The endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a useful procedure
for difficult cannulation of not only the bile duct, but also the pancreatic duct
[1]
[2]
[3]
[4]. In addition, if guidewire passage from the papilla across the obstructed site is
challenging, antegrade guidewire insertion under EUS guidance is one of several possible
methods. Herein, we describe a two-step EUS-RV technique combined with antegrade electrohydraulic
lithotripsy (EHL) for a huge pancreatic duct stone.
A 48-year-old man was admitted to our hospital with obstructive jaundice and acute
pancreatitis due to chronic pancreatitis that was complicated by a huge pancreatic
duct stone. Endoscopic retrograde cholangiopancreatography (ERCP) was therefore attempted.
First, biliary drainage using a fully covered metal stent was successfully performed.
Pancreatic duct drainage was then attempted; however, although pancreatic duct cannulation
could be performed, passage of the guidewire failed. Therefore, EUS-guided pancreatic
duct drainage was performed using a 6-mm covered metal stent.
After 1 week, the covered metal stent was removed and, to obtain partial stone fragmentation,
antegrade EHL was attempted using a digital single-operator cholangiopancreatoscope
(SPY-DS; Boston Scientific) ([Fig. 1] and [Fig. 2]). After stone fragmentation had been partially obtained, guidewire passage beyond
the huge pancreatic duct stone was again attempted, with the guidewire this time being
successfully deployed ([Fig. 3 a]). Next, the duodenoscope was removed, leaving the guidewire in position, before
the scope was advanced again to the region of the papilla. The guidewire was grasped
using biopsy forceps ([Fig. 3 b]) and pulled into the scope channel. An ERCP catheter was then inserted, with successful
passage of the catheter across the huge pancreatic duct stone. Finally, a plastic
stent was deployed without any adverse events ([Fig. 3 c]; [Video 1]).
Fig. 1 Radiographic image showing antegrade electrohydraulic lithotripsy being performed
through an endoscopic ultrasound-guided pancreatic duct drainage route.
Fig. 2 Endoscopic view showing partial fragmentation of the pancreatic duct stone.
Fig. 3 Radiographic images showing: a the guidewire being successfully advanced beyond the huge pancreatic duct stone and
through the ampulla of Vater into the intestine; b endoscopic ultrasound-guided rendezvous technique being attempted; c a plastic stent successfully deployed.
Video 1 Endoscopic ultrasound-guided rendezvous (EUS-RV) technique combined with antegrade
electrohydraulic lithotripsy (EHL). After guidewire placement, the covered metal stent
is removed. A digital pancreatoscope is then inserted into the main pancreatic duct
through the fistula and antegrade EHL is performed, resulting in partial stone fragmentation.
The guidewire can now be advanced into the intestine across the huge pancreatic duct
stone and through the ampulla of Vater. The EUS-guided rendezvous technique is then
performed and, finally, a plastic stent is successfully deployed.
Our technique may be useful for situations where it is challenging to pass the guidewire
across a site of obstruction.
Endoscopy_UCTN_Code_TTT_1AS_2AD
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
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