Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) is considered if the
pancreatic duct approach under endoscopic retrograde cholangiopancreatography guidance
is unsuccessful due to failure of pancreatic duct cannulation or an inaccessible papilla
[1]
[2]
[3]. During EUS-PD, guidewire manipulation may be one of the limiting steps, especially
in nonexpert hands [4]. Guidewire manipulation may fail due to the guidewire shearing against the needle.
During EUS-guided hepaticogastrostomy, to prevent guidewire shearing, the liver impaction
technique can be attempted [5]; however, during EUS-PD, the short length of pancreatic parenchyma on the puncture
route may render this technique challenging. To overcome this, technical tips for
a needle-free technique during EUS-PD are described.
A 71-year-old man was admitted to our hospital with stricture of the pancreatojejunostomy.
As the enteroscopic approach had failed, EUS-PD was attempted. First, the main pancreatic
duct was punctured using a 19-gauge needle, and then a 0.025-inch guidewire with an
angle tip was inserted; however, the guidewire was advanced into the pancreatic tail
instead of the head ([Fig. 1]). Attempts were made to change direction by pulling the guidewire; however, this
was unsuccessful because of shearing against the needle. In addition, the short length
of pancreatic parenchyma on the puncture route meant that the impaction technique
could not be performed. Therefore, the needle was first completely retracted into
the needle sheath ([Fig. 2]). By doing so, the tip of the needle was protected by the sheath and guidewire shearing
could not occur. After this procedure, it was possible to manipulate the guidewire
easily and smoothly. The guidewire was pulled gently ([Fig. 3]
a) and successfully advanced toward the stricture site ([Fig. 3]
b). After tract dilation, a 7-Fr plastic stent was successfully deployed without any
adverse events ([Video 1]).
Fig. 1 The guidewire was advanced into the pancreatic tail.
Fig. 2 To prevent guidewire shearing, the needle was completely retracted into the needle
sheath (arrow). a Endoscopic ultrasound guidance. b Fluoroscopic guidance.
Fig. 3 Fluoroscopic images. a Guidewire manipulation was performed smoothly. b Guidewire deployment into the head of the pancreas was successfully performed.
Needle-free technique for guidewire manipulation during endoscopic ultrasound-guided
pancreatic duct drainage.Video 1
In conclusion, the present technique might be useful for guidewire manipulation during
EUS-PD.
Endoscopy_UCTN_Code_TTT_1AS_2AD
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