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DOI: 10.1055/s-0043-110666
Advanced technique for the treatment of chronic calculous pancreatitis using endoscopic ultrasound-guided pancreatic duct drainage
Corresponding author
Publication History
Publication Date:
14 June 2017 (online)
A 64-year-old man who underwent distal gastrectomy with Billroth II reconstruction for duodenal ulcer perforation was hospitalized for painful chronic pancreatitis. The recurrent pain was caused by calculous obstruction of the pancreatic duct, resulting in upstream ductal hypertension. Computed tomography showed stones and a dilated main pancreatic duct (MPD) ([Fig. 1]).
We performed endoscopic retrograde pancreatography (ERP); however, we could not insert the guidewire deeply ([Fig. 2]). Therefore, we tried endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD). However, the guidewire could not be advanced across the papilla and tended to coil within the MPD. Hence, a fully covered metal stent was placed from the MPD to the stomach ([Fig. 3]).
After the fistula had matured, we again attempted guidewire advancement, which was difficult. Therefore, an intraductal pancreatoscope (IDP; SpyGlass DS system; Boston Scientific Corp., Natick, Massachusetts, USA) was inserted through the pancreatogastrostomy to facilitate direct visualization. The IDP image indicated complete obstruction of the MPD by the stones. Therefore, electrohydraulic lithotripsy (EHL; Lithotron EL 27 Compact; Walz Elektronik, Rohrdorf, Germany) was performed. The stones could be fragmented, allowing the guidewire to be negotiated through the minor papilla ([Fig. 4]; [Video 1]). We exchanged the scope for a colonoscope, dilated the minor papilla using a balloon up to 4 mm, and finally placed a 7 Fr single-pigtail stent from the minor papilla to the fistula using a rendezvous technique ([Fig. 5]). There were no adverse events.
Video 1 The metal stent was easily removed. The intraductal pancreatoscope was inserted through the pancreatogastrostomy. The images show complete obstruction of the main pancreatic duct by pancreatic stones. Electrohydraulic lithotripsy was performed to fragment the stones. Finally, the guidewire could be negotiated through the minor papilla.
Quality:
Although ERP is the conventional method for treating pancreatic ductal obstruction, it is sometimes challenging in patients with tight stenosis, complete ductal obstruction, or surgically altered anatomy [1]. Recently, EUS-PD has been reported to be useful in such cases [2] [3] [4] [5]. We report a first case: after formation of the EUS-PD fistula, EHL was easily performed using an IDP inserted via the pancreatogastrostomy. Our approach and treatment method could become one of the choices for such patients.
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Competing interests
None
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References
- 1 Widmer J, Sharaiha RZ, Kahaleh M. Endoscopic ultrasonography-guided drainage of the pancreatic duct. Gastrointest Endosc Clin N Am 2013; 23: 847-861
- 2 Chen YI, Levy MJ, Moreels TG. et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc 2017; 85: 170-177
- 3 Oh D, Park do H, 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
- 4 Tyberg A, Sharaiha RZ, Kedia P. et al. EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: a multicenter international collaborative study. Gastrointest Endosc 2017; 85: 164-169
- 5 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
Corresponding author
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References
- 1 Widmer J, Sharaiha RZ, Kahaleh M. Endoscopic ultrasonography-guided drainage of the pancreatic duct. Gastrointest Endosc Clin N Am 2013; 23: 847-861
- 2 Chen YI, Levy MJ, Moreels TG. et al. An international multicenter study comparing EUS-guided pancreatic duct drainage with enteroscopy-assisted endoscopic retrograde pancreatography after Whipple surgery. Gastrointest Endosc 2017; 85: 170-177
- 3 Oh D, Park do H, 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
- 4 Tyberg A, Sharaiha RZ, Kedia P. et al. EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: a multicenter international collaborative study. Gastrointest Endosc 2017; 85: 164-169
- 5 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