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Wang SY, Zhao SQ, Wang SP, Zhang Y, Sun SY, Wang S. Endoscopic ultrasound-guided pancreatic duct drainage: Progress and future outlook. World J Gastrointest Surg 2025; 17:104267. [DOI: 10.4240/wjgs.v17.i5.104267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Revised: 02/28/2025] [Accepted: 04/02/2025] [Indexed: 05/23/2025] Open
Abstract
As an innovative endoscopic intervention, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) demonstrates significant clinical value in resolving pancreatic ductal hypertension syndrome. By integrating real-time ultrasound guidance with catheter-based intervention techniques, this approach provides a safe and effective alternative for cases where conventional endoscopic retrograde cholangiopancreatography has failed. Current evidence indicates that EUS-PD achieves technical success rates ranging from 82% to 95% in alleviating symptomatic pancreatic duct hypertension caused by malignant obstructions and chronic pancreatitis-related strictures, with an overall complication rate (15%-20%) substantially lower than surgical interventions. Compared to conventional imaging modalities, EUS-PD offers superior anatomical visualization capabilities: Its high-frequency ultrasound probe enables precise identification of 3 mm-level pancreatic duct branches, while contrast-enhanced imaging significantly improves diagnostic accuracy in differentiating benign from malignant strictures (sensitivity 91% vs 73%, P < 0.05). Nevertheless, technical challenges persist, including difficult ductal puncture localization (particularly in pancreatic head lesions), complex guidewire axial control, and postoperative pancreatic fistula risks (7%-12%). This review systematically examines the clinical indications/contraindications, procedural protocols, device selection criteria, and management strategies for early/late complications associated with EUS-PD. Special emphasis is placed on establishing anatomical pathway selection standards for transgastric-pancreatic duct vs transduodenal-pancreatic duct approaches. Advancements in auxiliary technologies (e.g., three-dimensional elastography, AI-assisted navigation) and multidisciplinary team collaboration are pivotal to developing standardized protocols. We propose establishing international multicenter registry databases and conducting prospective randomized controlled trials to clarify EUS-PD's position within pancreatic disease management systems. Such initiatives will facilitate the clinical transformation of EUS-PD from an "alternative option" to a "preferred strategy", ultimately enhancing treatment precision and improving clinical outcomes in pancreatic disorders.
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Affiliation(s)
- Si-Yao Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Si-Qiao Zhao
- Endoscopy Center, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Shu-Peng Wang
- Department of Gastroenterology, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Yue Zhang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Si-Yu Sun
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
| | - Sheng Wang
- Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, Liaoning Province, China
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Tomishima K, Isayama H, Suzuki A, Ishii S, Takahashi S, Fujisawa T. Technical review of endoscopic ultrasound-guided drainage/anastomosis and trans-endosonographically created route procedures for the treatment of pancreatic diseases. DEN OPEN 2025; 5:e393. [PMID: 38854708 PMCID: PMC11157673 DOI: 10.1002/deo2.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Accepted: 05/17/2024] [Indexed: 06/11/2024]
Abstract
Endoscopic ultrasound (EUS)-guided pancreatic duct drainage includes two procedures: EUS-guided drainage/anastomosis (EUS-D/A) and trans-papillary drainage with EUS-assisted pancreatic rendezvous. EUS-guided pancreatogastrostomy is the most common EUS-D/A procedure and is recommended as a salvage procedure in cases in which endoscopic retrograde cholangiopancreatography fails or is difficult. However, initial EUS-D/A is performed in patients with surgically altered anatomy at our institution. It is one of the most difficult interventional EUS procedures and has a high incidence of adverse events. The technical difficulties differ according to etiology, and the incidence of adverse events varies between initial EUS-D/A and subsequent trans-endosonographically/EUS-guided created route procedures. Hence, it is important to meticulously prepare a procedure based on the patient's condition and the available devices. The technical difficulties in EUS-D/A include: (1) determination of the puncture point, (2) selection of a puncture needle and guidewire, (3) guidewire manipulation, and (4) dilation of the puncture route and stenting. Proper technical procedures are important to increase the success rate and reduce the incidence and severity of adverse events. The complexity of EUS-D/A is also contingent on the severity of pancreatic fibrosis and stricture. In post-pancreatectomy cases, determination of the puncture site is important for success because of the remnant pancreas. Trans-endosonographically/EUS-guided created route procedures following initial EUS-D/A are also important for achieving the treatment goal. This article focuses on effective strategies for initial EUS-D/A, based on the etiology and condition of the pancreas. We mainly discuss EUS-D/A, including its indications, techniques, and success-enhancing strategies.
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Affiliation(s)
- Ko Tomishima
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Hiroyuki Isayama
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Akinori Suzuki
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Shigeto Ishii
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Sho Takahashi
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
| | - Toshio Fujisawa
- Department of GastroenterologyGraduate School of MedicineJuntendo UniversityTokyoJapan
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Wang R, Su T, Xu C, Xiao T, Xu H, Shi X, Zhao S. Endoscopic Ultrasound-guided Pancreatic Duct Drainage: A Systematic Review and Meta-analysis. Surg Laparosc Endosc Percutan Tech 2025; 35:e1359. [PMID: 40066712 DOI: 10.1097/sle.0000000000001359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 01/17/2025] [Indexed: 04/05/2025]
Abstract
BACKGROUND AND OBJECTIVES Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as a minimally invasive therapeutic option for patients who cannot undergo traditional retrograde access to the pancreatic duct due to difficulties in cannulation or surgically altered anatomy. This meta-analysis aimed to evaluate the overall outcomes and safety of EUS-PD. METHODS We conducted a comprehensive search of major databases, including PubMed, EMBASE, Cochrane Library, and Science Citation Index, up until October 2023. The meta-analysis focused on technical and clinical success rates, as well as the overall adverse event (AE) rate. RESULTS A total of 27 trials involving 902 patients were included in the study. The cumulative rate of technical success is 89%, and the clinical success is 88%, whereas the AE rate was 17%. The most common AE observed was post-EUS-PD acute pancreatitis, with a rate of 3%. In addition, the cumulative rates of bleeding, perforation, pancreatic leak, and infection were 2%, 2%, 1%, and 1%, respectively. CONCLUSION EUS-PD demonstrates highly favorable technical and clinical success rates, alongside acceptable AE rates, making it a highly effective procedure.
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Affiliation(s)
- Ruixia Wang
- Department of Gastroenterology, The Second People's Hospital of Liaocheng, Linqing
| | - Tong Su
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Changqin Xu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tong Xiao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Hongwei Xu
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiuju Shi
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shulei Zhao
- Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Gornals JB, Sumalla-Garcia A, Luna-Rodriguez D, Puigcerver-Mas M, Velasquez-Rodriguez JG, Salord S, Maisterra S, Busquets J. Long-term outcomes of endoscopic ultrasound-guided pancreatic duct interventions: A single tertiary center experience. GASTROENTEROLOGIA Y HEPATOLOGIA 2025; 48:502221. [PMID: 38906323 DOI: 10.1016/j.gastrohep.2024.502221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/08/2024] [Accepted: 06/11/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound-guided pancreatic duct intervention (EUS-PDI) is one of the most technically challenging procedures. There remains a knowledge gap due to its rarity. The aim is to report the accumulated EUS-PDI experience in a tertiary center. METHODS Single tertiary center, retrospective cohort study of prospectively collected data during the study period, from January 2013 to June 2021. RESULTS In total, 14 patients (85% male; mean age, 61 years, range 37-81) and 25 EUS-PDI procedures for unsuccessful endoscopic retrograde pancreatography (ERP) were included. Principal etiology was chronic pancreatitis with pancreatic duct obstruction (78%). EUS-guided assisted (colorant and/or guidewire, rendezvous) ERP was performed in 14/25 (56%); and transmural drainage in 11 procedures, including pancreaticogastrosmy in 9/25 (36%) and pancreaticoduodenostomy in 2/25 (8%). Overall technical and clinical success was 78.5% (11/14). Three (21%) patients required a second procedure with success in all cases. Two failed cases required surgery. Three (21%) adverse events (AEs) were noted (fever, n=1; perforation, n=1; pancreatitis, n=1). Patients underwent a median of 58 months (range 24-108) follow-up procedures for re-stenting. Spontaneous stent migration was detected in 50% of cases. CONCLUSIONS EUS-PDI is an effective salvage therapy for unsuccessful ERP, although 21% of patients may still experience AEs. In case of EUS-guided rendezvous failure, it can cross over to a transmural drainage.
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Affiliation(s)
- Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
| | - Albert Sumalla-Garcia
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Daniel Luna-Rodriguez
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Maria Puigcerver-Mas
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Julio G Velasquez-Rodriguez
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Silvia Salord
- Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain; Hepato-biliary-pancreatic Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Sandra Maisterra
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, L'Hospitalet de llobregat, Barcelona, Spain; Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain
| | - Juli Busquets
- Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain; Hepato-biliary-pancreatic Unit, Department of General Surgery, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Wahba G, Lee JH. Updates on therapeutic endoscopic ultrasound. Curr Opin Gastroenterol 2025; 41:16-28. [PMID: 39560626 DOI: 10.1097/mog.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2024]
Abstract
PURPOSE OF REVIEW Multiple endoscopic ultrasound (EUS) guided therapeutic interventions have been developed for the management of benign and malignant pancreaticobiliary and gastrointestinal luminal pathology. Recent high-quality evidence is increasingly validating these interventions and positioning them within evidence-based therapeutic algorithms. RECENT FINDINGS Here we review therapeutic EUS-guided interventions including pancreatic fluid collection drainage, gastroenterostomy, biliary drainage, pancreatic duct drainage and gallbladder drainage. The most up-to-date high-quality evidence supporting these interventions is presented including comparative data with other conventional treatment options. Newer emerging interventions such as tumor ablation are also reviewed. Current controversies and future avenues for research are discussed. The key role of EUS-guided interventions in managing pancreaticobiliary pathology in patients with a surgically altered anatomy is highlighted. SUMMARY Multiple EUS therapeutic interventions have evolved from experimental or rescue options to now well established first- and second-line interventions over other endoscopic, percutaneous and surgical alternatives with the support of high-quality data. Further research is needed to better optimize patient selection and guide long term postintervention follow-up.
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Affiliation(s)
- George Wahba
- Department of Gastroenterology, Hepatology & Nutrition, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Sadek A, Hara K, Okuno N, Haba S, Kuwahara T, Fukui T, Urata M, Kondo T, Yamamoto Y, Tachi K. Safety and efficacy of endoscopic ultrasound-guided pancreatic duct drainage using a drill dilator: a retrospective study in Japan. Clin Endosc 2024; 57:666-674. [PMID: 38919059 PMCID: PMC11474476 DOI: 10.5946/ce.2023.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/24/2023] [Accepted: 11/25/2023] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND/AIMS Dilation of the tract before stent deployment is a challenging step in endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD). In this study, we examined the effectiveness and safety of a novel spiral dilator, Tornus ES (Asahi Intec), for EUS-PDD. METHODS This was a retrospective, single-arm, observational study at Aichi Cancer Center Hospital. The punctured tract was dilated using a Tornus ES dilator in all EUS-PDD cases. Our primary endpoint was the technical success rate of initial tract dilation. Technical success was defined as successful fistula dilation using a Tornus ES followed by successful stent insertion. Secondary endpoints were procedure times and early adverse events. RESULTS A total of 12 patients were included between December 2021 and March 2023. EUS-PDD was performed in 11 patients for post-pancreaticoduodenectomy anastomotic strictures and one patient with pancreatitis with duodenal perforation. The technical success rates of stent insertion and fistula dilation using a Tornus ES dilator was 100%. The median procedure time was 24 minutes. No remarkable adverse events related to the procedure were observed, apart from fever, which occurred in 2 patients. CONCLUSIONS Tract dilation in EUS-PDD using a Tornus ES is effective and safe.
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Affiliation(s)
- Ahmed Sadek
- Department of Internal Medicine, Faculty of Medicine, Helwan University, Cairo, Egypt
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nozomi Okuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shin Haba
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takamichi Kuwahara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Toshitaka Fukui
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Minako Urata
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Takashi Kondo
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshitaro Yamamoto
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Kenneth Tachi
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
- Department of Medicine and Therapeutics, University of Ghana Medical School, Korle Bu Teaching Hospital, Accra, Ghana
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Trieu JA, Seven G, Baron TH. Endoscopic Ultrasound-Guided Pancreatic Duct Drainage. Gastrointest Endosc Clin N Am 2024; 34:501-510. [PMID: 38796295 DOI: 10.1016/j.giec.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a method of decompressing the pancreatic duct (PD) if unable to access the papilla or surgical anastomosis, particularly in nonsurgical candidates. The 2 types of EUS-PDD are EUS-assisted pancreatic rendezvous (EUS-PRV) and EUS-guided pancreaticogastrostomy (EUS-PG). EUS-PRV should be considered in patients with accessible papilla or anastomosis, while EUS-PG is a comparable alternative in surgically altered foregut anatomy. While technical and clinical successes range from 79% to 100%, adverse events occur in approximately 20%. A multidisciplinary approach that considers the patient's anatomy, clinical indication, and long-term goals should be discussed with surgical and interventional radiology colleagues.
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Affiliation(s)
- Judy A Trieu
- Division of Gastroenterology, Washington University in St. Louis, 660 South Euclid Avenue, MSC 8124-21-427, St Louis, MO 63110, USA. https://twitter.com/TrieuMD
| | - Gulseren Seven
- Division of Gastroenterology, Bezmialem Foundation University, Bezmialem Vakif University School of Medicine, Adnan Menderes Boulevard, Fatih, Istanbul 34093, Turkey
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, 130 Mason Farm Road, Bioinformatics Building CB# 7080, Chapel Hill, NC 27599-7080, USA.
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Li JS, Zheng KL, Lv SL, Su XJ, Wang KX, Li ZS, Chen J, Chen Y. Endoscopic ultrasound-guided versus surgical pancreatic duct drainage after failed endoscopic retrograde pancreatography: a pilot comparative study. Surg Endosc 2024:10.1007/s00464-024-10978-6. [PMID: 38898340 DOI: 10.1007/s00464-024-10978-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Endoscopic ultrasound-guided pancreatic duct (PD) drainage (EUS-PDD) is being increasingly performed as an alternative method to surgical drainage to achieve PD decompression after failed endoscopic retrograde pancreatography (ERP). However, no directly study has compared EUS-PDD with surgical PD drainage after failed ERP in patients with chronic pancreatitis. METHODS Consecutive patients who underwent EUS-PDD or longitudinal pancreaticojejunostomy after failed ERP were retrospectively identified from our endoscopy and medical information systems. The primary end point was the Izbicki pain score. The secondary end points were pain relief at the end of follow-up, procedure outcomes, adverse events, readmission, and reintervention. RESULTS A total of 21 patients (11 EUS-PDD, 10 surgical drainages) were analyzed. There were no significant differences in mean Izbicki pain score (EUS-PDD, 13.6 ± 10.1 vs. surgical drainage 10.7 ± 7.9, p = 0.483) or complete/partial pain relief (60%/30% vs. 70%/30%, p = 0.752) at the end of follow-up of the two groups. The rates of overall adverse events (27.3% vs. 30.0%, p = 0.893) and readmission (63.6% vs. 40.0%, p = 0.290) were similar in the two treatment groups, while patients in EUS-PDD group required more reinterventions (45.5% vs. 0%, p = 0.039) compared with patients in the surgery group. CONCLUSION EUS-PDD showed comparable pain relief and safety to surgical PD drainage after failed ERP, with a higher rate of reintervention. The selection of EUS-PDD or surgical drainage may be appropriate based on an individualized strategy.
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Affiliation(s)
- Jia-Su Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Kai-Lian Zheng
- Department of Hepatobiliary Pancreatic Surgery, Changhai Hospital, Navy Medical University, Shanghai, China
| | - Shun-Li Lv
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xiao-Ju Su
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Kai-Xuan Wang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Jie Chen
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Devière J. Endoscopic Ultrasound-Guided Pancreatic Duct Interventions. Gastrointest Endosc Clin N Am 2023; 33:845-854. [PMID: 37709415 DOI: 10.1016/j.giec.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Endoscopic ultrasound (EUS)-guided pancreatic duct drainage is one of the most challenging procedures in therapeutic endoscopy. Technical success is lower than for other therapeutic EUS procedures. However, when successful in a clear clinical indication, this procedure can offer a useful therapeutic alternative and improves the overall clinical success of the endoscopic approach. Current challenges include the standardization of clinical indications and of the techniques used for accessing the pancreatic duct, the strategy for mid-term and long-term management, and definition of the scope of the training that should be offered to a few highly experienced endoscopists.
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Affiliation(s)
- Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, 808 Route de Lennik, Brussels B1070, Belgium.
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Motomura D, Irani S, Larsen M, Kozarek RA, Ross AS, Gan SI. Multicenter retrospective cohort of EUS-guided anterograde pancreatic duct access. Endosc Int Open 2023; 11:E358-E365. [PMID: 37077663 PMCID: PMC10110360 DOI: 10.1055/a-2029-2520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 01/31/2023] [Indexed: 04/21/2023] Open
Abstract
Background and study aims Pancreatic duct (PD) cannulation may be difficult during conventional endoscopic retrograde cholangiopancreatography (ERCP) due to underlying pathology, anatomical variants or surgically altered anatomy. Pancreatic access in these cases previously necessitated percutaneous or surgical approaches. Endoscopic ultrasound (EUS) allows for an alternative and can be combined with ERCP for rendezvous during the same procedure, or for other salvage options. Patients and methods Patients with attempted EUS access of the PD from tertiary referral centers between 2009 and 2022 were included in the cohort. Demographic data, technical data, procedural outcomes and adverse events were collected. The primary outcome was rendezvous success. Secondary outcomes included rates of successful PD decompression and change in procedural success over time. Results The PD was accessed in 105 of 111 procedures (95 %), with successful subsequent ERCP in 45 of 95 attempts (47 %). Salvage direct PD stenting was performed in 5 of 14 attempts (36 %). Sixteen patients were scheduled for direct PD stenting (without rendezvous) with 100 % success rate. Thus 66 patients (59 %) had successful decompression. Success rates improved from 41 % in the first third of cases to 76 % in the final third. There were 13 complications (12 %), including post-procedure pancreatitis in seven patients (6 %). Conclusions EUS-guided anterograde pancreas access is a feasible salvage method if retrograde access fails. The duct can be cannulated, and drainage can be achieved in the majority of cases. Success rates improve over time. Future research may involve investigation into technical, patient and procedural factors contributing to rendezvous success.
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Affiliation(s)
- Douglas Motomura
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia
| | - Shayan Irani
- Gastroenterology Section, Digestive Disease Institute, Virginia Mason Franciscan Health, Seattle, Washington, United States
| | - Michael Larsen
- Gastroenterology Section, Digestive Disease Institute, Virginia Mason Franciscan Health, Seattle, Washington, United States
| | - Richard A Kozarek
- Gastroenterology Section, Digestive Disease Institute, Virginia Mason Franciscan Health, Seattle, Washington, United States
| | - Andrew S Ross
- Gastroenterology Section, Digestive Disease Institute, Virginia Mason Franciscan Health, Seattle, Washington, United States
| | - S Ian Gan
- Division of Gastroenterology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia
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Teh JL, Teoh AYB. Techniques and Outcomes of Endoscopic Ultrasound Guided-Pancreatic Duct Drainage (EUS- PDD). J Clin Med 2023; 12:jcm12041626. [PMID: 36836161 PMCID: PMC9961828 DOI: 10.3390/jcm12041626] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/02/2023] [Accepted: 02/09/2023] [Indexed: 02/22/2023] Open
Abstract
Endoscopic ultrasound guided-pancreatic duct drainage (EUS- PDD) is one of the most technically challenging procedures for the interventional endoscopist. The most common indications for EUS- PDD are patients with main pancreatic duct obstruction who have failed conventional endoscopic retrograde pancreatography (ERP) drainage or those with surgically altered anatomy. EUS- PDD can be performed via two approaches: the EUS-rendezvous (EUS- RV) or the EUS-transmural drainage (TMD) techniques. The purpose of this review is to provide an updated review of the techniques and equipment available for EUS- PDD and the outcomes of EUS- PDD reported in the literature. Recent developments and future directions surrounding the procedure will also be discussed.
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Affiliation(s)
- Jun Liang Teh
- Department of Surgery, Juronghealth Campus, National University Health System, Singapore 609606, Singapore
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Anthony Yuen Bun Teoh
- Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
- Correspondence: ; Tel.: +852-3505-2627; Fax: +852-3505-7974
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12
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Kale A, Sundaram S, Satai M, Harindranath S, Garg L, Aggarwal M. EUS-guided pancreatic rendezvous for management of pancreaticopleural fistula with an undilated duct and pancreas divisum. Endosc Ultrasound 2022; 11:515-517. [PMID: 36537390 PMCID: PMC9921981 DOI: 10.4103/eus-d-21-00164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/30/2021] [Indexed: 02/14/2023] Open
Affiliation(s)
- Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Mayur Satai
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Love Garg
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Mohit Aggarwal
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
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Kale A, Sundaram S, Satai M, Harindranath S, Garg L, Aggarwal M. EUS-guided pancreatic rendezvous for management of pancreaticopleural fistula with an undilated duct and pancreas divisum. Endosc Ultrasound 2022; 11:515-517. [DOI: https:/doi.org/10.4103/eus-d-21-00164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/30/2021] [Indexed: 04/13/2025] Open
Affiliation(s)
- Aditya Kale
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Sridhar Sundaram
- Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Mayur Satai
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Sidharth Harindranath
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Love Garg
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
| | - Mohit Aggarwal
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, Maharashtra, India
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14
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Monino L, Barthet M. Futures perspectives and therapeutic applications. Best Pract Res Clin Gastroenterol 2022; 60-61:101816. [PMID: 36577535 DOI: 10.1016/j.bpg.2022.101816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Laurent Monino
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France; Department of Hepatogastroenterology, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Marc Barthet
- Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France.
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15
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Nakahara K, Michikawa Y, Sato J, Igarashi Y, Sekine A, Satta Y, Tateishi K. Pancreatic duct stenting using an endoscopic ultrasound-guided intrapancreatic duct rendezvous technique. Endoscopy 2022; 54:E954-E955. [PMID: 35863337 PMCID: PMC9736818 DOI: 10.1055/a-1882-4799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Kazunari Nakahara
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yosuke Michikawa
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Junya Sato
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yosuke Igarashi
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Akihiro Sekine
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yusuke Satta
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Keisuke Tateishi
- Department of Gastroenterology, St. Marianna University School of Medicine, Kawasaki, Japan
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16
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Duarte-Chavez R, Kahaleh M. Therapeutic endoscopic ultrasound. Transl Gastroenterol Hepatol 2022; 7:20. [PMID: 35548470 PMCID: PMC9081917 DOI: 10.21037/tgh-2020-12] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/12/2020] [Indexed: 08/30/2023] Open
Abstract
Endoscopic ultrasound (EUS) has been continuously evolving for the past three decades and has become widely used for both diagnostic and therapeutic purposes. The efficacy of therapeutic EUS (TEUS) has proven to be superior and better tolerated than conventional percutaneous or surgical techniques. TEUS has allowed the performance of multiple procedures including gallbladder, pancreatic duct and biliary drainage as well as gastrointestinal anastomoses. TEUS procedures generally require the following critical steps: needle access, guidewire placement, fistula creation and stent deployment. The indications and contraindication for TEUS procedures vary with different procedures but common contraindications include hemodynamic instability, severe coagulopathy unable to be reversed, large volume ascites or the inability to obtain access to the target site. Proficiency and high volume in endoscopic retrograde cholangiopancreatography (ERCP) and diagnostic EUS procedures are required for training in TEUS. The complexity of the cases performed can be seen as a pyramid with drainage of pancreatic fluid collections at the base, pancreaticobiliary decompression in the middle, and creation of digestive anastomosis at the top. The mastery of each level is crucial prior to reaching the next level of complexity. TEUS has been incorporated in our arsenal and is impacting on a daily basis the way we offer minimally invasive therapy.
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Affiliation(s)
- Rodrigo Duarte-Chavez
- Department of Internal Medicine, St. Luke’s University Health Network, Bethlehem, PA, USA
| | - Michel Kahaleh
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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17
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Efficacy and Safety of Peroral Pancreatoscopy Through the Fistula Created by Endoscopic Ultrasound-Guided Pancreaticogastrostomy. Pancreas 2022; 51:228-233. [PMID: 35584379 DOI: 10.1097/mpa.0000000000002003] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy (EUS-PGS) is a useful alternative when endoscopic retrograde pancreatography is difficult. Recently, many procedures, including peroral pancreatoscopy (POPS), have been performed through the mature fistula (MF) created by EUS-PGS. We evaluate the efficacy and safety of POPS to diagnose and treat pancreatic ductal stricture/pancreato-jejunal anastomotic stricture (PDS/PJAS) through the MF. METHODS Twenty patients underwent EUS-PGS; 13 of these underwent POPS through the MF at Juntendo University Hospital. All patients were studied retrospectively in terms of technical and clinical success rates and adverse events (AEs). RESULTS The technical and clinical success rates of EUS-PGS were 95% and 100%. The early and late AEs rates were 20% and 15%. The technical success rate of POPS was 100%, with one AE. Biopsy of PDS/PJAS under POPS guidance revealed recurrent/residual intrapapillary mucinous adenoma (3 patients) and benign fibrotic stricture (10 patients). In the latter patients, multiple plastic stents were placed to dilate PDS/PJAS. Four patients with improvement of PDS/PJAS were stent free, but the remaining patients were not yet. CONCLUSIONS Endoscopic ultrasound/endosonography-guided pancreaticogastrostomy and various procedures (including POPS) performed through the MF are feasible and effective and can diagnose and treat PDS/PJAS with acceptable AEs rates.
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18
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Yane K, Sumiyoshi T, Kondo H. Successful pancreatic duct cannulation using double-guidewire technique. Dig Endosc 2021; 33:e81-e82. [PMID: 33713495 DOI: 10.1111/den.13955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 02/09/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Kei Yane
- Department of Gastroenterology, Tonan Hospital, Hokkaido, Japan
| | | | - Hitoshi Kondo
- Department of Gastroenterology, Tonan Hospital, Hokkaido, Japan
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19
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Yoshimura Y, Yamashita S, Sato M, Iwano K, Kurita A, Hata D. The First Successful Rendezvous Procedure for Pancreatic Duct Drainage in a Pediatric Case With Obstructive Pancreatitis. Pancreas 2021; 50:e37-e39. [PMID: 33835986 DOI: 10.1097/mpa.0000000000001775] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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20
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Kogure H, Sato T, Nakai Y, Ishigaki K, Hakuta R, Saito K, Saito T, Takahara N, Hamada T, Mizuno S, Yamada A, Tada M, Isayama H, Koike K. Endoscopic management of pancreatic diseases in patients with surgically altered anatomy: clinical outcomes of combination of double-balloon endoscopy- and endoscopic ultrasound-guided interventions. Dig Endosc 2021; 33:441-450. [PMID: 32434287 DOI: 10.1111/den.13746] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/14/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In patients with surgically altered anatomy, endoscopic treatment of pancreatic diseases is technically challenging. We aimed to evaluate the feasibility, effectiveness, and safety of an interchangeable combination of double-balloon endoscope-assisted ERP (DB-ERP) and endoscopic ultrasonography-guided pancreatic duct drainage (EUS-PD) in this clinical setting. METHODS Consecutive patients with surgically altered anatomy undergoing endoscopic treatment (DB-ERP, EUS-PD, or both) for pancreatic diseases were studied. The primary outcome was technical success; secondary outcomes were clinical success and adverse events. RESULTS Forty patients who underwent DB-ERP (38) and EUS-PD (2) as an initial intervention were retrospectively studied. Indications for intervention included 18 pancreaticojejunostomy anastomotic stricture (PJAS), four pancreatic duct stone (PDS), four pancreatic fistula (PF), 11 PJAS with PDS, and three PJAS with PF. Prior surgical reconstruction was 26 Billroth-II, 13 Roux-en-Y, and one Imanaga reconstruction. Along with salvage procedures including three DB-ERP and seven EUS-PD, the overall technical success rates of DB-ERP and EUS-PD were 70.7% (29/41) and 100% (9/9), respectively. Clinical success was achieved in 85.0% (34/40) by combination of DB-ERP and EUS-PD; successful drainage for PJAS, complete removal of PDS, and resolution of PF were achieved in 90.6%, 80.0%, and 71.4%, respectively. Adverse event rates were 12.2% (5/41; one perforation, and four pancreatitis) in DB-ERP and 55.6% (5/9; three pancreatic leakage, and two abdominal pain) in EUS-PD. CONCLUSIONS A combination of DB-ERP and EUS-PD can achieve high technical and clinical success for pancreatic diseases in surgically altered anatomy patients. A prospective multicenter study to investigate an appropriate treatment algorithm is warranted.
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Affiliation(s)
- Hirofumi Kogure
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Sato
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yousuke Nakai
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of, Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazunaga Ishigaki
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ryunosuke Hakuta
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kei Saito
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomotaka Saito
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Naminatsu Takahara
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tsuyoshi Hamada
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Suguru Mizuno
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsuo Yamada
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Tada
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of, Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Departments of, Department of, Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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21
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Deprez PH. Endoscopic ultrasound-guided pancreatic drainage vs device-assisted endoscopic retrograde pancreatography in surgically altered anatomy: Friends rather than competitors. Dig Endosc 2021; 33:342-343. [PMID: 33152807 DOI: 10.1111/den.13853] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/31/2020] [Accepted: 09/22/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Pierre H Deprez
- Hepato-Gastroenterology Department, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
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22
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DeWitt JM, Arain M, Chang KJ, Sharaiha R, Komanduri S, Muthusamy VR, Hwang JH. Interventional Endoscopic Ultrasound: Current Status and Future Directions. Clin Gastroenterol Hepatol 2021; 19:24-40. [PMID: 32950747 DOI: 10.1016/j.cgh.2020.09.029] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/11/2020] [Accepted: 09/15/2020] [Indexed: 02/06/2023]
Abstract
The evolution of endoscopic ultrasound (EUS) from a diagnostic to a therapeutic procedure has resulted in a paradigm shift toward endoscopic management of disease states that previously required percutaneous or surgical approaches. The past few years have seen additional techniques and devices that have enabled endoscopists to expand its diagnostic and therapeutic capabilities. Some of these techniques initially were reported more than a decade ago; however, with further device development and refinement in techniques there is potential for expanding the application of these techniques and new technologies to a broader group of interventional gastroenterologists. Lack of formalized training, devices, and prospective data regarding their use in addition to a scarcity of guidelines on implementation of these technologies into clinical practice are contributing factors impeding the growth of the field of interventional EUS. In April 2019, the American Gastroenterological Association's Center for Gastrointestinal Innovation and Technology conducted its annual Tech Summit and a key session focused on interventional EUS. This article is a White Paper generated from the conference, discusses the published literature pertaining to the topic of interventional EUS, and outlines a proposed framework for the implementation of interventional EUS techniques into clinical practice. Three primary areas of interventional EUS are addressed: (1) EUS-guided access; (2) EUS-guided tumor ablation; and (3) endohepatology. There was general agreement among participants on several key components. The introduction of these novel interventions requires better tools, more data on safety/outcomes, and improved training for endoscopists. Participants also agreed that widespread implementation and use of these techniques will require support from Gastrointestinal Societies and other key stakeholders including payers. Continued work by the Gastrointestinal Societies and manufacturers to provide training programs, appropriate equipment/work environments, and policies that motivate endoscopists to adopt new techniques is essential for growing the field of interventional EUS.
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Affiliation(s)
- John M DeWitt
- Department of Gastroenterology and Hepatology, Indiana University Medical Center, Indianapolis, Indiana
| | - Mustafa Arain
- Division of Gastroenterology, University of California, San Francisco, San Francisco, California
| | - Kenneth J Chang
- H. H. Chao Comprehensive Digestive Disease Center, Division of Gastroenterology and Hepatology, Department of Medicine, University of California, Irvine, California
| | - Reem Sharaiha
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Weill Cornell Medicine, New York, New York
| | - Sri Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, California.
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23
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Nakai Y. Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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24
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Imoto A, Ogura T, Higuchi K. Endoscopic Ultrasound-Guided Pancreatic Duct Drainage: Techniques and Literature Review of Transmural Stenting. Clin Endosc 2020; 53:525-534. [PMID: 32967409 PMCID: PMC7548157 DOI: 10.5946/ce.2020.173] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 08/22/2020] [Indexed: 12/16/2022] Open
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.
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Affiliation(s)
- Akira Imoto
- Aoyama Hospital, Fujiidera, Osaka, Japan.,Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Takeshi Ogura
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine, Osaka Medical College, Takatsuki, Osaka, Japan
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25
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Ogura T, Ohama H, Higuchi K. Endoscopic Ultrasound-Guided Pancreatic Transmural Stenting and Transmural Intervention. Clin Endosc 2019; 53:429-435. [PMID: 31771320 PMCID: PMC7403024 DOI: 10.5946/ce.2019.130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/28/2019] [Indexed: 12/16/2022] Open
Abstract
Endoscopic ultrasound (EUS)-guided pancreatic access is an emergent method that can be divided into the two main techniques of EUS-guided rendezvous and pancreatic transmural stenting (PTS). While many reports have described EUS-guided procedures, the indications, technical tips, clinical effects, and safety of EUS-guided pancreatic duct drainage (EUS-PD) remain controversial. This review describes the current status of and problems associated with EUS-PD, particularly PTS. We reviewed clinical data derived from a total of 334 patients. Rates of technical and clinical success ranged from 63% to 100% and 76% to 100%, respectively. In contrast, the rate of procedure-related adverse events was high at 26.7% (89/334). The most frequent adverse events comprised abdominal pain (n=38), acute pancreatitis (n=15), bleeding (n=9), and issues associated with pancreatic juice leakage such as perigastric fluid, pancreatic fluid collection, or pancreatic juice leaks (n=8). In conclusion, indications for EUS-PTS are limited, as is the evidence of its viability, due to the scarcity of expert operators. Despite improvements made to various devices, EUS-PTS remains technically challenging. Therefore, a long-term, large-scale, multicenter study is required to establish this technique as a viable alternative drainage method.
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Affiliation(s)
- Takeshi Ogura
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Hideko Ohama
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
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26
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The Dilemma of the Dilated Main Pancreatic Duct in the Distal Pancreatic Remnant After Proximal Pancreatectomy for IPMN. J Gastrointest Surg 2019; 23:1593-1603. [PMID: 30603862 DOI: 10.1007/s11605-018-4026-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/18/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE(S) A dilated main pancreatic duct in the distal remnant after proximal pancreatectomy for intraductal papillary mucinous neoplasms (IPMN) poses a diagnostic dilemma. We sought to determine parameters predictive of remnant main-duct IPMN and malignancy during surveillance. METHODS Three hundred seventeen patients underwent proximal pancreatectomy for IPMN (Indiana University, 1991-2016). Main-duct dilation included those ≥ 5 mm or "dilated" on radiographic reports. Statistics compared groups using Student's T/Mann-Whitney U tests for continuous variables or chi-square/Fisher's exact test for categorical variables with P < 0.05 considered significant. RESULTS High-grade/invasive IPMN or adenocarcinoma at proximal pancreatectomy predicted malignant outcomes (100.0% malignant outcomes; P < 0.001) in remnant surveillance. Low/moderate-grade lesions revealed benign outcomes at last surveillance regardless of duct diameter. Twenty of 21 patients undergoing distal remnant reoperation had a dilated main duct. Seven had main-duct IPMN on remnant pathology; these patients had greater mean maximum main-duct diameter prior to reoperation (9.5 vs 6.2 mm, P = 0.072), but this did not reach statistical significance. Several features showed high sensitivity/specificity for remnant main-duct IPMN. CONCLUSIONS Remnant main-duct dilation after proximal pancreatectomy for IPMN remains a diagnostic dilemma. Several parameters show a promise in accurately diagnosing main-duct IPMN in the remnant.
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27
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Tonozuka R, Yunoki S, Itoi T, Sofuni A, Tsuchiya T, Ishii K, Tanaka R, Honjo M, Mukai S, Fujita M, Yamamoto K, Asai Y, Matsunami Y, Kurosawa T, Kojima H, Nagakawa Y, Nagakawa Y. Ex vivo assessment of anchoring force of covered biflanged metal stent and covered self-expandable metal stent for interventional endoscopic ultrasound. J Gastroenterol Hepatol 2019; 34:194-201. [PMID: 29871029 DOI: 10.1111/jgh.14307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/08/2018] [Accepted: 05/29/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Endoscopic ultrasound (EUS)-guided transmural drainage using a covered biflanged metal stent (CBFMS) and a conventional tubular biliary covered self-expandable metal stent (CSEMS) has recently been performed by EUS experts. However, appropriate traction force of the sheath to prevent the migration during stent deployment is well unknown. Herein, we assessed the anchoring force (AF) of the distal flange in CBFMSs and CSEMSs. METHODS The AFs of four CBFMSs (Stents AX, NG, PL, and SX) and six CSEMSs (Stents BF, BP, EG, HN, SP, and WF) were compared in an ex vivo setting. We assessed the AF produced by each stent using an EUS-guided transmural drainage model and an EUS-guided hepaticogastrostomy model consisting of sheet-shaped specimens of the stomach, gelatin gel, and gelatin tubes. RESULTS For CBFMSs, the maximum AF of Stent AX was significantly higher than those of Stents PL and SX (P < 0.05) in the porcine model. In the gelatin series, all stents except Stent NG showed a nearly similar AF. For CSEMSs, Stents HN, EG, BF, and WF showed gradual AF elevation in the porcine stomach. Stents SP and BP showed a lower AF than the other four stents. For the gelatin setting, the maximum AF of Stents HN, EG, and WF was higher than those of the other stents regardless of the type of specimens. CONCLUSIONS The significance of the AF and traction distance according to the property of various CBFMSs and CSEMSs could be elucidated using ex vivo models.
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Affiliation(s)
- Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shunji Yunoki
- Tokyo Metropolitan Industrial Technology Research Institute, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Mitsuyoshi Honjo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Mitsuru Fujita
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Kurosawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Hiroyuki Kojima
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yoshiyasu Nagakawa
- Tokyo Metropolitan Industrial Technology Research Institute, Tokyo, Japan
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Abstract
Endoscopic transpapillary or transanastomotic pancreatic duct drainage (PD) is the mainstay of drainage in symptomatic pancreatic duct obstruction or leakage. However, transpapillary or transanastomotic PD can be technically difficult due to the tight stricture or surgically altered anatomy (SAA), and endoscopic ultrasound (EUS)-guided PD (EUS-PD) is now increasingly used as an alternative technique. There are two approaches in EUS-PD: EUS-guided rendezvous (EUS-RV) and EUS-guided transmural drainage (EUS-TMD). In cases with normal anatomy, EUS-RV should be the first approach, whereas EUS-TMD can be selected in cases with SAA or duodenal obstruction. In our literature review, technical success and adverse event rates were 78.7% and 21.8%, respectively. The technical success rate of EUS-RV appeared lower than EUS-TMD due to the difficulty in guidewire passage. In future, development of dedicated devices and standardization of EUS-PD procedure are necessary.
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Affiliation(s)
- Yousuke Nakai
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Address for correspondence: Dr. Yousuke Nakai, Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo - 113-8655, Japan. E-mail:
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Isayama
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Zarzavadjian Le Bian A, Cesaretti M, Tabchouri N, Wind P, Fuks D. Late Pancreatic Anastomosis Stricture Following Pancreaticoduodenectomy: a Systematic Review. J Gastrointest Surg 2018; 22:2021-2028. [PMID: 29980974 DOI: 10.1007/s11605-018-3859-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/21/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND With an increasing postoperative survival and prolonged follow-up, late complications following pancreaticoduodenectomy (PD) have yet to be thoroughly described and analyzed. Among those, pancreatic anastomosis stricture may lead to severe consequences. METHODS A systematic review focusing on pancreaticojejunostomy anastomosis (PJA) stricture. RESULTS PJA stricture incidence reached 1.4-11.4% with a median time interval of 34 months after PD. No risk factor was identified. PJA stricture repercussions were inconsistent but postprandial abdominal pain and recurrent acute pancreatitis were the most common symptoms, followed by impaired pancreatic function. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography (SMRCP) sensitivity reached 56-100%. As impaired pancreatic function is not improved by any procedure, only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted "rendezvous") should be proposed prior to surgical repair, with a morbidity, an overall technical and clinical success reaching 16.5-33% and 28.6-100% and 33-100%, respectively. Regarding surgical repair, overall morbidity varied between 14.3 and 33%, with a clinical success reaching 26.1-100%. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies. CONCLUSION PJA stricture following PD is a late, unusual, and potentially serious complication. When there is currently no clear consensus, PJA stricture leading to abdominal pain or acute pancreatitis should be considered treatment. With increasing survival after PD, further studies should focus on late complications. CORE TIP Stricture of pancraticojejunostomy is a late and potentially serious complication after pancreaticoduodenectomy. Incidence reaches 1.4-11.4% and no risk factor is identified. Symptoms are inconsistent but postprandial abdominal pain, recurrent acute pancreatitis, and impaired pancreatic function are the most frequent. To confirm diagnosis, secretin-enhanced magnetic resonance cholangiopancreatography is the best modality. Only PJA stricture leading to abdominal pain or acute pancreatitis should be considered for treatment. Endoscopic techniques (mainly ultrasound-assisted "rendezvous") should be proposed prior to surgical repair. Finally, total pancreatectomy with islet auto-transplantation should be considered only for pain intractable to medical management and recurrent acute pancreatitis which has failed medical, endoscopic, and traditional surgical management strategies.
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Affiliation(s)
- Alban Zarzavadjian Le Bian
- Department of Digestive Surgery and Surgical Oncology - Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Université Paris XIII, 125 rue de Stalingrad, 93000, Bobigny, France.
| | - Manuela Cesaretti
- Department of Digestive Surgery, Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond Losserand, 75014, Paris, France
| | - Nicolas Tabchouri
- Department of Digestive, Oncologic and Metabolic Surgery - Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Philippe Wind
- Department of Digestive Surgery and Surgical Oncology - Hôpital Avicenne, Assistance Publique - Hôpitaux de Paris, Université Paris XIII, 125 rue de Stalingrad, 93000, Bobigny, France
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery - Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France.,Université Paris Descartes, 15 rue de l'Ecole de Médecine, 75006, Paris, France
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Matsunami Y, Itoi T, Sofuni A, Tsuchiya T, Kamada K, Tanaka R, Tonozuka R, Honjo M, Mukai S, Fujita M, Yamamoto K, Asai Y, Kurosawa T, Tachibana S, Nagakawa Y. Evaluation of a new stent for EUS-guided pancreatic duct drainage: long-term follow-up outcome. Endosc Int Open 2018; 6:E505-E512. [PMID: 29713675 PMCID: PMC5906111 DOI: 10.1055/s-0044-101753] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 12/01/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic ultrasonography-guided pancreatic duct drainage (EUS-PD) has been reported as an alternative for failed conventional endoscopic retrograde cholangiopancreatography (ERCP). However, there are few dedicated devices for EUS-PD. Recently, we have developed a new plastic stent dedicated to EUS-PD and have conducted a feasibility study to evaluate its efficacy. In the current study, we evaluated the long-term efficacy of this new plastic stent. PATIENTS AND METHODS Thirty patients (61 ± 14.3 years old, 14 men) with acute recurrent pancreatitis caused by a stricture in the main pancreatic duct (MPD) or stenotic pancreatoenterostomy were treated at our institution using our recently developed 7Fr plastic stent between August 2013 and April 2017. RESULTS The stent was placed successfully in all patients (30/30) and early clinical success was achieved in all of them. Early adverse events (AEs) occurred in seven patients (23.3 %), namely, self-limited abdominal pain (n = 5), mild pancreatitis (n = 1), and bleeding which required transcatheter arterial embolization (n = 1). Two patients died of primary disease and three were lost to follow-up. The remaining 25 patients were followed up after initial EUS-PD for a median of 23 months (range, 6 - 44 months). Twenty patients required regular stent exchange (3 times; range, 1 - 12 times). Spontaneous stent dislodgement was observed in six patients. Four patients wanted their stents removed 1 year after the initial intervention. Twelve patients (48 %) had regular stent exchange 1 year after the initial intervention. Three patients converted to standard transpapillary pancreatic duct stenting by conventional ERCP. Finally, nine patients (36 %) had complete stent removal either intentionally or by spontaneous dislodgement without any symptoms. CONCLUSION The new plastic stent for EUS-PD was associated with not only short-term technical success but also long-term clinical success in the majority of patients evaluated in this study.
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Affiliation(s)
- Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan,Corresponding author Takao Itoi, MD, PhD, FASGE Department of Gastroenterology and HepatologyTokyo Medical University6-7-1 Nishishinjuku, Shinjuku-kuTokyo 160-0023, Japan+81-3-5381-6654
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Kamada
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Mitsuyoshi Honjo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Mitsuru Fujita
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takashi Kurosawa
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shingo Tachibana
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Nagakawa
- Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Tokyo, Japan
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Lu L, Jin HB, Yang JF, Zhang XF. Endoscopic ultrasound-guided pancreaticogastrostomy for symptomatic pancreatic duct obstruction caused by migrated pancreatic stent. World J Gastrointest Endosc 2017; 9:535-539. [PMID: 29085565 PMCID: PMC5648997 DOI: 10.4253/wjge.v9.i10.535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 05/28/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023] Open
Abstract
Endoscopic pancreatic stenting has been widely used in various pancreatic conditions. With the increasing use of pancreatic stents, many complications have been recognized. Especially, proximal stent migration presents a serious condition because of subsequent pancreatic duct obstruction, impaired drainage, ductal dilation, and pancreatic pain. Although endoscopic retrieval is the preferred treatment for proximally migrated pancreatic stents, it is not always successful, resulting in conversion to surgery. To date, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has never been reported for treatment of pancreatic duct obstruction caused by proximally migrated pancreatic stent. We herein describe a case of pancreatic duct rupture and obstruction caused by proximally migrated pancreatic stent that was successfully treated by EUS-guided pancreaticogastrostomy while keeping the former stent in situ after failed endoscopic retrograde cholangiopancreatography. We believe that this report adds to the increasing evidence of symptomatic pancreatic duct obstruction being successfully treated by EUS-PD.
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Affiliation(s)
- Lei Lu
- Department of Gastroenterology, Hangzhou First People’s Hospital, Nanjing Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Hang-Bin Jin
- Department of Gastroenterology, Hangzhou First People’s Hospital, Nanjing Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Jian-Feng Yang
- Department of Gastroenterology, Hangzhou First People’s Hospital, Nanjing Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, Hangzhou First People’s Hospital, Nanjing Medical University, Hangzhou 310000, Zhejiang Province, China
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Dhir V, Isayama H, Itoi T, Almadi M, Siripun A, Teoh AYB, Ho KY. Endoscopic ultrasonography-guided biliary and pancreatic duct interventions. Dig Endosc 2017; 29:472-485. [PMID: 28118509 DOI: 10.1111/den.12818] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 01/19/2017] [Indexed: 12/14/2022]
Abstract
Drainage of obstructed bile duct and pancreatic duct under endoscopic ultrasonography (EUS) guidance has evolved into viable techniques suitable for patients with failed endoscopic retrograde cholangiopancreatography (ERCP) and/or altered surgical anatomy. One of the major advantages of EUS guidance is the possibility of multiple access points depending upon patient and ductal anatomy. Unlike ERCP, an approachable papilla is not a requisite for successful EUS-guided biliary or pancreatic ductal drainage. Moreover, as the access is away from the papilla, there is the possibility of reduced pancreatitis. A variety of procedures have become available for EUS-guided drainage, and it is important to develop standard terminology and procedural details. EUS-specific stents, including lumen-apposing metal stents have recently become available, and are likely to impact the outcomes of these procedures. Available data show a high success rate and acceptable adverse event rate for EUS-guided biliary drainage. Success rate appears to be low for pancreatic duct drainage because of a variety of reasons. Outcomes of EUS-guided biliary drainage appear equivalent to percutaneous drainage and ERCP. EUS-guided gallbladder drainage appears promising for patients requiring gallbladder drainage but unfit for surgery. Further large controlled studies are needed to evaluate the exact role of these procedures.
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Affiliation(s)
- Vinay Dhir
- Baldota Institute of Digestive Sciences, Global Hospitals, Mumbai, India
| | | | | | - Majid Almadi
- King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | | | - Anthony Y B Teoh
- Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong
| | - Khek Yu Ho
- National University Health System, Singapore
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Coronel E, DaVee T, Lee JH. Advances in endotherapy in chronic pancreatitis. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Emmanuel Coronel
- Department of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL, USA
| | - Tomas DaVee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey H. Lee
- Department of Gastroenterology, Hepatology and Nutrition, MD Anderson Cancer Center, Houston, TX, USA
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Shimamura Y, Mosko J, Teshima C, May GR. Endoscopic Ultrasound-Guided Pancreatic Duct Intervention. Clin Endosc 2017; 50:112-116. [PMID: 28391672 PMCID: PMC5398367 DOI: 10.5946/ce.2017.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/22/2017] [Indexed: 12/14/2022] Open
Abstract
Endoscopic ultrasound-guided pancreatic duct intervention (EUS-PDI) is an emerging endoscopic approach allowing access and intervention to the pancreatic duct (PD) for patients with failed endoscopic retrograde pancreatography (ERP) or patients with surgically altered anatomy. As opposed to biliary drainage for which percutaneous drainage is an alternative following failed endoscopic retrograde cholangiopancreatography (ERCP), the treatment options after failed ERP are very limited. Therefore, endoscopic ultrasound (EUS)-guided access to the PD and options for subsequent drainage may play an important role as an alternative to surgical intervention. However, this approach is technically demanding with a high risk of complications, and should only be performed by highly experienced endoscopists. In this review, we describe an overview of the current endoscopic approaches, basic technical tips, and outcomes using these procedures.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Jeffrey Mosko
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Christopher Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Gary R May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, ON, Canada
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35
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Wai TM, Kim EY. Challenges of Endoscopic Management of Pancreaticobiliary Complications in Surgically Altered Gastrointestinal Anatomy. Clin Endosc 2016; 49:502-505. [PMID: 27894188 PMCID: PMC5152776 DOI: 10.5946/ce.2016.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/04/2016] [Indexed: 11/14/2022] Open
Abstract
Pancreaticobiliary complications following various surgical procedures, including liver transplantation, are not uncommon and are important causes of morbidity and mortality. Therapeutic endoscopy plays a substantial role in these patients and can help to avoid the need for reoperation. However, the endoscopic approach in patients with surgically altered gastrointestinal (GI) anatomy is technically challenging because of the difficulty in entering the enteral limb to reach the target orifice to manage pancreaticobiliary complications. Additional procedural complexity is due to the need of special devices and accessories to obtain successful cannulation and absence of an elevator in forward-viewing endoscopes, which is frequently used in this situation. Once bilioenteric anastomosis is reached, the technical success rates achieved in expert hands approach those of patients with intact GI anatomy. The success of endoscopic therapy in patients with surgically altered GI anatomy depends on multiple factors, including the expertise of the endoscopist, understanding of postoperative anatomic changes, and the availability of suitable scopes and accessories for endoscopic management. In this issue of Clinical Endoscopy, the focused review series deals with pancreatobiliary endoscopy in altered GI anatomy such as bilioenteric anastomosis and post-gastrectomy.
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Affiliation(s)
- Tin Moe Wai
- Department of Gastroenterology, Yangon General Hospital, University of Medicine (1), Yangon, Myanmar
| | - Eun Young Kim
- Division of Gastroenterology, Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Jirapinyo P, Lee LS. Endoscopic Ultrasound-Guided Pancreatobiliary Endoscopy in Surgically Altered Anatomy. Clin Endosc 2016; 49:515-529. [PMID: 27894187 PMCID: PMC5152780 DOI: 10.5946/ce.2016.144] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 11/05/2016] [Indexed: 12/11/2022] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has become the mainstay of therapy for pancreatobiliary diseases. While ERCP is safe and highly effective in the general population, the procedure remains challenging or impossible in patients with surgically altered anatomy (SAA). Endoscopic ultrasound (EUS) allows transmural access to the bile or pancreatic duct (PD) prior to ductal drainage using ERCP-based techniques. Also known as endosonography-guided cholangiopancreatography (ESCP), the procedure provides multiple advantages over overtube-assisted enteroscopy ERCP or percutaneous or surgical approaches. However, the procedure should only be performed by endoscopists experienced in both EUS and ERCP and with the proper tools. In this review, various EUS-guided diagnostic and therapeutic drainage techniques in patients with SAA are examined. Detailed step-by-step procedural descriptions, technical tips, feasibility, and safety data are also discussed.
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Affiliation(s)
| | - Linda S Lee
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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37
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Kida A, Shirota Y, Houdo Y, Wakabayashi T. Endoscopic characteristics and usefulness of endoscopic dilatation of anastomotic stricture following pancreaticojejunostomy: case series and a review of the literature. Therap Adv Gastroenterol 2016; 9:913-919. [PMID: 27803744 PMCID: PMC5076772 DOI: 10.1177/1756283x16663877] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The incidence of pancreatitis induced by anastomotic stricture following pancreaticodigestive tract anastomosis as a late-onset adverse event has been reported to be 3% or lower, but some cases repeatedly relapse and are difficult to treat. Endoscopic identification and treatment of the anastomotic site are considered to be difficult, and only a small number of cases have been reported. We present three cases with recurrent pancreatitis induced by anastomotic stricture following pancreaticojejunostomy applied after pancreaticoduodenectomy. We successfully identified the anastomotic site and performed endoscopic dilatation of the anastomotic stricture, and pancreatitis has not recurred. We characterized endoscopic features of the anastomotic site, understanding of which is essential to identify the site, and investigated useful techniques to identify the site and perform cannulation for pancreatography. Furthermore, we showed the safety and usefulness of endoscopic dilatation for anastomotic stricture following pancreaticojejunostomy according to our three cases and a review of the literature.
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Affiliation(s)
| | - Yukihiro Shirota
- Department of Gastroenterology, Ishikawa Prefectural Saiseikai Kanazawa Hospital, Ishikawa, Japan
| | - Yuji Houdo
- Department of Gastroenterology, Ishikawa Prefectural Saiseikai Kanazawa Hospital, Ishikawa, Japan
| | - Tokio Wakabayashi
- Department of Gastroenterology, Ishikawa Prefectural Saiseikai Kanazawa Hospital, Ishikawa, Japan
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Haseeb A, Abu Dayyeh BK, Levy MJ, Fujii LL, Pearson RK, Chari ST, Gleeson FC, Peterson BT, Swaroop Vege S, Topazian M. Endoscopic Ultrasound-Guided Treatment of Pancreaticocutaneous Fistulas. ACG Case Rep J 2016; 3:e105. [PMID: 27807567 PMCID: PMC5062650 DOI: 10.14309/crj.2016.78] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 01/04/2016] [Indexed: 12/23/2022] Open
Abstract
Pancreaticocutaneous fistulas (PCFs) may be refractory to medical therapy or endoscopic retrograde cholangopancreaticography. Four patients underwent endoscopic ultrasound-guided management of refractory PCFs, which were internalized by endoscopic ultrasound-guided transmural puncture of the pancreatic duct (n = 2), fistula tract (n = 1), or both (n = 1), with placement of transmural stents providing internal drainage to the stomach (n = 3) or duodenum (n = 1). Drainage from PCFs ceased in all patients, and all percutaneous drains were removed; internal stents were left in place indefinitely. Endoscopic ultrasound-guided interventions may successfully treat PCFs, allowing removal of percutaneous drains, and are an attractive alternative for patients who might otherwise require pancreatic resection.
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Affiliation(s)
- Abdul Haseeb
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | - Michael J Levy
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | | | - Suresh T Chari
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
| | | | | | | | - Mark Topazian
- Division of Gastroenterology, Mayo Clinic, Rochester, MN
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Chapman CG, Waxman I, Siddiqui UD. Endoscopic Ultrasound (EUS)-Guided Pancreatic Duct Drainage: The Basics of When and How to Perform EUS-Guided Pancreatic Duct Interventions. Clin Endosc 2016; 49:161-7. [PMID: 27012290 PMCID: PMC4821509 DOI: 10.5946/ce.2016.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 01/11/2016] [Accepted: 01/14/2016] [Indexed: 12/17/2022] Open
Abstract
Despite the advances in endoscopy, endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) remains a technically challenging procedure. Technical success rates are greater than 70%; however, the average rate of adverse events is nearly 20%, which increases to 55% when stent migration is included. Until recently, a significant difficulty with this technique was the absence of dedicated devices. Proper patient selection is of utmost importance, and EUS-PDD should be reserved for patients who have failed endoscopic retrograde pancreatography. Furthermore, EUS-PDD must be performed by experienced endoscopists who are familiar with the technique. The most common indications include chronic pancreatitis induced strictures and stones, disconnected pancreatic ducts, inaccessible ampulla, and post-surgical altered anatomy. This manuscript will review the accessories used, techniques employed, and published literature reporting outcomes as well as adverse events regarding EUS-PDD.
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Affiliation(s)
- Christopher G Chapman
- Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, IL, USA
| | - Irving Waxman
- Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, IL, USA
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics (CERT), University of Chicago Medicine, Chicago, IL, USA
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40
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Abstract
ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.
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41
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Arcidiacono PG, Mangiavillano B, Carrara S, Petrone MC, Santoro T, Testoni PA. Cannulation of the biliary tree under endoscopic control with an echoendoscope, without fluoroscopy: report of a case series. Therap Adv Gastroenterol 2015; 8:121-124. [PMID: 25949525 PMCID: PMC4416297 DOI: 10.1177/1756283x15576856] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Endoscopic ultrasonography (EUS) is a validated technique allowing precise diagnosis and staging of pancreatic, biliary and ampullary disease. Developments in instruments and accessories have led to a more extensive use of this technology to perform operations. The use of EUS as an operative technique, alone or in conjunction with other endoscopic procedures, has already been described in the literature in several reports. However, despite the use of EUS, fluoroscopy has always been required to perform these operations. There are no data in the literature describing the feasibility, safety and efficacy of operative EUS in the treatment of common bile duct (CBD) obstruction, following a malignant or benign disease, performed completely under EUS guidance without fluoroscopic assistance. METHODS In this series we describe three cases of EUS treatment of CBD diseases performed without fluoroscopic assistance. RESULTS All the cases were treated by EUS without fluoroscopic assistance and no complications were encountered. CONCLUSION Operative EUS without fluoroscopy appears to be a feasible technique. Its major advantages could be to shorten the examination time and to enable biliary or pancreatic operative endoscopy in patients in whom fluoroscopy could be dangerous, such as pregnant women. The endoscopist should have a good training both in EUS and endoscopic retrograde cholangiopancreatography. Prospective, larger studies are needed to confirm our preliminary data.
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Affiliation(s)
- Paolo Giorgio Arcidiacono
- Gastroenterology and Gastrointestinal Endoscopy Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Silvia Carrara
- Gastroenterology and Gastrointestinal Endoscopy Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiara Petrone
- Gastroenterology and Gastrointestinal Endoscopy Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Tara Santoro
- Department of Gastrointestinal Endoscopy, San Paolo Universitary Hospital, Milan, Italy
| | - Pier Alberto Testoni
- Gastroenterology and Gastrointestinal Endoscopy Unit, San Raffaele Scientific Institute, Milan, Italy
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Abstract
Over the last 2 decades, endoscopic ultrasound (EUS) has evolved from a noninvasive diagnostic tool to a combined diagnostic and therapeutic modality. The use of EUS complementary to endoscopic retrograde cholangiopancreatography (ERCP) has made possible biliary and pancreatic drainage in situations where conventional ERCP is unsuccessful or unlikely to be feasible. The degree of proximity to the pancreas achieved during the procedure has enabled therapeutic interventions such as drainage of peripancreatic fluid collections, pancreatic cyst ablation, and pancreatic cancer therapy. Real-time visualization of flow in adjacent blood vessels using Doppler ultrasound has allowed endovascular therapy for ablation of gastric varices and feeding vessels. Furthermore, the role of EUS is evolving in a multitude of applications such as bilioenteric and enteroenteric anastomosis in a minimally invasive manner, potentially reducing the need for surgery. This article reviews the role of EUS as an alternative to surgery in selective situations and provides an overview of future directions and evolving uses of EUS.
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Fujii-Lau LL, Levy MJ. Endoscopic ultrasound-guided pancreatic duct drainage. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2014; 22:51-7. [PMID: 25385528 DOI: 10.1002/jhbp.187] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Endoscopic ultrasound (EUS) has evolved from a purely diagnostic procedure to one with therapeutic capabilities. One of the most challenging therapeutic intervention for endosonographers is EUS-guided pancreatic drainage. The development of this technique has allowed access and drainage of the main pancreatic duct after failed endoscopic retrograde pancreatography and can avoid invasive procedures such as surgical and percutaneous interventions. This review discusses the indications, technique, challenges, and an algorithmic approach to EUS-guided pancreatic drainage.
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Affiliation(s)
- Larissa L Fujii-Lau
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
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Fujii LL, Topazian MD, Abu Dayyeh BK, Baron TH, Chari ST, Farnell MB, Gleeson FC, Gostout CJ, Kendrick ML, Pearson RK, Petersen BT, Truty MJ, Vege SS, Levy MJ. EUS-guided pancreatic duct intervention: outcomes of a single tertiary-care referral center experience. Gastrointest Endosc 2013; 78:854-864.e1. [PMID: 23891418 DOI: 10.1016/j.gie.2013.05.016] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Accepted: 05/09/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND EUS can provide access to the main pancreatic duct (MPD) for therapeutic intervention. The long-term clinical success of EUS-guided MPD interventions is unknown. OBJECTIVE To determine technical and clinical success rates, predictors of success, and long-term outcomes of EUS-guided MPD intervention. DESIGN Retrospective, single-center study. SETTING Tertiary-care referral center. PATIENTS Forty-five patients. INTERVENTION EUS-guided MPD stent retrieval or placement. MAIN OUTCOME MEASUREMENTS Technical and clinical success rates, adverse events, and long-term clinical outcomes. RESULTS Among the 45 patients, 37 had undergone failed ERCP, and 29 had surgically altered anatomy. Median follow-up after initial EUS-guided intervention was 23 months. Two patients underwent EUS for stent removal, and EUS-guided MPD stent placement was attempted in 43 patients. Technical success was achieved in 32 of 43 patients (74%) with antegrade (n = 18) or retrograde (n = 14) stent insertion. Serious adverse events occurred in 3 patients (6%). Patients underwent a median of 2 (range 1-6) follow-up procedures for revision or removal of stents, without adverse events. Complete symptom resolution occurred in 24 of 29 patients (83%) while stents were in place, including all 6 with nondilated ducts. Stents were removed in 23 patients, who were then followed for an additional median of 32 months; 4 patients had recurrent symptoms. Among the 11 failed cases, most had persistent symptoms or required surgery. LIMITATIONS Retrospective study design, individualized patient management. CONCLUSION EUS-guided MPD intervention is feasible and safe, with long-term clinical success in the majority of patients. EUS provides important treatment options, particularly in patients who would otherwise undergo surgery.
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Affiliation(s)
- Larissa L Fujii
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Suresh T Chari
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael B Farnell
- Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ferga C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Christopher J Gostout
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael L Kendrick
- Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Randall K Pearson
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Mark J Truty
- Division of Gastroenterologic and General Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Santhi S Vege
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Itoi T, Yasuda I, Kurihara T, Itokawa F, Kasuya K. Technique of endoscopic ultrasonography-guided pancreatic duct intervention (with videos). JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2013; 21:E4-9. [PMID: 24123911 DOI: 10.1002/jhbp.43] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To date, several endoscopic ultrasonography (EUS)-guided interventions have been reported. Of these interventions, EUS-guided pancreatic duct (PD) intervention seems to be the most difficult and challenging procedure to accomplish. We provide suggestions for EUS-guided PD intervention, which includes PD stenting and the rendezvous technique following EUS-guided pancreatography. PD stenting is performed between the PD and the gastrointestinal tract (stomach, duodenum, or jejunum). The rendezvous technique is performed using a guidewire across the papilla or anastomotic site for retrograde stent insertion. EUS-guided PD intervention is still challenging because it is not established yet. Thus, although EUS-guided PD intervention seems to be promising, it should be performed in selected patients such as those of failed standard endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
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Abstract
Over the last 2 decades there has been continuing development in endoscopic ultrasonography (EUS). EUS-guided pancreatic drainage is an evolving procedure that can be offered to patients who are high-risk surgical candidates and in whom the pancreatic duct cannot be accessed by endoscopic retrograde pancreatography. Although EUS-guided pancreatic drainage is a minimally invasive alternative option to surgery and interventional radiology, owing to its complexity and potential for fulminant complications it is recommended that these procedures be performed by highly skilled endoscopists. Additional data are needed to define risks and long-term outcomes more accurately via a dedicated prospective registry.
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Takikawa T, Kanno A, Masamune A, Hamada S, Nakano E, Miura S, Ariga H, Unno J, Kume K, Kikuta K, Hirota M, Yoshida H, Katayose Y, Unno M, Shimosegawa T. Pancreatic duct drainage using EUS-guided rendezvous technique for stenotic pancreaticojejunostomy. World J Gastroenterol 2013; 19:5182-5186. [PMID: 23964156 PMCID: PMC3746394 DOI: 10.3748/wjg.v19.i31.5182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/02/2013] [Accepted: 06/20/2013] [Indexed: 02/06/2023] Open
Abstract
The patient was a 30-year-old female who had undergone excision of the extrahepatic bile duct and Roux-en-Y hepaticojejunostomy for congenital biliary dilatation at the age of 7. Thereafter, she suffered from recurrent acute pancreatitis due to pancreaticobiliary maljunction and received subtotal stomach-preserving pancreaticoduodenectomy. She developed a pancreatic fistula and an intra-abdominal abscess after the operation. These complications were improved by percutaneous abscess drainage and antibiotic therapy. However, upper abdominal discomfort and the elevation of serum pancreatic enzymes persisted due to stenosis from the pancreaticojejunostomy. Because we could not accomplish dilation of the stenosis by endoscopic retrograde cholangiopancreatography, we tried an endoscopic ultrasonography (EUS) guided rendezvous technique for pancreatic duct drainage. After transgastric puncture of the pancreatic duct using an EUS-fine needle aspiration needle, the guidewire was inserted into the pancreatic duct and finally reached to the jejunum through the stenotic anastomosis. We changed the echoendoscope to an oblique-viewing endoscope, then grasped the guidewire and withdrew it through the scope. The stenosis of the pancreaticojejunostomy was dilated up to 4 mm, and a pancreatic stent was put in place. Though the pancreatic stent was removed after three months, the patient remained symptom-free. Pancreatic duct drainage using an EUS-guided rendezvous technique was useful for the treatment of a stenotic pancreaticojejunostomy after pancreaticoduodenectomy.
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Kawakami H, Kuwatani M, Sakamoto N. Endoscopic ultrasound-guided rendezvous procedure for unidentifiable papilla and non-dilated pancreatic duct (with video). Dig Endosc 2013; 25:466. [PMID: 23560435 DOI: 10.1111/den.12090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Hiroshi Kawakami
- Department of Gastroenterology and HepatologyHokkaido University Graduate School of Medicine Sapporo Japan
| | - Masaki Kuwatani
- Department of Gastroenterology and HepatologyHokkaido University Graduate School of Medicine Sapporo Japan
| | - Naoya Sakamoto
- Department of Gastroenterology and HepatologyHokkaido University Graduate School of Medicine Sapporo Japan
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Kida M, Araki M, Tokunaga S, Yamauchi H, Okuwaki K, Miyazawa S, Iwai T, Takezawa M, Kikuchi H, Watanabe M, Imaizumi H, Koizumi W. Role of a forward-viewing echoendoscope in fine-needle aspiration. GASTROINTESTINAL INTERVENTION 2013. [DOI: 10.1016/j.gii.2013.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Itoi T, Kasuya K, Sofuni A, Itokawa F, Kurihara T, Yasuda I, Nakai Y, Isayama H, Moriyasu F. Endoscopic ultrasonography-guided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc 2013; 25:241-52. [PMID: 23490022 DOI: 10.1111/den.12048] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 01/15/2013] [Indexed: 12/13/2022]
Abstract
Endoscopic ultrasonography-guided (EUS)-guided pancreatic interventions have gained increasing attention. Here we review EUS-guided pancreatic duct (PD) access techniques and outcomes. EUS-guided PD intervention is divided into two types, antegrade and rendezvous techniques, following EUS-guided pancreatography. In the antegrade technique, pancreaticoenterostomy is carried out by stent placement between the PD and the stomach, duodenum, or jejunum. Transenteric antegrade PD stenting is conducted by stent placement, advancing anteriorly into the PD through the pancreatic tract. The rendezvous technique is carried out by using a guidewire through the papilla or anastomotic site for retrograde stent insertion. In terms of EUS-guided PD stenting, 11 case reports totaling 75 patients (35 normal anatomy, 40 altered anatomy) have been published. The technical success rate was greater than 70%. Early adverse events, including severe hematoma and severe pancreatitis,occurred in seven (63.6%) of 11 reports. Regarding the rendezvous technique, 12 case reports totaling 52 patients (22 normal anatomy, 30 altered anatomy) have been published. The technical success rate ranged from 25% to 100%. It was 48% in one report that involved more than 20 cases. Once stents were placed, all patients became free of symptoms. Early mild adverse events occurred in four (36.4%) of 11 reports. In conclusion, although it can be risky because of possible serious or even fatal adverse events, including pancreatic juice leakage, perforation and severe acute pancreatitis, EUS-PD access seems to be promising for treating symptomatic pancreatic diseases caused by PD stricture and pancreaticoenterostomy stricture.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo 160-0023, Japan.
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