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

Abstract

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.

• References

• 1 Schlitt HJ, Schmidt U, Simunec D. et al. Morbidity and mortality associated with pancreatogastrostomy and pancreatojejunostomy following partial pancreatoduodenectomy. Br J Surg 2002; 89: 1245-1251
• 2 Yeo CJ, Cameron JL, Sohn TA. et al. Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes. Ann Surg 1997; 226: 248-257 ; discussion 257-260
• 3 Byrne RL, Gompertz RH, Venables CW. Surgery for chronic pancreatitis: a review of 12 years experience. Ann R Coll Surg Engl 1997; 79: 405-409
• 4 Kalady MF, Broome AH, Meyers WC. et al. Immediate and long-term outcomes after lateral pancreaticojejunostomy for chronic pancreatitis. Am Surg 2001; 67: 478-483
• 5 Dumonceau JM, Deviere J, Le Moine O. et al. Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results. Gastrointest Endosc 1996; 43: 547-555
• 6 Ponchon T, Bory RM, Hedelius F. et al. Endoscopic stenting for pain relief in chronic pancreatitis: results of a standardized protocol. Gastrointest Endosc 1995; 42: 452-456
• 7 Cremer M, Deviere J, Delhaye M. et al. Stenting in severe chronic pancreatitis: results of medium-term follow-up in seventy-six patients. Endoscopy 1991; 23: 171-176
• 8 Gabbrielli A, Pandolfi M, Mutignani M. et al. Efficacy of main pancreatic-duct endoscopic drainage in patients with chronic pancreatitis, continuous pain, and dilated duct. Gastrointest Endosc 2005; 61: 576-581
• 9 Rosch T, Daniel S, Scholz M. et al. Endoscopic treatment of chronic pancreatitis: a multicenter study of 1000 patients with long-term follow-up. Endoscopy 2002; 34: 765-771
• 10 Eleftherladis N, Dinu F, Delhaye M. et al. Long-term outcome after pancreatic stenting in severe chronic pancreatitis. Endoscopy 2005; 37: 223-230
• 11 Widmer J, Sharaiha RZ, Kahaleh M. Endoscopic ultrasonography-guided drainage of the pancreatic duct. Gastrointest Endosc Clin N Am 2013; 847-861
• 12 Tessier G, Bories E, Arvanitakis M. et al. EUS-guided pancreatogastrostomy and pancreatobulbostomy for the treatment of pain in patients with pancreatic ductal dilatation inaccessible for transpapillary endoscopic therapy. Gastrointest Endosc 2007; 65: 233-241
• 13 Wright BE, Cass OW, Freeman ML. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc 2002; 56: 225-232
• 14 Francois E, Kahaleh M, Giovannini M. et al. EUS-guided pancreaticogastrostomy. Gastrointest Endosc 2002; 56: 128-133
• 15 Kahaleh M, Yoshida C, Yeaton P. EUS antegrade pancreatography with gastropancreatic duct stent placement: Review of two cases. Gastrointest Endosc 2003; 58: 919-923
• 16 Will U, Meyer F, Manger T. et al. Endoscopic ultrasound-assisted rendezvous maneuver to achieve pancreatic duct drainage in obstructive chronic pancreatitis. Endoscopy 2005; 37: 171-173
• 17 Mallery S, Matlock J, Freeman ML. EUS-guided rendezvous drainage of obstructed biliary and pancreatic ducts: Report of 6 cases. Gastrointest Endosc 2004; 59: 100-107
• 18 Puri R, Choudhary NS, Kotecha H. et al. Pancreatic duct leak in a case of post Whipple surgery: Managed by endoscopic ultrasound guided pancreatogastrostomy. Endosc Ultrasound 2014; 3: 195-197
• 19 Katanuma A, Maguchi H, Fukazawa M. et al. Endoscopic ultrasonography-guided pancreaticogastrostomy for a case of occlusion of gastro-pancreatic anastomosis after pancreaticoduodenectomy. Dig Endosc 2009; 21 (Suppl. 01) S87-S91
• 20 James TW, Baron TH. Antegrade pancreatoscopy via EUS-guided pancreaticogastrostomy allows removal of obstructive pancreatic duct stones. Endosc Int Open 2018; 6: E735-E738
• 21 Kahaleh M, Hernandez AJ, Tokar J. et al. EUS-guided pancreaticogastrostomy: analysis of its efficacy to drain inaccessible pancreatic ducts. Gastrointest Endosc 2007; 65: 224-230
• 22 Oh D, Park DH, Cho MK. et al. Feasibility and safety of a fully covered self-expandable metal stent with antimigration properties for EUS-guided pancreatic duct drainage: early and midterm outcomes (with video). Gastrointest Endosc 2016; 83: 366-373 e362
• 23 Ergun M, Aouattah T, Gillain C. et al. Endoscopic ultrasound-guided transluminal drainage of pancreatic duct obstruction: long-term outcome. Endoscopy 2011; 43: 518-525
• 24 Cotton PB, Lehman G, Vennes J. et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991; 37: 383-393
• 25 Kinney TP, Li R, Gupta K. et al. Therapeutic pancreatic endoscopy after Whipple resection requires rendezvous access. Endoscopy 2009; 41: 898-901
• 26 Drewes AM, Bouwense SAW, Campbell CM. et al. Guidelines for the understanding and management of pain in chronic pancreatitis. Pancreatology 2017; 17: 720-731
• 27 Costamagna G, Bulajic M, Tringali A. et al. Multiple stenting of refractory pancreatic duct strictures in severe chronic pancreatitis: long-term results. Endoscopy 2006; 38: 254-259
• 28 Freeman ML, Cass OW, Dailey J. Dilation of high-grade pancreatic and biliary ductal strictures with small-caliber angioplasty balloons. Gastrointest Endosc 2001; 54: 89-92