Endoscopic ultrasonography-guided drainage of the pancreatic duct (EUS-PD) in postoperative anastomotic stenosis after previous pancreatic resection

• Published in: Zeitschrift fur Gastroenterologie Vol. 62; no. 12; p. 2039
• Main Authors: Will, Uwe, Füldner, Frank, Buechner, Theresa, Meyer, Frank
• Format: Journal Article
• Language: English
• Published: Germany 01.12.2024
• Subjects: Adult; Aged; Aged, 80 and over; Anastomosis, Surgical - methods; Constriction, Pathologic - surgery; Drainage - instrumentation; Drainage - methods; Endosonography - methods; Female; Humans; Male; Middle Aged; Pancreatectomy - methods; Pancreatic Ducts - diagnostic imaging; Pancreatic Ducts - surgery; Postoperative Complications; Treatment Outcome
• ISSN: 1439-7803
• DOI: 10.1055/a-2435-4888

As an alternative instead of a repeat surgical intervention, results (feasibility, safety, and technical and clinical success rate) of EUS-guided pancreatic duct drainage (EUS-PD) in a consecutive patient cohort because of symptomatic postoperative anastomotic stenosis as part of a unicenter observational study in daily clinical practice are presented.EUS-guided puncture (19-G needle) of the pancreatic duct, pancreaticography, and advancement of a guide wire (0.035 inches) via the anastomosis into the small intestine after previous dilatation of the transgastric access site (using ring knife): 1. if possible, balloon dilatation of the anastomosis and placement of a prosthesis as a gastro-pancreaticojejunostomy ("ring drainage", "gastro-pancreaticojejunostomy"); 2. if not possible (frustrating advancement of the guide wire), again, dilatation of the transgastric access site (using ring knife) and balloon dilatation with a following transgastric placement of a prosthesis (pancreaticogastrostomy).Out of the complete consecutive patient series with EUS-PD ( =119 cases) from 2004 to 2015, 34 patients (28.5%) were found with a medical history significant for previous surgical intervention at the pancreas who were approached using EUS-PD: in detail, pancreatic head resection in 1.) chronic pancreatitis ( =21; 61.8%) and 2.) malignant tumor lesions ( =13; 38.2%), resp. Pancreaticography was achieved in all subjects ( =34/34; rate, 100%). In 9/34 cases, a sufficient flow of contrast media via the anastomotic segment was detected; therefore, drainage was not placed. In the remaining 25 cases, the primary technical success (successful placement of drainage) rate was 64% ( =16/25 cases). In 9/25 patients, only dilatation using the passage of a ring knife over the guide wire and a balloon was performed. In detail, stent insertion was either not necessary because of good contrast flow via anastomosis ( =4) or not successful because of dislocation of the guide wire ( =5). However, these nine subjects underwent reintervention: in five patients, ring drainage ( =3) and transgastric drainage ( =2) were achieved, resulting in the definitive technical (drainage placement) success rate of 84% ( =21/25). In further detail, the two different techniques of drainage insertion such as pancreaticogastrostomy and gastro-pancreaticojejunostomy (ring drainage) were used in 11 patients (plastic stent, =8; metal stent, =3 [biliary wallstent, =2; LAMS, =1]) and ten subjects, resp.Finally, long-term clinical success was 92% ( =23/25).Overall, there were complications in 6/34 individuals (rate, 17.6%): bleeding, pressing ulcer by the stent, abscess within the lower sac, postinterventional pseudocyst (n=1 each), and paraluminal collection of contrast medium ( =2).Alternative EUS-PD is feasible and safe and can avoid surgical intervention; this can result in a distinct improvement in the quality of life, including an acceptable interventional risk. Because of the high technical demands, EUS-PD should only be performed in centers of interventional EUS, with great expertise in this field. Further clinical long-term observation, greater patient cohorts, evaluation of procedural knowledge and data, and further technical advances are required.