Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: Techniques and Literature Review of Transmural Stenting

Abstract

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an option in patients with failure of retrograde access to the pancreatic duct (PD) because of difficulty in cannulation or surgically altered anatomy. This article provides a comprehensive review of the techniques and outcomes of EUS-PD, especially EUS-guided pancreatic transmural stenting. The clinical data derived from a total of 401 patients were reviewed in which the overall technical and clinical success rates were 339/401 (85%, range 63%-100%) and 328/372 (88%, range 76%-100%), respectively. Short-term adverse events occurred in 25% (102/401) of the cases, which included abdominal pain (n=45), acute pancreatitis (n=17), bleeding (n=10), and issues associated with pancreatic juice leakage such as perigastric or peripancreatic fluid collection (n=9). In conclusion, although EUS-PD remains a challenging procedure with a high risk of adverse events such as pancreatic juice leakage, perforation, and severe acute pancreatitis, the procedure seems to be a promising alternative for PD drainage in patients with altered anatomy or unsuccessful endoscopic retrograde pancreatography.

Keywords: Drainage; Endoscopic ultrasound; Pancreatic; Post-surgery; Stent.

Fig. 1.

Technique of endoscopic ultrasound-guided rendezvous. (A) The contrast agent is injected after puncturing the main pancreatic duct. (B) Attempts are made to advance the guidewire in an antegrade fashion across the stricture site into the intestine. (C) A duodenoscope is inserted into the level of the ampulla of Vater, and the guidewire is grasped. (D, E) After the guidewire is pulled into the duodenoscope, cannulation into the main pancreatic duct and stenting are performed in retrograde fashion.

Fig. 2.

Technical tips for endoscopic ultrasound-guided pancreatic transmural stenting. (A) The main pancreatic duct is punctured with a 19-G needle and confirmed by injection of contrast medium. (B) A guidewire is advanced into the main pancreatic duct. (C) The tract fistula is dilated using a balloon dilator. (D) Antegrade stent deployment is performed.

Fig. 3.

REN (KANEKA Medics, Osaka, Japan). This balloon catheter is characterized by a 3 Fr ultra-tapered tip and coaxial guidewire followability.

Fig. 4.

Fine 025 (Medico’s HIRATA Inc., Osaka, Japan). The distal end of this diathermic dilator is only 3 Fr, and it contains a metal tip. This catheter is coaxial with a guidewire and can be useful for tract dilation in a severely fibrotic pancreas.

Fig. 5.

ES dilator (Zeon Medical Co., Tokyo, Japan). This mechanical dilator can be pushed to a greater degree and exhibits only a small difference in the diameter of the inner lumen and the guidewire.

Fig. 6.

TYPE IT (Gadelius Medical Co., Tokyo, Japan). This 7 Fr single pigtail type plastic stent has a total length of 20 cm and an effective length of 15 cm. The length and a pigtail anchor together with its four flanges are effective in preventing stent migration.