Endoscopic ultrasonography-guided pancreaticoduodenostomy with a lumen-apposing metal stent to treat main pancreatic duct dilatation

A 60-year-old woman was referred to our hospital for work-up of a mass in the pancreas with main pancreatic duct (MPD) dilatation. She had no symptoms, but had a history of abnormal glucose tolerance for 2 years. A contrast-enhanced computed tomography (CT) scan showed a low density mass with scattered contrast enhancement in the pancreatic head and dilatation of the distal MPD ([Fig. 1]). Endoscopic ultrasonography (EUS) revealed a multilocular cyst with microcysts in the area, which was compressing the MPD and causing the MPD dilatation ([Fig. 2]). The lesion was eventually diagnosed as a serous cystadenoma and was observed with regular imaging tests.

Fig. 1 Contrast-enhanced computed tomography image showing a low density mass with scattered contrast enhancement in the pancreatic head (arrowhead) and dilatation of the distal main pancreatic duct (arrows).

Fig. 2 Endoscopic ultrasonography image showing a multilocular cyst with microcysts in the pancreatic head (arrowhead) and dilatation of the distal main pancreatic duct (arrows).

Over a period of 4 years, the MPD dilatation and atrophy of the pancreatic body and tail gradually progressed ([Fig. 3]) and her glucose tolerance tests worsened. Because pancreaticoduodenectomy was judged to be too invasive, endoscopic ultrasonography-guided pancreaticoduodenostomy (EUS-PDS) using a lumen-apposing metal stent (LAMS) was scheduled, with her written informed consent, as a minimally invasive alternative.

Fig. 3 Magnetic resonance image showing cystic main pancreatic duct dilatation (arrow) and atrophy of the pancreatic body and tail 4 years after the initial diagnosis.

After inserting an echoendoscope to the bulb of the duodenum, we saw remarkable MPD dilatation, with the appearance of a cyst measuring 4.2 × 4.8 cm at the pancreatic head, adjacent to the duodenum; a safe puncture route was confirmed. Thereafter, a skilled endoscopist punctured the MPD with cautery assistance and a LAMS was placed within 80 seconds and without adverse events ([Video 1]). CT images 2 months after the procedure confirmed decompression of the MPD had been achieved ([Fig. 4]) and this was sustained without adverse events 3 months after endoscopic removal of the LAMS ([Fig. 5]).

Video 1 Endoscopic ultrasonography-guided pancreaticoduodenostomy using a lumen-apposing metal stent for the treatment of cystic main pancreatic duct dilatation.

Fig. 4 Contrast-enhanced computed tomography image 2 months after the procedure showing decompression of the main pancreatic duct.

Fig. 5 Magnetic resonance image 3 months after endoscopic removal of the lumen-apposing metal stent showing the sustained decompression of the main pancreatic duct (arrow).

EUS-guided pancreatic duct drainage, including by EUS-PDS, is one of the methods of endoscopic pancreatic duct drainage and has been used for MPD dilatation due to pancreatitis, pancreatic fistulas, or postoperative anastomotic strictures [1] [2] [3] [4]. This is the first case reported with a serous cystadenoma and cystic MPD dilatation for which EUS-PDS was feasible and available. This therapy is minimally invasive and could provide a new option for patients with MPD dilatation before pancreatic resection.

Endoscopy_UCTN_Code_TTT_1AS_2AD

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Krafft MR, Nasr JY. Anterograde endoscopic ultrasound-guided pancreatic duct drainage: a technical review. Dig Dis Sci 2019; 64: 1770-1781
• 2 Zein CO, Baron TH, Morgan DE. Endoscopic pancreaticoduodenostomy for treatment of pancreatic duct disconnection because of severe acute pancreatitis. Gastrointest Endosc 2003; 58: 130-134
• 3 Arvanitakis M, Delhaye M, Bali MA. et al. Endoscopic treatment of external pancreatic fistulas: when draining the main pancreatic duct is not enough. Am J Gastroenterol 2007; 102: 516-524
• 4 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. Gastrointest Endosc 2016; 83: 366-373

Publication History

Article published online:
30 March 2021