Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct

Abstract

Aim: To evaluate the use of translumenal pancreatography with placement of endoscopic ultrasonography (EUS)-guided drainage of the pancreatic duct.

Methods: This study enrolled all consecutive patients between June 2002 and April 2014 who underwent EUS-guided pancreatography and subsequent placement of a drain and had symptomatic retention of fluid in the pancreatic duct after one or more previous unsuccessful attempts at endoscopic retrograde cannulation of the pancreatic duct. In all, 94 patients underwent 111 interventions with one of three different approaches: (1) EUS-endoscopic retrograde drainage with a rendezvous technique; (2) EUS-guided drainage of the pancreatic duct; and (3) EUS-guided, internal, antegrade drainage of the pancreatic duct.

Results: The mean duration of the interventions was 21 min (range, 15-69 min). Mean patient age was 54 years (range, 28-87 years); the M:F sex ratio was 60:34. The technical success rate was 100%, achieving puncture of the pancreatic duct including pancreatography in 94/94 patients. In patients requiring drainage, initial placement of a drain was successful in 47/83 patients (56.6%). Of these, 26 patients underwent transgastric/transbulbar positioning of a stent for retrograde drainage; plastic prostheses were used in 11 and metal stents in 12. A ring drain (antegrade internal drainage) was placed in three of these 26 patients because of anastomotic stenosis after a previous surgical intervention. The remaining 21 patients with successful drain placement had transpapillary drains using the rendezvous technique; the majority (n = 19) received plastic prostheses, and only two received metal stents (covered self-expanding metal stents). The median follow-up time in the 21 patients with transpapillary drainage was 28 mo (range, 1-79 mo), while that of the 26 patients with successful transgastric/transduodenal drainage was 9.5 mo (range, 1-82 mo). Clinical success, as indicated by reduced or absence of further pain after the EUS-guided intervention was achieved in 68/83 patients (81.9%), including several who improved without drainage, but with manipulation of the access route.

Conclusion: EUS-guided drainage of the pancreatic duct is a safe, feasible alternative to endoscopic retrograde drainage when the papilla cannot be reached endoscopically or catheterized.

Keywords: Clinical success; Endoscopic ultrasonography; Endoscopic ultrasonography-guided drainage of the pancreatic duct; Endoscopic ultrasonography-guided transmural pancreatography; Metal stent; Plastic prosthesis; Prospective, long-term, single-center study; Technical success.

Figure 1

Patient with dilated pancreatic duct, recurrent pancreatitis, and pancreas divisum in whom endoscopic retrograde cholangiopancreatography has failed. A: After endoscopic ultrasonography-guided puncture and administration of contrast medium, imaging of the pancreatic duct under fluoroscopic control shows there is almost no outflow of contrast medium out of the minor papilla; B: The guide wire is advanced into the pancreatic duct and through and out of the minor papilla; C: After changing to a duodenoscope, the guide wire was identified and an extending papillotomy was performed using a conventional technique; D: An 11.5-Fr. prosthesis is placed into the minor papilla, with subsequent adequate outflow of contrast medium.

Figure 2

Will’s high-frequency ring knife (MTW-Endoskopie, Wesel, Germany). The inset top left shows the tip of the device, enlarged.

Figure 3

Patient with recurrent episodes of severe chronic pancreatitis and manifested retention of fluid in the pancreatic duct against a background of pancreatolithiasis in whom endoscopic retrograde cholangiopancreatography failed. A: Endoscopic ultrasonography-guided puncture of the clearly dilated pancreatic duct; B: Pancreatography showed complete obturation of the pancreatic duct; C: After failure to advance the guide wire through and out of the papilla, a 10 mm × 10 mm AXIOS^TM stent was released and the position of the intraductal part of the stent checked by endoscopic ultrasonography; D: The intragastric part of the AXIOS^TM stent with secreted opaque pancreatic juice flowing into the gastric lumen.

Figure 4

Patient with anastomotic stenosis and painful retention in the pancreatic duct after previous resection of the pancreatic head for a metastasis of bronchial carcinoma. A: After endoscopic ultrasonography-guided puncture and pancreatography, retention of fluid in the pancreatic duct is revealed - there is no flow of contrast through the stenotic anastomosis; B: The guide wire is advanced through the anastomotic stenosis; C: Balloon dilatation of the anastomotic stenosis up to 8 mm; D: Transgastric implantation of a 7-Fr double-pigtail prosthesis as a so-called “ring drainage” (gastropancreatojejunostomy).

Figure 5

Overview of the endoscopic ultrasonography-guided interventions of the pancreatic duct performed at the Gera Municipal Hospital from June 2002 to April 2014. EUS: Endoscopic ultrasonography; SEM: Self-expanding metal stent.

Figure 6

Treatment algorithm for patients with symptomatic retention in the pancreatic duct. ERC: Endoscopic retrograde cholangiography; DPTS: Disconnected pancreatic tail syndrome; EUS: Endoscopic ultrasonography; EUS-RT: EUS-guided rendezvous technique.