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CC BY 4.0 · Endoscopy 2024; 56(S 01): E544-E545
DOI: 10.1055/a-2334-0926
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Pancreatic duct occlusion after endoscopic ultrasound-guided transmural pancreatic duct drainage: a pitfall and its rescue technique

Anthony Rivera Gerodias
1   Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
2   Institute of Digestive and Liver Diseases, Department of Medicine, Saint Lukeʼs Medical Center, Quezon City, Philippines (Ringgold ID: RIN37064)
,
Akihisa Ohno 
1   Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
,
Yasuhiro Komori
1   Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
,
Yosuke Minoda
1   Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
,
Keijiro Ueda
1   Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
,
Tomohiko Moriyama
3   International Medical Department, Kyushu University Hospital, Fukuoka, Japan (Ringgold ID: RIN145181)
,
Nao Fujimori
1   Department of Medicine and Bioregulatory Science, Kyushu University, Graduate School of Medical Sciences, Fukuoka, Japan
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Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PDD) is a procedure to access the pancreatic duct in cases of failed endoscopic retrograde cholangiopancreatography (ERCP) [11] [22]. In patients with surgically altered anatomy, transmural drainage is the preferred technique [33]. A single-pigtail plastic stent designed for EUS-PDD has been developed with favorable outcomes [44] ([Fig. 1Fig. 1]).

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

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

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

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Fig. 2 Fig. 2 a Endoscopic view of pancreatic stent protruding from jejunal-pancreatic duct anastomotic site. b Fluoroscopic view of endoscope accessing the pancreatic stent from jejunal-pancreatic duct anastomotic site. c Endoscopic view of mechanical dilatation of the pancreatic duct. d Fluoroscopic view of mechanical dilatation of the pancreatic duct. e Endoscopic view of post-insertion of additional pancreatic stent. f Fluoroscopic view post-insertion of additional pancreatic stent.
Endoscopic ultrasound-guided pancreatic duct drainage following failure of balloon endoscopic retrograde cholangiopancreatography. Stent insertion was completed; however, the patient developed acute pancreatitis post-procedure and hence a rescue procedure was performed.Video 1Video 1

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

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

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

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Publication History

Article published online:
01 July 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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