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Endoscopy
Endoscopy
10.1055/s-00000012
Endoscopy
Endoscopy
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10.1055/a-2334-0926
E-Videos-2024-03-4891-EV
E-Videos
Pancreatic duct occlusion after endoscopic ultrasound-guided transmural pancreatic duct drainage: a pitfall and its rescue technique
Gerodias Anthony Rivera Dr. MD
http://orcid.org/0000-0003-1372-166X
Ohno Akihisa Dr. MD
Komori Yasuhiro Dr.
Minoda Yosuke Dr.
Ueda Keijiro Dr.
Moriyama Tomohiko Dr.
Fujimori Nao MD, PhD
1 Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
2 37064 Institute of Digestive and Liver Diseases, Department of Medicine, Saint Lukeʼs Medical Center, Quezon City, Philippines
3 145181 International Medical Department, Kyushu University Hospital, Fukuoka, Japan
Correspondence Nao Fujimori, MD, PhD Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University3-1-1 Maidashi Higashi-kuFukuoka 812-8582Japanfujimori.nao.239@m.kyushu-u.ac.jp
01 7 2024
12 2024
1 7 2024
56 Suppl 1 E544E545
The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
2024
The Author(s).
https://creativecommons.org/licenses/by/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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pmc Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a procedure to access the pancreatic duct in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) 11 22 . In patients with surgically altered anatomy, transmural drainage is the preferred technique 33 . A single-pigtail plastic stent designed for EUS-PDD has been developed with favorable outcomes 44 ( Fig. 1Fig. 1 ).

Fig. 1 Fig. 1 Single-pigtail plastic pancreatic duct stent designed for endoscopic ultrasound-guided pancreatic duct drainage.

A 58-year-old man with a history of pancreatic cancer who underwent pylorus-preserving pancreaticoduodenectomy 14 years previously was admitted to our institution for recurrent acute pancreatitis. Computed tomography revealed no recurrence of malignancy, pancreatic duct dilatation, or obstruction. To assess the pancreatic duct-jejunal anastomotic site, balloon ERCP was performed. The anastomotic site could not be identified, hence we performed EUS-PDD and inserted a single-pigtail stent (7 Fr, 14 cm, Type IT; Gadelius, Tokyo, Japan).

Post-procedure he developed severe abdominal pain with elevated pancreatic enzymes, leading to a diagnosis of acute pancreatitis. Evaluation presumed pancreatic duct occlusion from the stent location. A rescue procedure was performed via balloon ERCP, identifying the pancreatic duct from the distal end of the stent followed by dilatation using a balloon dilation device (4mm, REN; Kaneka, Tokyo, Japan). Finally, a single-pigtail stent was inserted (4 Fr, 5 cm; Gadelius) ( Fig. 2Fig. 2 a–f , Video 1Video 1 ). The procedure was successful, and he was discharged with no further recurrence of pancreatitis.

Fig. 2 Fig. 2a Endoscopic view of pancreatic stent protruding from jejunal-pancreatic duct anastomotic site. b Fluoroscopic view of endoscope accessing the pancreatic stent from jejunal-pancreatic duct anastomotic site. c Endoscopic view of mechanical dilatation of the pancreatic duct. d Fluoroscopic view of mechanical dilatation of the pancreatic duct. e Endoscopic view of post-insertion of additional pancreatic stent. f Fluoroscopic view post-insertion of additional pancreatic stent.

Endoscopic ultrasound-guided pancreatic duct drainage following failure of balloon endoscopic retrograde cholangiopancreatography. Stent insertion was completed; however, the patient developed acute pancreatitis post-procedure and hence a rescue procedure was performed.

Video 1

Video 1

We determined three contributing factors that caused ductal occlusion: the pancreatic duct was not dilated, the puncture site was near the anastomotic site, and hence the stent drainage holes were located outside the pancreatic duct ( Fig. 3Fig. 3 a–d ).

Fig. 3 Fig. 3a Endoscopic view of pancreatic stent from the gastric side with side holes visible outside the pancreatic duct. b Endoscopic view of pancreatic stent from jejunal side with side holes visible outside the pancreatic duct. c Computed tomography image of puncture site with an illustration of the stent in place. d Illustration representing puncture site and position of pancreatic stent.

To our knowledge, this is the first report of duct occlusion occurring after EUS-PDD. In conclusion, careful consideration of the puncture site and awareness of the side hole location are key for prevention. Additionally, a rescue procedure is feasible with insertion of an additional stent for optimal drainage.

Endoscopy_UCTN_Code_CPL_1AL_2AD

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E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/ ). This section has its own submission website at https://mc.manuscriptcentral.com/e-videos .

Conflict of Interest The authors declare that they have no conflict of interest.
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References

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2 van der Merwe SW van Wanrooij RLJ Bronswijk M Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) Guideline Endoscopy 2022 54 185 205 10.1055/a-1717-1391 34937098
3 Matsunami Y Itoi T EUS-PD for Pancreaticojejunostomy Stricture Singapore Springer Nature Singapore Pte Ltd 2022 95 99
4 Itoi T Sofuni A Tsuchiya T Initial evaluation of a new plastic pancreatic duct stent for endoscopic ultrasonography-guided placement Endoscopy 2015 47 462 465 10.1055/s-0034-1391083 25590174
