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]).
Fig. 1 Computed tomography at the previous hospital revealed multiple walled-off necrosis
(arrows).
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.
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.
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.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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