Endoscopic ultrasound-guided pancreatic duct drainage with a two-step puncture technique for a non-dilated pancreatic duct

Abstract

Figures

a Endoscopic ultrasound revealed a 2-mm non-dilated pancreatic duct (arrow). b Contrast injection showing pancreatogram.

The pancreatic duct was dilated by the continuous injection of contrast medium.

a The dilatation of the pancreatic duct by contrast injection (arrow) facilitated re-puncture by the fine-needle. b The guidewire could be advanced into the pancreatic duct

A plastic stent was placed from the jejunum to the stomach through the pancreatic duct.

Full text

Endoscopic ultrasound-guided pancreatic duct drainage (EUS-PD) has emerged as an option in patients with failure of standard transpapillary endoscopic retrograde access to the pancreatic duct (PD) or surgically altered anatomy 1 . The ductal pressure of a non-dilated PD is often low and the duct can be easily compressed by the tip of the needle, thus requiring a technical tip to handle this situation 2 . We describe successful EUS-PD with a two-step puncture technique for a non-dilated PD after pancreaticoduodenectomy as a result of solid pseudopapillary neoplasm ( Video 1 ).

Endoscopic ultrasound-guided pancreatic duct drainage with two-step puncture technique for a non-dilated pancreatic duct was achieved. This method is effective for draining a non-dilated pancreatic duct.Video 1

An 18-year-old woman was referred to our hospital because of gradual PD dilatation after pancreaticoduodenectomy. A double-balloon endoscopy was performed but failed to detect the pancreatic-jejunal anastomosis. Subsequently, EUS-PD was performed. A convex ultrasound gastrovideoscope (GF-UCT260; Olympus, Tokyo, Japan) was used to puncture from the gastric stomach to the caudal PD with a 22-gauge EUS-guided fine-needle (EZ Shot 3 Plus, Olympus). EUS and fluoroscopy both revealed a 2-mm non-dilated PD ( Fig. 1 a , b ), but an 0.018-inch guidewire (Fielder, Olympus) could not be advanced into the non-dilated PD. Therefore, contrast injection was continued to temporarily increase the ductal pressure and dilate the PD ( Fig. 2 ). The dilated PD facilitated subsequent re-puncture by a fine needle and allowed the guidewire to proceed into the PD ( Fig. 3 a , b ). Then the puncture tract was dilated using a 7 Fr drill dilator (Tornus ES, Olympus). After dilation of the tract, an MTW catheter (ABIS, Tokyo, Japan) was inserted into the PD. An 0.025-inch guidewire was advanced through the PJA. Then the PJA was dilated with a 3-mm diameter balloon catheter (REN, Kaneka Medix, Osaka, Japan). Finally, a 15-cm 7 Fr plastic stent (TYPE-IT; Gadelius Medical K.K., Tokyo, Japan) was placed from the jejunum to the stomach through the PD ( Fig. 4 ). No complications were observed after the procedure.

a Endoscopic ultrasound revealed a 2-mm non-dilated pancreatic duct (arrow). b Contrast injection showing pancreatogram.

The pancreatic duct was dilated by the continuous injection of contrast medium.

a The dilatation of the pancreatic duct by contrast injection (arrow) facilitated re-puncture by the fine-needle. b The guidewire could be advanced into the pancreatic duct

A plastic stent was placed from the jejunum to the stomach through the pancreatic duct.

EUS-PD with a two-step puncture technique is effective for draining a non-dilated PD.

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