levels in pancreatic juice (PJ‐CEA) and the histological subtype of intraductal papillary mucinous neoplasm (IPMN).MethodsWe enrolled IPMN patients who underwent endoscopic retrograde pancreatography between March 2002 and March 2018. Clinical factors associated with IPMN histological subtypes of 67 patients who underwent surgery were analyzed. Furthermore, the relationship between CEA immunohistochemistry findings and histological subtypes was investigated.ResultsMedian PJ‐CEA were 15 ng/ml in the gastric type, 150 ng/ml in the intestinal type, and 175 ng/ml in the pancreatobiliary type. Both intestinal and pancreatobiliary types had significantly higher PJ‐CEA than the gastric type (p = 0.001). In the analysis of histological subtype predictors, high PJ‐CEA (≥63 ng/ml) only showed a significant difference in multivariate analyses (95% confidence interval 4.8–70.2; p < 0.001). Immunohistochemistry findings revealed significantly higher CEA expression in the non‐gastric type than in the gastric type (p < 0.001). The non‐gastric type showed a significantly worse prognosis than the gastric type (p = 0.017).ConclusionPJ‐CEA was an independent predictor of IPMN histological subtypes in a preoperative setting. High PJ‐CEA predict the non‐gastric type, while low PJ‐CEA predict the gastric type.

An Atypical Complication of Chronic Pancreatitis

An Atypical Complication of Chronic Pancreatitis

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

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)