The patient was a 58-year-old man with a long-standing history of alcohol abuse and
chronic pancreatitis leading to multiple hospitalizations. He continued to have pain
despite conservative management, pain control, and alcohol cessation. His chronic
pancreatitis and pancreatic duct (PD) stones resulted in a tight PD stricture at the
head of the pancreas. Multiple prior attempts at conventional endoscopic retrograde
cholangiopancreatography (ERCP) had failed. He presented to our institution seeking
advanced therapy after extracorporeal shock wave lithotripsy (ESWL). At our index
ERCP we could not get conventional transpapillary access to the PD. Instead, given
his stone burden, after ESWL, we chose to treat him with an EUS-guided pancreaticogastrostomy,
and placement of a fully covered self-expanding metal stent (FCSEMS) followed by a
pancreatoscopy with holmium laser lithotripsy ([Fig. 1] and [Fig. 2]). The patient responded to treatment, with resolution of his pain at 12 months after
the intervention.
Fig. 1 Echoendoscope with a guidewire in a dilated pancreatic duct that is being injected
with contrast. Transpapillary access for placement of a fully covered metal stent
had not been successful in this patient with chronic pancreatitis and pancreatic duct
stones.
Fig. 2 Pancreatoscopy shows two of the pancreatic duct stones inside the dilated pancreatic
duct, before initiation of laser lithotripsy.
Video 1 Endoscopic ultrasound-guided access into the main pancreatic duct, with placement
of a fully covered metal stent creating a pancreaticogastrostomy. In a repeat procedure,
access via the pancreaticogastrostomy was used to perform laser lithotripsy of pancreatic
stones.
In chronic pancreatitis, chronic inflammation causes endocrine and exocrine insufficiency,
pancreatic atrophy, calcification, and multiple pancreatic duct strictures that lead
to chronic pain [1]. This chronic disease has much associated morbidity. Current therapies include pain
control and supportive measures aimed at treatment of endocrine and exocrine insufficiencies.
PD strictures and PD stones frequently accompany chronic pancreatitis. Endoscopic
management of chronic pancreatitis includes ERCP with transpapillary plastic stent
placement, PD balloon dilation, and ESWL for PD stones. FCSEMS placement has been
reported as a treatment for refractory PD strictures in patients in whom other therapeutic
modalities have failed [2]. However, in the patient described here, a conventional transpapillary ERCP approach
for placement of the FCSEMS was not successful, and we used an EUS-guided technique
to place an FCSEMS, and we then used this access for laser lithotripsy [3].
EUS-guided pancreaticogastrostomy is an option when conventional transpapillary stent
placement is not possible. This case illustrates that pancreaticogastrostomy can be
used as access for laser lithotripsy.
Endoscopy_UCTN_Code_TTT_1AR_2AI
Endoscopy E-Videos is an open-access online section, reporting on interesting cases ans new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions ara freely accessible online.
This section has its own submission website at https://mc.manuscript-central.com/e-videos.
