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

Abstract

Aim

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.

Patients and Methods

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).

Results

Out of the complete consecutive patient series with EUS-PD (n=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 (n=21; 61.8%) and 2.) malignant tumor lesions (n=13; 38.2%), resp. Pancreaticography was achieved in all subjects (n=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% (n=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 (n=4) or not successful because of dislocation of the guide wire (n=5). However, these nine subjects underwent reintervention: in five patients, ring drainage (n=3) and transgastric drainage (n=2) were achieved, resulting in the definitive technical (drainage placement) success rate of 84% (n=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, n=8; metal stent, n=3 [biliary wallstent, n=2; LAMS, n=1]) and ten subjects, resp.

Finally, long-term clinical success was 92% (n=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 (n=2).

Conclusion

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.

Zusammenfassung

Ziel

Als Alternative zur nochmaligen Operation werden die klinischen Ergebnisse (Machbarkeit, Sicherheit, technische und klinische Erfolgsrate) der EUS-geführten Pankreasgangdrainage (EUS-PD) bei symptomatischer postoperativer Anastomosenstenose an einer konsekutiven Patientenkohorte im Rahmen einer klinisch-systematischen unizentrischen Observationsstudie in täglicher klinischer Praxis vorgestellt.

Patienten und Methoden

EUS-gestützte Punktion (19-G-Nadel) des Pankreasganges, Pankreatikographie, Vorschub eines Führungsdrahtes (0,035 Inch) in Richtung und über die Anastomose in den Dünndarm nach vorheriger Dilatation des transgastrischen Zugangsweges (mittels Ringmesser): 1. wenn möglich, Ballondehnung der Anastomose und Protheseneinlage i.S. einer Gastropancreaticojejunostomie („Ringdrainage“); 2. wenn nicht möglich (frustraner Drahtvorschub): Erweiterung des transgastrischen Zuganges (mittels Ringmesser) und Ballondehnung mit folgender transgastrischer Prothesenanlage (Pancreaticogastrostomie).

Ergebnisse

Von 2004–2015 wurden aus einer kompletten EUS-PD-Patientenserie von 119 Patienten 34 Fälle (28,5%) mit Z.n. Op (Pankreaskopfresektion 1. bei chronischer Pankreatitis [n=21; 61,8%], 2. wegen malignen Tumors [n=13; 38,2%]) einer EUS-PD-Patientenserie zugeführt. Die Pankreatikographie gelang bei n=34/34 (100%). In 9/34 Fällen war ein suffizienter KM-Abfluss über die Anastomose erkennbar, auf eine Drainage wurde daher verzichtet. Bei den verbleibenden 25 Patienten lag die technische Erfolgsrate einer effektiven initialen Drainageanlage bei 64% (n=16/25).

Bei 9/25 Patienten wurde nur eine Dilatation mit Ringmesserpassage über den Draht und Ballon durchgeführt. Im Detail war eine Stentinsertion entweder nicht notwendig wegen guten KM-Abflusses über die Anastomose (n=4) oder nicht erfolgreich wegen Drahtdislokation (n=5). Diese 9 Individuen wurden einer Reintervention unterzogen: Bei fünf Patienten wurde eine Ringdrainage (n=3) und transgastrische Drainage (n=2) erreicht, resultierend in einem definitiven technischen Erfolg (Drainageplatzierung) von 84% (n=21/25).

Zwei verschiedene Drainagetechniken wie die Pancreaticogastrostomie und die Gastropancreaticojejunostomie (Ringdrainage) wurden bei 11 Patienten (Plastik-Stent: n=8; Metallstent: n=3 [biliärer Wallstent: n=2; “lumen-apposing metal stent” [LAMS]: n=1]) bzw. in 10 Fällen angewandt. Die letztendliche klinische Langzeit-Erfolgsrate war 92% (n=23/25).

Insgesamt traten Komplikationen bei 6/34 Individuen auf (Rate: 17,6%): Blutung, Stent-bedingtes Druckulkus, Bursaabszess, postinterventionelle Pseudozyste (jeweils n=1) und paraluminale KM-Ansammlung (n=2).

Schlussfolgerung

Die EUS-PD stellt hierfür eine geeignete alternative, minimal-invasive Therapieoption für die Patienten dar, um eine erneute Op zu vermeiden. Aufgrund der hohen technischen Anforderungen sollte die EUS-PD-Patientenserie nur Zentren mit entsprechender Expertise der interventionellen EUS vorbehalten bleiben. Eine weitere Evaluierung des Verfahrens durch größere Patientenserien, Langzeit-Beobachtungen sowie technische Verbesserungen sind notwendig.

Keywords

EUS-guided transluminal drainage of the pancreatic duct (EUS-PD) - enlargement of the pancreatic duct - retention of the pancreatic duct - ERCP - consecutive unicenter patient cohort - systematic clinical prospective observational study (real-world data) - feasibility - safety - quality assurance

Schlüsselwörter

EUS-geführte transluminale Drainage des Pankreasgangs (EUS-PD) - Vergrößerung des Pankreasgangs - Stau des Pankreasgangs - ERCP - konsekutive „Unicenter“-Patientenkohorte - systematische klinische prospektive Observationsstudie („real-world"-Daten) - Machbarkeit - Sicherheit - Qualitätssicherung

Publication History

Received: 05 March 2024

Accepted after revision: 30 September 2024

Article published online:
06 December 2024

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