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CC BY 4.0 · Endoscopy 2024; 56(S 01): E990-E991
DOI: 10.1055/a-2445-8419
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Peroral pancreatoscopy-guided lithotripsy via an endoscopic ultrasonography-guided pancreatogastrostomy

Authors

  • Masatoshi Murakami 

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

  • Nao Fujimori

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

  • Akihiko Suenaga

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

  • Yumeka Kawaguchi

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

  • Akihisa Ohno 

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

  • Kazuhide Matsumoto

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan

  • Keijiro Ueda

    1   Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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A 72-year-old man with autoimmune pancreatitis type 2 presented with acute pancreatitis due to an impacted pancreatic stone ([Fig. 1]). Immediate transpapillary drainage was unsuccessful, leading us to attempt drainage via endoscopic ultrasonography-guided pancreaticogastrostomy (EUS-PGS) ([Video 1]).

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Fig. 1 Imaging studies. a Computed tomography scan showing multiple pancreatic stones, with a maximum size of 10 mm (arrow), in the pancreatic head. b Magnetic resonance imaging revealing a dilated main pancreatic duct, with a maximum diameter of 8 mm.
Endoscopic ultrasonography-guided pancreaticogastrostomy for stone removal and stent placement.Video 1

A linear echoendoscope (EG-740UT; Fujifilm, Tokyo, Japan) was used to puncture the pancreatic duct with a 19-G fine-needle aspiration needle (EZ Shot 3 Plus; Olympus, Tokyo, Japan). The guidewire was successfully advanced into the duodenum using a 3-Fr microcatheter (Daimon ERCP catheter; Hanaco Medical, Saitama, Japan), which improved guidewire control. After the punctured tract over the stones had been dilated with a drill dilator (Tornus ES; Asahi Intecc, Aichi, Japan), a plastic stent (TYPE-IT; Gadelius Medical, Tokyo, Japan) was placed ([Fig. 2] a).

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Fig. 2 Stone fragmentation and removal. a Easy dilation of the puncture tract over the stone using a drill dilator (Tornus catheter; Asahi Intecc, Aichi, Japan), despite challenges with endoscopic retrograde cholangiopancreatography and balloon catheters. b Electrohydraulic lithotripsy fragmentation and stone removal by pushing the peroral pancreatoscope into the duodenum (arrow; electrohydraulic lithotripsy probe). Procedures were performed using a 9-Fr peroral pancreatoscope (eyeMAX; Micro-Tech, Nanjing, China). c Endoscopic confirmation of minimal residual stones.

One month later, a 9-Fr peroral pancreatoscope (POPS) (eyeMAX; Micro-Tech, Nanjing, China) was inserted via the EUS-PGS, and the stones were fragmented using electrohydraulic lithotripsy (EHL; Nortech AUTOLITH lithotripter with a 1.9-Fr probe; Northgate Technologies, Illinois, USA). Following endoscopic pancreatic sphincterotomy using a rendezvous technique, the fragmented stones were completely crushed transgastrically and removed by pushing the POPS through the papilla ([Fig. 2] b, c). Due to obstruction of the papilla by the fragmented stones, stent placement via the EUS-PGS was not possible. The stones were therefore removed endoscopically using grasping forceps, and the stent was pulled out from the papilla under fluoroscopic guidance to secure the EUS-PGS route. The patient remained asymptomatic 2 months after the intervention.

Recently, numerous procedures have been conducted via EUS-PGS [1], and the efficacy of transgastric POPS with EHL has been documented [2] [3] [4]. In the current case, the stones were successfully removed by propelling the POPS through the papilla into the duodenum, in conjunction with conventional endoscopic retrograde cholangiopancreatography techniques. Stone removal using POPS via EUS-PGS could potentially be a valuable treatment option for challenging stones.

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Conflict of Interest

The authors declare that they have no conflict of interest.


Correspondence

Nao Fujimori, MD, PhD
Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University
3-1-1 Maidashi
Higashi-ku, Fukuoka 812-8582
Japan   

Publication History

Article published online:
13 November 2024

© 2024. 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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Zoom
Fig. 1 Imaging studies. a Computed tomography scan showing multiple pancreatic stones, with a maximum size of 10 mm (arrow), in the pancreatic head. b Magnetic resonance imaging revealing a dilated main pancreatic duct, with a maximum diameter of 8 mm.
Zoom
Fig. 2 Stone fragmentation and removal. a Easy dilation of the puncture tract over the stone using a drill dilator (Tornus catheter; Asahi Intecc, Aichi, Japan), despite challenges with endoscopic retrograde cholangiopancreatography and balloon catheters. b Electrohydraulic lithotripsy fragmentation and stone removal by pushing the peroral pancreatoscope into the duodenum (arrow; electrohydraulic lithotripsy probe). Procedures were performed using a 9-Fr peroral pancreatoscope (eyeMAX; Micro-Tech, Nanjing, China). c Endoscopic confirmation of minimal residual stones.