A release from WONderland: endoscopic ultrasonography-guided reconnection of disconnected pancreatic ducts across a walled-off necrosis cavity

Disconnected pancreatic duct syndrome (DPDS) in cases with walled-off necrosis (WON) is associated with recurrence of pancreatic fluid collection [1] and new-onset diabetes [2]. Transpapillary stent placement across disconnected pancreas has been attempted but the technical success rate of this procedure is low [3] [4].

An 82-year-old man was hospitalized for endoscopic management of DPDS. Computed tomography revealed a disconnected pancreas by the intervening WON and endoscopic retrograde pancreatography confirmed complete disconnection of the main pancreatic duct (MPD) ([Fig. 1]). As transpapillary stent placement across the disconnected MPD was unsuccessful, we proceeded to reconnection of the MPD using a rendezvous technique [5].

Fig. 1 Complete disconnection of the main pancreatic duct at the body of the pancreas in a patient with walled-off necrosis (WON) associated with biliary pancreatitis. A double-pigtail stent was previously placed into the cavity of the WON from the duodenum. a Coronal view of computed tomography delineated a disconnection between upstream (arrowhead) and downstream (arrow) pancreatic ducts for 3 cm. b Endoscopic retrograde pancreatography.

First, the distal MPD was punctured using a 19-gauge needle (EZshot3; Olympus Medical, Tokyo, Japan) under endoscopic ultrasonography (EUS) guidance ([Fig. 2]). Pancreatogram revealed complete obstruction of the MPD at the pancreas body and a plastic stent was inserted in a retrograde fashion into the tail of the pancreas. In the second session after fistula maturation, a guidewire was advanced through the occluded MPD, and a plastic stent was inserted into the WON cavity. In the third session, a guidewire was successfully advanced across the disconnected pancreas into the downstream MPD, and then the duodenum ([Fig. 3 a]). Leaving the guidewire in situ, a duodenoscope was advanced to the ampulla, and the guidewire left in the duodenum was withdrawn through the working channel in a rendezvous fashion. Subsequently, by using a double-lumen catheter (Uneven double lumen cannula; Kaneka, Osaka, Japan), a second guidewire was successfully advanced into the pancreas tail ([Fig. 3 b]). Finally, a 5-Fr transpapillary stent was successfully placed across the disconnected pancreas.

Fig. 2 Endoscopic ultrasonography-guided pancreatography revealed disconnection of the main pancreatic duct.

Fig. 3 The rendezvous technique using a guidewire passed through the cavity of the walled-off necrosis (WON). a A 0.025-inch guidewire was advanced in an antegrade manner through the gastropancreatico fistula to the WON cavity, the downstream main pancreatic duct, and the duodenum. b The guidewire was successfully advanced into the tail of the pancreas in a retrograde manner alongside the rendezvous guidewire.

Although short-term outcomes of WON have improved due to the development of endoscopic treatment, DPDS potentially poses long-term consequences for patients. This EUS-guided rendezvous approach ([Video 1]) may be an effective treatment option that enables the reconnection of a completely disconnected MPD.

Video 1 Reconnection of completely disconnected pancreatic ducts across a walled-off necrosis cavity using an endoscopic ultrasound-guided rendezvous technique.

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Competing Interests

Y. Nakai declares research funding from Boston Scientific Japan, Century Medical, Fujifilm, Gadelius Medical, Hitachi Medical, Kaneka, and Medico’s Hirata; this work was not supported by any of those companies. M. Fujishiro received lecture honoraria from Olympus Co. and Fujifilm Co., and research grant from Olympus Co., and Fujifilm Co. outside the submitted work. T. Sato, T. Saito, and T. Hamada declare that they have no conflict of interest.

^* These authors are members of the WONDERFUL (WON and peripancreatic fluid collection) study group in Japan.

• References

• 1 Hamada T, Iwashita T, Saito T. et al. Disconnected pancreatic duct syndrome and outcomes of endoscopic ultrasound-guided treatment of pancreatic fluid collections: systematic review and meta-analysis. Dig Endosc 2021;
• 2 Basha J, Lakhtakia S, Nabi Z. et al. Impact of disconnected pancreatic duct on recurrence of fluid collections and new-onset diabetes: do we finally have an answer?. Gut 2021; 70: 447-449
• 3 Amin S, Yang DJ, Lucas AL. et al. There is no advantage to transpapillary pancreatic duct stenting for the transmural endoscopic drainage of pancreatic fluid collections: a meta-analysis. Clin Endosc 2017; 50: 388-394
• 4 Yang D, Amin S, Gonzalez S. et al. Transpapillary drainage has no added benefit on treatment outcomes in patients undergoing EUS-guided transmural drainage of pancreatic pseudocysts: a large multicenter study. Gastrointest Endosc 2016; 83: 720-729
• 5 Ishii K, Itoi T, Tsuchiya T. et al. EUS-guided pancreatic duct rendezvous in a child with traumatic pancreatic duct disruption. Gastrointest Endosc 2014; 80: 519-520

Publication History

Article published online:
10 October 2022