A novel peroral pancreatoscopy combined endoscopic ultrasonography-assisted rendezvous procedure: a new strategy for bridging disconnected pancreatic duct syndrome

A 48-year-old man with a history of acute necrotizing pancreatitis presented to our institution for management of a persistent external pancreatic fistula. He had required percutaneous catheter drainage for a pseudocyst in the pancreatic neck before this complication. A pancreatogram showed that the pseudocyst was in communication with the main pancreatic duct (MPD) in the head; however, there was no opacification of the upstream MPD, confirming complete MPD disconnection ([Fig. 1]). It had not been possible to traverse the MPD disconnection with a guidewire during prior attempts.

Fig. 1 Fluoroscopic image during endoscopic retrograde cholangiopancreatography and accompanying schematic showing the pseudocyst with no opacification of the upstream main pancreatic duct, confirming disconnected pancreatic duct syndrome.

We attempted to advance a novel peroral cholangiopancreatoscope (“eyeMax”, 9 Fr; Micro-Tech Co., Ltd., Nanjing, China) across the papilla into the pseudocyst but were unable to find the opening of the upstream MPD. Therefore, we decided to use the endoscopic ultrasonography-assisted rendezvous technique (EUS-RV) to help locate the opening with the cholangiopancreatoscope. Using a linear echoendoscope, the upstream MPD was recognized and punctured with a 19G fine-needle aspiration (FNA) needle in the stomach. A second guidewire was inserted through the needle into the MPD and further down into the pseudocyst ([Fig. 2]). Under pancreatoscopic guidance again, we were able to see the EUS guidewire coming out of the disrupted orifice of the upstream MPD ([Fig. 3]). Following the EUS guidewire, the cholangiopancreatoscope guidewire was smoothly inserted into the upstream MPD ([Video 1]). An endoscopic retrograde cholangiopancreatography (ERCP) catheter was used to adjust the direction of the guidewire to gain deep access to the MPD and a 7-Fr × 9-cm single-pigtail plastic stent was placed via the papilla across the disconnection ([Fig. 4]; [Video 1]). The percutaneous drainage catheter was removed, with successful closure of the cutaneous opening of the fistula noted 2 months later.

Fig. 2 Fluoroscopic image showing endoscopic ultrasonography-guided puncture of the upstream main pancreatic duct, with the guidewire passing into the pseudocyst.

Fig. 3 Peroral pancreatoscopy showing the endoscopic ultrasonography guidewire in the pseudocyst.

Video 1 A completely disrupted pancreatic duct is bridged using a novel peroral cholangiopancreatoscope combined with an endoscopic ultrasonography-assisted rendezvous technique.

Fig. 4 Fluoroscopic image showing a single-pigtail plastic stent that was placed via the papilla across the disconnection of the main pancreatic duct.

In conclusion, the combination of ERCP, EUS, and peroral pancreatoscopy offers a novel, accurate, and microinvasive treatment method for pancreatic duct related disorders [1] [2] [3].

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• References

• 1 Baron TH, DiMaio CJ, Wang AY. et al. American Gastroenterological Association Clinical Practice Update: Management of pancreatic necrosis. Gastroenterology 2020; 158: 67-75
• 2 Verma S, Rana SS. Disconnected pancreatic duct syndrome: Updated review on clinical implications and management. Pancreatology 2020; 20: 1035-1044
• 3 Varadarajulu S, Noone TC, Tutuian R. et al. Predictors of outcome in pancreatic duct disruption managed by endoscopic transpapillary stent placement. Gastrointest Endosc 2005; 61: 568-575