EUS-assisted rendezvous stenting of the pancreatic duct for chronic calcifying pancreatitis with multiple pseudocysts

Abstract

Introduction: The best choice of endoscopic drainage of pancreatic pseudocysts complicating chronic pancreatitis is currently unknown, with EUS-guided transmural drainage competing with ERCP transpapillary techniques. However, recent studies currently recommend the use of both techniques in complex cases.

Case presentation: We present the case of a 60-year-old male patient with chronic calcifying pancreatitis, with severe ductal obstruction and multiple communicating pancreatic pseudocysts. The patient presented in the emergency department with weight loss, jaundice, steatorrhea and diabetes. Initial imaging evaluation (by transabdominal US, EUS and MRCP) depicted a dilated common bile duct, intrahepatic bile ducts and dilated main pancreatic duct (up to 1 cm) with multiple stones, as well as three pseudocysts at the level of the pancreatic head and one pseudocyst at the level of the pancreatic tail. ERCP with direct cannulation and transpapillary drainage of the bile duct or pancreatic duct was unsuccessful. Consequently, a EUS-assisted rendezvous stenting of the pancreatic duct was done, with the transpapillary placement of a 5-cm stent. Biliary cannulation was also possible with the placement of a double pigtail 9-cm stent in the common bile duct. Subsequent evolution was rapidly favorable with the disappearance of the pancreatic pseudocysts on the control CT after 24 h.

Conclusion: Our case clearly showed the benefit of combined draining procedures even in cases of chronic pancreatitis with multiple pseudocysts where surgical drainage was previously deemed necessary.