Endoscopic Ultrasound-guided Pancreatic Duct 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.

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.

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.

Percutaneous transluminal angioplasty balloons for endoscopic ultrasound-guided pancreatic duct interventions.

BACKGROUNDEndoscopic ultrasound (EUS)-guided main pancreatic duct (PD) access may be used when conventional endoscopic retrograde cholangiopancreatography (ERCP) techniques fail. The use of a percutaneous transluminal angioplasty balloon (PTAB), originally developed for vascular interventions, can be used to facilitate transmural (e.g., transgastric) PD access and to dilate high-grade pancreatic strictures.AIMTo describe the technique, efficacy, and safety of PTABs for EUS-guided PD interventions.METHODSPatients who underwent EUS with use of a PTAB from March 2011 to August 2021 were retrospectively identified from a tertiary care medical center supply database. PTABs included 3-4 French angioplasty catheters with 3-4 mm balloons designed to use over a 0.018-inch guidewire. The primary outcome was technical success. Secondary outcomes included incidence of adverse events (AEs) and need for early reintervention. RESULTSA total of 23 patients were identified (48% female, mean age 55.8 years). Chronic pancreatitis was the underlying etiology in 13 (56.5%) patients, surgically altered anatomy (SAA) with stricture in 7 (30.4%), and SAA with post-operative leak in 3 (13.0%). Technical success was achieved in 20 (87%) cases. Overall AE rate was 26% (n = 6). All AEs were mild and included 1 pancreatic duct leak, 2 cases of post-procedure pancreatitis, and 3 admissions for post-procedural pain. No patients required early re-intervention.CONCLUSIONEUS-guided use of PTABs for PD access and/or stricture management is feasible with an acceptable safety profile and can be considered in patients when conventional ERCP cannulation fails.

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.

Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage

Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage

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.

Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: Techniques and Literature Review of Transmural Stenting.

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an option in patients with failure of retrograde access to the pancreatic duct (PD) because of difficulty in cannulation or surgically altered anatomy. This article provides a comprehensive review of the techniques and outcomes of EUS-PD, especially EUS-guided pancreatic transmural stenting. The clinical data derived from a total of 401 patients were reviewed in which the overall technical and clinical success rates were 339/401 (85%, range 63%–100%) and 328/372 (88%, range 76%–100%), respectively. Short-term adverse events occurred in 25% (102/401) of the cases, which included abdominal pain (n=45), acute pancreatitis (n=17), bleeding (n=10), and issues associated with pancreatic juice leakage such as perigastric or peripancreatic fluid collection (n=9). In conclusion, although EUS-PD remains a challenging procedure with a high risk of adverse events such as pancreatic juice leakage, perforation, and severe acute pancreatitis, the procedure seems to be a promising alternative for PD drainage in patients with altered anatomy or unsuccessful endoscopic retrograde pancreatography.

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

Endoscopic endgame for obstructive pancreatopathy: outcomes of anterograde EUS-guided pancreatic duct drainage. A dual-center study

Anterograde endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) refers to transmural drainage of the main pancreatic duct via an endoprosthesis passed anterograde through the gastric (or intestinal) wall. Anterograde EUS-PDD is a rescue procedure for recalcitrant cases of benign obstructive pancreatopathy. We conducted a dual-center retrospective chart review of 28 patients (mean age, 59 years; 50% female) who underwent attempted anterograde EUS-PDD between April 2016 and September 2019 for chronic pancreatitis (CP) (93%) or pancreaticojejunostomy stenosis (PJS) after Whipple resection (7%). The study endpoint was achievement of transpapillary/transanastomotic drainage (definitive therapy). Gastropancreaticoenterostomy (ring drainage, definitive therapy) was successfully performed during the index procedure in the 2 patients with PJS (technical success, 100%). Clinical success was 100% in the 2 ring drainage recipients during a mean 18-month follow-up period. The remaining 26 patients with CP underwent attempted pancreaticogastrostomy (PG) with 81% technical success, 75% clinical success, and 15% adverse events (AEs). Repeat endoscopic transmural interventions were performed in the 15 patients with clinical success after PG creation. Definitive therapy transpired in all 15 patients after a median 1 repeat procedure per patient. Clinical success after definitive therapy was maintained in all 15 patients (100%) during a median 4.5-month follow-up. In agreement with previous studies, our study showed mild to moderately high rates of technical failure (19%), clinical failure (25%), and AEs (15%) during index drainage (PG creation). Among patients with CP with both technical and clinical success after index PG creation (n= 15), 100% definitive therapy was achieved and clinical outcomes were excellent (100% clinical success, 0% AEs).

Endoscopic ultrasound-guided pancreatic duct intervention and pancreaticogastrostomy using a novel cross-platform technique with small-caliber devices.

Background and study aims Endoscopic ultrasound (EUS)-guided pancreaticogastrostomy (PG) has been used as an alternative to surgery to drain pancreatic ducts for treatment of disconnected pancreatic duct syndrome (DPDS). Previous techniques involved using needle-knife cautery, bougie dilation or a stent extraction screw to allow stent passage through the gastric wall and pancreatic parenchyma, with potential for severe complications including duct leak, especially if drainage fails. A novel technique employing EUS guided puncture of the main pancreatic duct (MPD) with a 19- or a 22-gauge needle, passage of an 0.018-guidewire, dilation of the tract with a small-diameter (4 F) angioplasty balloon and placement of 3F plastic stents with the pigtail curled inside the duct as an anchor. Methods This is a retrospective case series at a single tertiary center. EUS-guided PG was considered when conventional endoscopic pancreatic duct drainage failed. Main outcomes included technical and clinic success and complications. Results Eight patients underwent PG. Indications were DPDS (n = 4), stenotic pancreaticoenteral anastomosis after Whipple procedure (n = 3) and chronic pancreatitis with dilated MPD (n = 1). Median MPD diameter was 6.75 mm [IQR 2.8 – 7.6]. Technical success was achieved in seven of eight cases (88 %); angioplasty balloon passed into the pancreatic duct in all accessed ducts. There was one asymptomatic duct leak, and no major or delayed complications, with clinical improvement (complete or partial) in five of eight (71 %). Conclusions EUS-guided PG using a small-caliber guidewire, 4F angioplasty balloon, and reverse 3F single pigtail stents offers a safe and atraumatic alternative without use of cautery.

Long-term outcome of endoscopic ultrasound-guided pancreatic duct drainage using a fully covered self-expandable metal stent for pancreaticojejunal anastomosis stricture.

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has been proposed for pancreatic duct obstruction after failure of endoscopic retrograde pancreatography. We evaluate the long-term outcomes of EUS-PD using a fully covered self-expandable metal stent (FCSEMS) for pancreaticojejunal anastomosis (PJA) strictures following Whipple procedures. Twenty-three patients with PJA strictures underwent EUS-PD according to the findings of EUS-guided pancreatogram and the passage of the guidewire through PJA stricture (complete vs partial stricture) after failure of endoscopic retrograde pancreatography. Technical and clinical success, adverse events (AEs), and long-term outcomes were assessed. Technical and clinical success was achieved in all patients. The complete and partial strictures were 11 and 12, respectively. The direct transanastomotic and transmural plastic stenting in partial PJA stricture was successful in only three patients (13%). Therefore, 20 patients underwent EUS-guided transmural FCSEMS placement during the initial attempt. Early AEs, including abdominal pain (n=3) and peripancreatic fluid collection (n=1), occurred in four patients (17.4%). During the follow-up periods (median, 27.2months; interquartile range [IQR], 18.7-40.6), five patients (21.7%) developed late AEs, including asymptomatic stent fracture at the gastric end (n=3), asymptomatic stent migration (n=1), and stent occlusion (n=1). The total duration of stent placement was 27.2months (IQR, 18.7-40.6), and the median number of stent revision was 2 (IQR, 1-2). In terms of safety and efficacy, EUS-PD with an FCSEMS showed favorable success and acceptable AEs rate and durable long-term outcomes.

Endoscopic ultrasound-guided pancreatic duct stent placement for symptomatic pancreaticojejunostomy stricture.

Endoscopic ultrasound-guided pancreatic duct stent placement for symptomatic pancreaticojejunostomy stricture.

Tu1355 ANTEROGRADE ENDOSCOPIC ULTRASOUND-GUIDED PANCREATIC DUCT DRAINAGE: AN EFFECTIVE SALVAGE PROCEDURE FOR PANCREATIC DUCTAL OBSTRUCTION

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is indicated after failed endoscopic retrograde pancreatography (ERP) and is an alternative to enteroscopy assisted-endoscopic retrograde pancreatography (EA-ERP) in cases of surgically altered anatomy. Rendezvous-assisted ERP and anterograde EUS-PDD are the two predominant types of EUS-PDD. Rendezvous-assisted ERP is the preferred modality because it treats the underlying pathology and preserves native ductal anatomy, but it is technically limited when the papilla / anastomosis is endoscopically inaccessible or is impassable via anterograde guidewire insertion. Anterograde EUS-PDD refers to transmural stent placement and fistula formation (e.g., pancreaticogastrostomy), and is a “salvage” procedure after technical failure of rendezvous-assisted ERP. In this study, we investigated outcomes of the index anterograde EUS-PDD, indicated for pancreatic ductal decompression.

Endoscopic ultrasound-guided pancreatic duct drainage using a fine-gauge balloon catheter.

Endoscopic ultrasound-guided pancreatic duct drainage using a fine-gauge balloon catheter.

Anterograde Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: A Technical Review.

The advancement of pancreatic endotherapy has increased the availability of minimally invasive endoscopic pancreatic ductal drainage techniques. In this regard, familiarity with endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is critical for treatment of obstructed pancreatic ductal systems, especially in nonsurgical candidates and in patients desiring a minimally invasive approach. Two distinct forms of EUS-PDD exist, viz. rendezvous-assisted endoscopic retrograde pancreatography (rendezvous-assisted ERP) and anterograde EUS-PDD. Anterograde EUS-PDD refers to transmural anterograde passage of a pancreatic drainage catheter or stent directly into the main pancreatic duct, through either the gastric or enteral wall. Rendezvous-assisted ERP should be attempted after failed conventional ERP, and anterograde EUS-PDD should be considered if rendezvous-assisted ERP fails or is not technically feasible. Common clinical scenarios that fulfil these conditions are chronic pancreatitis with high-grade main pancreatic duct obstruction, surgically altered anatomy with ductal/anastomotic obstruction, pancreas divisum, and disconnected pancreatic duct syndrome. The focus of this review article is anterograde EUS-PDD and its indications, technique, and outcomes. It also provides a summary of our own experience with this procedure, and a video demonstration of the technique.