Endoscopy 2021; 53(04): 450-451
DOI: 10.1055/a-1216-0809
E-Videos

Salvage endoscopic ultrasound-guided rendezvous technique for disconnected pancreatic duct syndrome in a patient with severe acute pancreatitis

Shinichi Hashimoto
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
,
Hiromichi Iwaya
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
,
Shiroh Tanoue
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
,
Yusuke Fujino
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
,
Makoto Hinokuchi
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
,
Shiho Arima
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
,
Akio Ido
Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Kagoshima, Japan
› Author Affiliations
 

Disconnected pancreatic duct syndrome (DPDS) is characterized by extraductal leakage of pancreatic juice and destruction of tissue surrounding the pancreas [1]. Many DPDS cases need surgical treatment [2]. Transpapillary pancreatic stenting and endoscopic ultrasound (EUS)-guided transmural drainage of PD and walled-off necrosis (WON) are also reported to be effective for DPDS [2] [3] [4]. The EUS-guided rendezvous technique (EUS-RV) was shown to be effective as a salvage procedure to connect to the disruption directly when drainage procedures to treat DPDS proved ineffective.

A 60-year-old man suffered from severe pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) for PD stenosis of the pancreatic head. He was transferred to our hospital for further treatment because his WON-related symptoms ([Fig. 1]) had worsened. We performed EUS-guided transmural drainage for the infected WON and percutaneous drainage for the abdominal effusion with a high amylase level. ERCP was performed for drainage to relieve the DPDS. Pancreatography showed only the proximal PD and extravasation of contrast medium in the WON ([Fig. 2a]). A nasocystic tube was placed in the WON via the PD because guidewire negotiation to the distal PD had failed ([Fig. 2b]). Pancreatic juice still leaked, so EUS-RV was performed to treat the DPDS ([Video 1]).

Zoom Image
Fig. 1 Computed tomography at the previous hospital revealed multiple walled-off necrosis (arrows).
Zoom Image
Fig. 2 Pancreatography. a The proximal pancreatic duct without the distal duct and extravasation of contrast medium to the walled-off necrosis. b A nasocystic drainage tube (arrows) was placed in the walled-off necrosis that communicated with the pancreatic duct. Percutaneous drainage of the abdominal effusion had been performed previously (arrowhead).

Video 1 Effective endoscopic ultrasound-guided rendezvous technique to connect to a pancreatic duct that had become disconnected due to severe acute pancreatitis.


Quality:

The PD was punctured transgastrically by a 19-gauge needle (EZ shot 3 Plus; Olympus Medical, Tokyo, Japan), and a 0.025-inch hydrophilic guidewire was manipulated through the duodenal papilla along the nasocystic tube ([Fig. 3a]). The echoendoscope was switched to a duodenoscope. The guidewire was grasped and brought into the accessory channel. Another catheter was cannulated over the guidewire to the PD. Finally, an 8.5-Fr pancreatic stent (Olympus Medical) was placed across the disconnected PD ([Fig. 3b]). The exudate fluid was markedly reduced with external drainage, so the patient was transferred to the previous hospital 9 days after PD stenting without any complications.

Zoom Image
Fig. 3 The endoscopic ultrasound-guided rendezvous technique. a A hydrophilic guidewire was advanced across the papilla of Vater after puncture of the pancreatic duct, using the nasocystic tube as a guide. b A pancreatic stent was placed to connect to the disconnected pancreatic duct.

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Competing interests

The authors declare that they have no conflicts of interest.


Corresponding author

Shinichi Hashimoto, MD
Digestive and Lifestyle Diseases
Kagoshima University Graduate School of Medical and Dental Sciences
Kagoshima
8-35-1 Sakuragaoka
Kagoshima 890-8520
Japan   
Fax: +81-99-2643504   

Publication History

Publication Date:
24 July 2020 (online)

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Computed tomography at the previous hospital revealed multiple walled-off necrosis (arrows).
Zoom Image
Fig. 2 Pancreatography. a The proximal pancreatic duct without the distal duct and extravasation of contrast medium to the walled-off necrosis. b A nasocystic drainage tube (arrows) was placed in the walled-off necrosis that communicated with the pancreatic duct. Percutaneous drainage of the abdominal effusion had been performed previously (arrowhead).
Zoom Image
Fig. 3 The endoscopic ultrasound-guided rendezvous technique. a A hydrophilic guidewire was advanced across the papilla of Vater after puncture of the pancreatic duct, using the nasocystic tube as a guide. b A pancreatic stent was placed to connect to the disconnected pancreatic duct.