EUS-guided Pancreatic Duct Drainage Research Articles

Endoscopic ultrasound-guided pancreatic duct drainage: a single center observational study

Background and aimsPancreatic duct obstruction can cause pain and atrophy of the pancreatic parenchyma. Endoscopic drainage is the first-line treatment, usually by endoscopic retrograde cholangiopancreatography. However, in some patients, the classic transpapillary approach cannot be performed because of anatomical inability to access the papilla, rupture of the main pancreatic duct, intracanal stones that cannot be crossed or tight stenosis of the main pancreatic duct due to extrinsic compression by parenchymal calcifications. Endoscopic ultrasound-guided pancreatic duct drainage is an efficient and minimally invasive therapeutic alternative for these patients. We aimed to evaluate clinical success of endoscopic ultrasound-guided pancreatic duct drainage in our center. MethodsData of patients who underwent endoscopic ultrasound-guided pancreatic duct drainage in our center between 2016 and 2022 were retrospectively reviewed. Clinical success was defined as pain ≤2 on the pain Visual Analog Scale (VAS, 0-10) and no recurrence of obstructive pancreatitis after successful stent placement. If the indication to the procedure was chronic pancreatitis with painless weight loss, then clinical success was defined as weight stabilization or weight regain after the procedure. Results46 patients (mean age 58 years old, 69.6% male) were included. Indications of endoscopic ultrasound-guided pancreatic duct drainage were chronic pancreatitis in 69.6% of patients (78.1% due to alcohol abuse). Other indications included post-operative complications, rupture of pancreatic duct and pancreatic cancer. Technical success was achieved in 93.5% of patients. 40 patients had pancreaticogastrostomy and 3 patients pancreaticoduodenostomy. The mean hospital stay was 2 days. Clinical success was 93% in patients who achieved technical success. Remaining pain on the VAS > 2 occurred in 9.3% of patients and obstructive pancreatitis recurrence in 6.9%. Adverse event occurred in 5 patients (11.6%). 18 stent dysfunctions were observed, 16 stent migrations and 2 stent obstructions. No patient died from the procedure. ConclusionEndoscopic ultrasound-guided pancreatic duct drainage showed a high clinical success rate. It is therefore a good minimally invasive alternative to avoid pancreatic surgery in patients with symptomatic pancreatic duct stenosis of benign or malignant etiology who failed endoscopic retrograde cholangiopancreatography.

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

Background/study aim: 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/materials 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, recurrent pancreatic duct obstruction (RPO), and time to RPO were assessed. Results: Of the ten 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 adverse event (self-limited abdominal pain) occurred in one (10.0%) patient. Two (20.0%) patients 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%. Conclusion: The novel plastic stent shows potential as a useful and safe tool in EUS-PD.

Enhancing visualization with low echo reduction during endoscopic ultrasound-guided pancreatic duct drainage.

Enhancing visualization with low echo reduction during endoscopic ultrasound-guided pancreatic duct drainage.

Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A retrospective study evaluating indications, technical challenges and outcomes

Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A retrospective study evaluating indications, technical challenges and outcomes

Transmural pancreatoscopy-assisted lithotripsy through endoscopic ultrasound-guided pancreatic duct drainage tract created by a novel drill dilator.

Watch a video of this article.

EUS-guided pancreatic duct drainage using a novel plastic stent with ultratapered tip (with video).

EUS-guided pancreatic duct drainage using a novel plastic stent with ultratapered tip (with video).

Endoscopic ultrasound-guided antegrade dilation using a drill dilator for a pancreatojejunostomy anastomotic stricture, with pancreatoscopic findings.

Pancreaticojejunal anastomotic stricture (PJS) occurs as a complication after pancreaticoduodenostomy, with a reported incidence rate of 1.4 %–11.4 % [1]. Because abdominal pain or acute pancreatitis can occur in patients with a PJS, resolution of the PJS is desirable. The endoscopic approach is more often selected because, compared with surgical treatment, it is a noninvasive procedure. Although the enteroscopic approach is usually attempted [2] [3], it has disadvantages such as prolonged procedure time. Accordingly, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has been developed [4]. This alternative method is reported to have a high technical success rate and requires dilation of the PJS. The Tornus ES drill dilator (Asahi Intecc) ([Fig. 1]) has recently become available in Japan [5]. It enables the tract to be easily dilated using a clockwise rotation without any pushing force. We herein describe its successful use for dilation of a PJS, with the pancreatoscopic findings shown.

Current paradigm of endoscopic ultrasound in biliary and pancreatic duct drainage: an update.

Endoscopic retrograde cholangiopancreatography (ERCP) is the workhorse for biliary and pancreatic ductal interventions. Despite advances in both endoscopes and accessories for ERCP, it still has limitations in the presence of altered anatomy, luminal obstruction hindering access to the papilla, and proximal duct obstructions by tight stricture, calculi or intraductal growth. Endoscopic ultrasound-guided biliary drainage (EUS-BD) and EUS-guided pancreatic duct drainage (EUS-PDD) have expanded the rescue procedures after failed ERCP. This review discusses the techniques and results of various EUS-BD procedures, as well as EUS-PDD.

Evolution of interventional endoscopic ultrasound.

Endoscopic ultrasound (EUS) has become an indispensable modality for the assessment of the gastrointestinal tract and adjacent structures since its origin in the 1980s. Following the development of the linear echoendoscope, EUS has evolved from a purely diagnostic modality to a sophisticated tool for intervention, with numerous luminal, pancreaticobiliary, and hepatic applications. Broadly, these applications may be subdivided into three categories: transluminal drainage or access procedures, injection therapy, and EUS-guided liver interventions. Transluminal drainage or access procedures include management of pancreatic fluid collection, EUS-guided biliary drainage, EUS-guided bile duct drainage, EUS-guided pancreatic duct drainage, and enteral anastomosis formation. Injection therapies include therapeutic EUS-guided injections for management of malignancies accessible by EUS. EUS-guided liver applications include EUS-guided liver biopsy, EUS-guided portal pressure gradient measurement, and EUS-guided vascular therapies. In this review, we discuss the origins of each of these EUS applications, evolution of techniques leading to the current status, and future directions of EUS-guided interventional therapy.

Use of a transpapillary stent as a guidepost for endoscopic ultrasound-guided pancreatic duct drainage in the treatment of disconnected pancreatic duct syndrome.

Use of a transpapillary stent as a guidepost for endoscopic ultrasound-guided pancreatic duct drainage in the treatment of disconnected pancreatic duct syndrome.

An Atypical Complication of Chronic Pancreatitis

Question: A 55-year-old man with a history of chronic alcoholic pancreatitis presented with a 4-day history of progressively worsening abdominal pain, nausea, and vomiting. Physical examination revealed tenderness in the epigastrium, without guarding or rebound. Laboratory tests were significant for the following: white blood cell count, 16,600/μL; amylase level, 452 U/L; lipase level, 437 U/L; and C-reactive protein level, 32.5 mg/dL. Contrast-enhanced computed tomography (CT) of the abdomen showed a dilated main pancreatic duct, peripancreatic fluid collections, and fluid collection at the tail of the pancreas adjacent to the splenic hilum (Figure A). Because the patient was hemodynamically stable, he was initially managed conservatively, but the cystic lesion at the tail of the pancreas enlarged, and a follow-up CT performed 1 week later showed the cystic lesion extending into the splenic parenchyma (Figure B) and the left chest (Figure C). The patient’s clinical condition was deteriorating. What is the diagnosis and what should be the next steps in management? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Thoracentesis of the left pleural effusion had a high amylase content (66,162 U/L). These findings confirmed the diagnosis of a pancreatic pseudocyst with acute exacerbation of chronic pancreatitis involving the spleen and the chest. Magnetic resonance cholangiopancreatography showed communication between the pancreatic duct and the pseudocyst. Endoscopic retrograde pancreatography revealed strictures of the main pancreatic duct in the pancreatic head and body, and a flow of contrast medium from the main pancreatic duct into the pseudocyst was visualized (Figure D, arrow). An endoscopic pancreatic sphincterotomy was performed and a 7-French (Fr), 9-cm straight plastic pancreatic stent was placed into the main pancreatic duct. However, there was no improvement in the patient’s condition, and the size of the pseudocyst remained unchanged. Endoscopic ultrasound (EUS)–guided transmural drainage was not performed because the stomach and the pseudocyst were not in close proximity. Therefore, the patient underwent ultrasound-guided percutaneous trans-splenic pseudocyst drainage (7-Fr) and percutaneous pleural drainage (20-Fr), with immediate decompression of the pseudocyst (Figure E) and symptomatic relief. Drainage tubes were removed when there was no further drainage, and he was asymptomatic at discharge. A follow-up CT at 2 months revealed that the pseudocyst had resolved completely. The pancreatic stent was removed 1 year after discharge, resulting in the recurrence of acute pancreatitis. The pancreatic duct strictures had not improved, and an 8.5-Fr pancreatic duct stent was replaced. The pancreatic stent was thereafter replaced regularly every 4–6 months. He was still doing well during a 10-year follow-up period with no recurrence of pseudocyst. Pancreatic pseudocysts are a common complication of acute or chronic pancreatitis. Most pseudocysts are found in peripancreatic region, but they can also be found in atypical locations such as the liver, spleen, mediastinum, pelvis, kidney, and retroperitoneum. Although uncommon, due to the close proximity of the pancreatic tail and the splenic hilum, splenic complications such as isolated splenic vein thrombosis, intrasplenic pseudocysts, splenic rupture, infarction, and necroses as well as splenic hematoma and severe bleeding from eroded splenic vessels may occur in the course of acute or chronic pancreatitis.1Lankisch P.G. The spleen in inflammatory pancreatic disease.Gastroenterology. 1990; 98: 509-516Abstract Full Text PDF PubMed Scopus (73) Google Scholar Pseudocysts that are symptomatic or present with complications such as infection, bleeding, rupture, or fistulization to adjacent hollow structures require intervention.2Dumonceau J.M. Delhaye M. Tringali A. et al.Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) guideline - updated August 2018.Endoscopy. 2019; 51: 179-193Crossref PubMed Scopus (151) Google Scholar Management options are considered based on the timing, their size and location, relationship with adjacent anatomic structure, and symptoms. The treatment strategy includes conservative treatment, percutaneous, endoscopic, and surgical drainage, or excision. Medical therapy consists of enteral or parenteral nutrition, enzyme supplementation, and somatostatin analogues. It has been reported that there is no significant difference in pseudocyst resolution between surgical and endoscopic approaches; thus, the minimally invasive approach is recommended. Endoscopic drainage has become the preferred therapeutic modality. At present, EUS-guided transmural drainage is the first-line treatment for pseudocysts and walled-off pancreatic necrosis. Endoscopic transpapillary drainage is also an effective treatment when the pseudocyst and the main pancreatic duct are connected.2Dumonceau J.M. Delhaye M. Tringali A. et al.Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) guideline - updated August 2018.Endoscopy. 2019; 51: 179-193Crossref PubMed Scopus (151) Google Scholar Prolonged stenting (6–12 months) is effective in treating for remodeling pancreatic duct strictures.3Strand D.S. Law R.J. Yang D. et al.AGA Clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis: Expert review.Gastroenterology. 2022; 163: 1107-1114Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In addition to plastic stents, placement of a fully covered self-expanding metal stent has also become a management option for refractory benign pancreatic duct strictures.2Dumonceau J.M. Delhaye M. Tringali A. et al.Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) guideline - updated August 2018.Endoscopy. 2019; 51: 179-193Crossref PubMed Scopus (151) Google Scholar,3Strand D.S. Law R.J. Yang D. et al.AGA Clinical practice update on the endoscopic approach to recurrent acute and chronic pancreatitis: Expert review.Gastroenterology. 2022; 163: 1107-1114Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar When transpapillary drainage can be technically difficult due to severe strictures, pancreatic duct stones, or surgically altered anatomy, EUS-guided pancreatic duct drainage is becoming an alternative technique.2Dumonceau J.M. Delhaye M. Tringali A. et al.Endoscopic treatment of chronic pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) guideline - updated August 2018.Endoscopy. 2019; 51: 179-193Crossref PubMed Scopus (151) Google Scholar However, if the pseudocyst does not connect with the pancreatic duct and is located away from the stomach or duodenum, percutaneous or surgical drainage could be considered. Surgery may be required if the other modalities of treatment have failed, cystic neoplasm cannot be ruled out, or complications have occurred such as perforation or hemorrhage not controlled by embolization. Pseudocyst management often necessitates multiple interventions. The approach should be individualized for each patient. A multidisciplinary strategy involving the expertise of therapeutic endoscopists, interventional radiologists, and pancreaticobiliary surgeons is highly preferred to provide the best possible outcome.

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)

Utility of a novel drill dilator for easier EUS-guided pancreatic duct drainage.

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EUS-guided pancreatic duct drainage with rendezvous technique for post-Whipple pancreatic duct stone.

Video 1EUS-guided pancreatic drainage using the rendezvous technique in a patient with pancreaticojejunal anastomosis stenosis and pancreatic duct stone.

Antegrade brushing cytology through the EUS-guided pancreatic duct drainage route (with video)

Antegrade brushing cytology through the EUS-guided pancreatic duct drainage route (with video)

Endoscopic pancreatic stenting using the combination technique of injection needle and needle knife for complete pancreaticojejunal anastomotic obstruction.

Watch a video of this article. A 69-year-old woman who underwent pancreaticoduodenectomy presented with chronic diarrhea and exacerbation of diabetes mellitus. Magnetic resonance cholangiopancreatography revealed dilatation of the main pancreatic duct (MPD) (Fig. 1a). Exocrine and endocrine pancreatic insufficiency due to pancreaticojejunal anastomotic stenosis (PJS) were considered as possible causes of the symptoms. Therefore, endoscopic retrograde pancreatography (ERP) was planned. On endoscope (PCF-H290ZI; Olympus Medical Systems, Tokyo, Japan) insertion, the anastomotic site (AS), which was characterized by membranous obstruction, was identified (Fig. 2a). ERP using a conventional cannulation method was considered difficult because of complete anastomotic obstruction (CAO). As we confirmed that there were no major blood vessels around the AS on computed tomography (Fig. 1b), ERP using an injection needle (23-G TOP endoscopic injection needle; TOP, Tokyo, Japan) was performed. Four punctures were required for ERP and dilatation of the MPD was observed (Fig. 2b). The AS was incised using a needle knife (KD-1L-1; Olympus Medical Systems) (Fig. 2c). After incision of the AS and guidewire placement, it was dilated using a dilator (ES dilator; Zeon Medical, Tokyo, Japan) and a 5-Fr × 5-cm pancreatic stent (Advanix Pancreatic Stent; Boston Scientific Japan, Tokyo, Japan) was placed without adverse events (Fig. 2d) (Video S1). For CAO in PJS, endoscopic ultrasound-guided pancreatic duct drainage is preferred because endoscopic pancreatic stenting under ERP (EPS) is technically challenging.1-3 However, EPS has the advantage that it can be safely performed using a physiological route.4 Similar to our technique, for CAO in hepaticojejunostomy, cholangiography and guidewire placement were simultaneously performed through a 20-G injection needle, and the access route to the bile duct was secured using a diathermic dilator via a guidewire.5 This technique should also be considered because it does not involve a blind incision with the risk of perforation. EPS using these techniques may be a treatment option for CAO. This study was conducted in accordance with the ethical standards described in the latest revision of the Declaration of Helsinki. Informed consent for patient participation and publication was received. All data relevant to the study are included in the article. Authors declare no conflict of interest for this article. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Safety and efficacy of EUS-guided pancreatic duct drainage in symptomatic main pancreatic duct obstruction: Is there still a place for surgery?

Abstract Background and study aims In patients with symptomatic dilation of the main pancreatic duct (MPD) for whom endoscopic retrograde cholangiopancreatography (ERCP) is impossible, surgery has long been the only available treatment. EUS-PD is described as a minimally invasive alternative for ductal decompression surgery. We describe the results of our experience with it. Patients and methods This was a retrospective single-center study over 9 years. Twenty-seven patients, median age 61.8 years (range 36 to 85) who underwent EUS-PD for symptomatic MPD dilatation were included. The main objective was to evaluate the technical success (placement of a plastic stent between the stomach and the MPD). Secondary objectives were to document clinical success based on pain and quality of life (visual analogic scales and treatments) and complication rates, and to define a standardized management algorithm. Results The technical success rate was 92.5 %. The rate of minor adverse events was 21 % (4 cases of non-specific postoperative pain and two cases of delayed benign edematous pancreatitis). The clinical success rate was 88 %, and half of patients in whom the procedure was successful had "complete regression" of pain and half "partial regression." Median follow-up was 34.2 months (range 4 to 108). During follow-up, 74 % of patients reported improvement in quality of life and no patients required secondary surgery. Conclusion Provided it is performed in an expert center, EUS-PD is a minimally invasive, effective, and safe alternative to pancreatic surgical drainage in patients with symptomatic MPD dilatation with failure or in whom ERCP is impossible.

EUS-guided drainage for a non-dilated pancreatic duct using a re-puncture technique in a patient with stricture-related pancreatitis (with video).

Highlight EUS-guided pancreatic duct drainage has emerged as an effective method for the treatment of post-pancreaticojejunostomy anastomotic stricture, but cases with non-dilated pancreatic duct usually represent a great challenge. Fujigaki and colleagues demonstrate the feasibility of EUS-guided pancreatic duct drainage with the re-puncture technique in a case with non-dilated pancreatic duct.

Piercing technique for recanalization of pancreaticojejunal obstruction through the endoscopic ultrasound-guided pancreatic duct drainage route

Piercing technique for recanalization of pancreaticojejunal obstruction through the endoscopic ultrasound-guided pancreatic duct drainage route

Efficacy and safety of endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD): A systematic review and meta-analysis of 714 patients.

Background and study aims  Endoscopic ultrasound guided pancreatic duct drainage (EUS-PDD) is a minimal-invasive therapeutic option to surgery and in patients with failed endoscopic retrograde pancreatography (ERP). The aim of this review was to quantitatively appraise the clinical outcomes of EUS-PDD by meta-analysis methods. Methods  We searched multiple databases from inception through March 2020 to identify studies that reported on EUS-PDD. Pooled rates of technical success, successful drainage of pancreatic duct, clinical success, and adverse events were calculated. Study heterogeneity was assessed using I 2 % and 95 % prediction interval. Results  A total of 22 studies (714 patients) were included. The pooled rate of technical success in EUS-PDD was 84.8 % (95 % CI 79.1–89.2). The pooled rate of successful PD drained by EUS-PDD was 77.5 % (95 % CI 63.1–87.4). The pooled rate of clinical success of EUS-PDD was 89.2 % (95 % CI 82.1–93.7). The pooled rate of all adverse events was 18.1 % (95 % CI 14.2–22.9). On sub-group analysis, the pooled technical success and clinical success of EUS-PDD from Japanese data were considerably superior (91.2 %, 83–95.6 & 92.5 %, 83.9–96.7, respectively). The pooled rate of post EUS-PDD acute pancreatitis was 6.6 % (95 % CI 4.5–9.4), bleeding was 4.1 % (95 % CI 2.7–6.2), perforation and/or pneumoperitoneum was 3.1 % (95 % CI 1.9–5), pancreatic leak and/or pancreatic fluid collection was 2.3 % (95 % CI 1.4–4), and infection was 2.8 % (95 % CI 1.7–4.6). Conclusion  EUS-PDD demonstrates high technical success and clinical success rates with acceptable adverse events. Technical success was especially high for anastomotic strictures.