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

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.

Fig. 1 a Endoscopic ultrasound revealed a 2-mm non-dilated pancreatic duct (arrow). b Contrast injection showing pancreatogram.

Fig. 2 The pancreatic duct was dilated by the continuous injection of contrast medium.

Fig. 3 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

Fig. 4 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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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Tyberg A, Sharaiha RZ, Kedia P. et al. EUS-guided pancreatic drainage for pancreatic strictures after failed ERCP: a multicenter international collaborative study. Gastrointest Endosc 2017; 85: 164-169
• 2 Nakai Y. Technical tips for endoscopic ultrasound-guided pancreatic duct access and drainage. Int J Gastrointest Interv 2020; 9: 154-159

Publication History

Article published online:
14 March 2024