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DOI: 10.1055/a-2638-3110
Endoscopic ultrasound-guided pancreatic ring drainage via a pancreaticoenteric fistula
A 50-year-old patient with a history of necrotizing pancreatitis and disconnected pancreatic duct syndrome (DPDS) was referred for endoscopic management [1]. Cross-sectional imaging revealed a dilated main pancreatic duct (PD) with an abrupt cutoff at the genu ([Fig. 1]).
During initial endoscopic retrograde pancreatography, a 0.018-in. guidewire and cannula could only be advanced into the ventral PD. A contrast pancreatogram revealed a cut-off at the genu. A 5-Fr by 3-cm pancreatic stent was placed for pancreatitis prophylaxis and as a marker for endoscopic ultrasound-guided PD drainage.
Initial transgastric endosonographic views showed the PD dilated to 5 mm, which was punctured with a 19-G needle ([Video 1]). A contrast pancreatogram showed the duct in the body and tail and no PD opacification in the head. Pressurization of the PD with contrast showed a small fistulous tract communicating with the small bowel, likely sequelae from prior necrotizing pancreatitis ([Fig. 2]). We utilized this fistulous tract to perform ring drainage [2].
Endoscopic ultrasound-guided pancreatic ring drainage via a spontaneous pancreaticoenteric fistula for management of disconnected pancreatic duct syndrome.Video 1
A 0.025-in. guidewire was advanced into the PD, through the fistulous tract, and coiled in the small bowel. A 6-Fr cystotome was used to access the PD. This was followed by tract dilation with a 4- to 6-Fr rigid dilator and a 4-mm balloon dilator ([Fig. 3]). One 7-Fr by 15-cm double-pigtail plastic stent was placed, with the distal pigtail deployed in the small bowel lumen and the proximal pigtail in the gastric lumen ([Fig. 4]).
At 13 months following her initial procedure, the patient’s recurrent episodes of pain have resolved. She continues to do well with regular stent exchanges twice yearly.
Endoscopic management of DPDS is often limited by an inability to pass a guidewire and any devices across the disconnected segment [3]. Here, we report a pragmatic approach whereby a spontaneous fistula was used to enable ring drainage with successful management of DPDS.
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Publication History
Article published online:
29 July 2025
© 2025. 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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References
- 1 Verma S, Rana SS. Disconnected pancreatic duct syndrome: updated review on clinical implications and management. Pancreatology 2020; 20: 1035-1044
- 2 Krafft MR, Nasr JY. Anterograde endoscopic ultrasound-guided pancreatic duct drainage: a technical review. Dig Dis Sci 2019; 64: 1770-1781
- 3 Wang Z-J, Song Y-H, Li S-Y. et al. Endoscopic management of pancreatic fluid collections with disconnected pancreatic duct syndrome. Endosc. Ultrasound 2023; 12: 29-37