Contrast-enhanced harmonic endoscopic ultrasound-guided drainage of a postoperative pancreatic fistula

The effectiveness of endoscopic ultrasound (EUS)-guided drainage of a postoperative pancreatic fistula (POPF) has been reported [1] [2] [3]. It is sometimes difficult to distinguish a POPF from surrounding organs and tissues because echogenicity of necrotic or infected tissue becomes as high as that of surrounding tissue in a POPF. Contrast-enhanced harmonic EUS (CH-EUS) may help to identify the spread of a POPF. Here, we present a video case of CH-EUS-guided drainage of a POPF after pancreaticoduodenectomy.

A 66-year-old man with bile duct cancer underwent pancreaticoduodenectomy at our hospital. Eighteen days later, he developed abdominal pain and high fever due to POPF. Contrast-enhanced computed tomography detected a POPF (50 × 25 mm) around the pancreas ([Fig. 1]). We attempted EUS-guided drainage; however, the spread of the POPF could not be identified by fundamental B-mode EUS. There was no anechoic lesion, but a high echoic area around the pancreas. Therefore, we performed CH-EUS to identify the spread of the POPF. Fifteen seconds after infusion of 0.7 mL contrast agent, the avascular area of the high echoic area was identified in a CH-EUS image ([Fig. 2], [Video 1]). The POPF was punctured using a 19-gauge needle under CH-EUS, and its lumen was recognized by injecting contrast medium via this needle. A 0.025-inch guidewire was inserted through the needle and coiled into the POPF. The needle was withdrawn and the guidewire was left inside the POPF. A 7-Fr endoscopic nasobiliary drainage tube was deployed into the POPF for drainage.

Fig. 1 Contrast-enhanced computed tomography showed that there was fluid collection around the pancreas (yellow arrowheads).

Fig. 2 Endoscopic ultrasound images. a A heterogeneous high echoic area without anechoic lesion was observed on a fundamental B-mode image. b An avascular area with a sharp margin (yellow arrowheads) was seen on a contrast-enhanced harmonic image. The postoperative pancreatic fistula was punctured with a 19-gauge needle under guidance of contrast-enhanced harmonic endoscopic ultrasound.

Video 1 Contrast-enhanced harmonic endoscopic ultrasound-guided drainage of a postoperative pancreatic fistula.

Abdominal pain improved and the size of the POPF and amount of pancreatic juice drained via the external tube decreased ([Fig. 3]). Ten days later, we cut the external drainage tube, dropped it into the stomach ([Fig. 4]), and used it as an internal catheter for POPF drainage because clinical improvement had been observed.

Fig. 3 Contrast-enhanced computed tomography images. a Before endoscopic ultrasound (EUS)-guided drainage, showing fluid collection around the pancreas. b At 10 days after performing EUS-guided drainage, showing that the fluid collection around the pancreas had resolved.

Fig. 4 Endoscopy image showing the external drainage tube after it was dropped into the stomach.

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• References

• 1 Kwon YM, Gerdes H, Schattner MA. et al. Management of peripancreatic fluid collections following partial pancreatectomy: a comparison of percutaneous versus EUS-guided drainage. Surg Endosc 2013; 27: 2422-2427
• 2 Onodera M, Kawakami H, Kuwatani M. et al. Endoscopic ultrasound-guided transmural drainage for pancreatic fistula or pancreatic duct dilation after pancreatic surgery. Surg Endosc 2012; 26: 1710-1717
• 3 Varadarajulu S, Wilcox CM, Christein JD. EUS-guided therapy for management of peripancreatic fluid collections after distal pancreatectomy in 20 consecutive patients. Gastrointest Endosc 2011; 74: 418-423